Medicare coverage is governed by National Coverage Determination (NCD) which is located at http://www.cms.hhs.gov/mcd/. Non-Medicare insurance coverage varies based on the patient's plan.
The provider is required to report the most appropriate diagnosis code based upon the patient's condition and reason for treatment.
|L57.0||Actinic Keratoses (AK)|
Levulan Kerastick® Application
Report the appropriate HCPCS code for Levulan Kerastick. The units reported should equal the number of sticks utilized.
|J7308||Aminolevulinic acid HCl for topical administration, 20%, single unit dosage form (Levulan Kerastick)|
BLU-U® Light Treatment
Report each PDT treatment session regardless of length or number of lesions treated.
|96567||Photodynamic therapy by external application of light to destroy premalignant and/or malignant lesions of the skin and adjacent mucosa by activation of photosensitive drug(s), each phototherapy exposure session|
Evaluation and Management (E&M)
The billing of E/M services (e.g. evaluation and management services by the physician in conjunction with a patient visit) is appropriate if the physician provides the evaluation and management services as described in the applicable E/M code.
For Medicare, E/M services are not permitted to be reported on the same date of service that PDT (CPT 96567) is performed. You may report an E/M code if an unrelated condition is treated or evaluated during the same visit as PDT. This will require a secondary diagnosis on the claim related to the E/M visit. A modifier -25 may be required.
Procedure coding should be based upon medical necessity and procedures and supplies provided to the patient. Coding and reimbursement information is provided for educational purposes and does not assure coverage of the specific item or service in a given case. DUSA Pharmaceuticals and The Pinnacle Health Group make no guarantee of coverage or reimbursement of fees. Contact your local Medicare Fiscal Intermediary, Carrier or CMS for specific information that is subject to continuous change. To the extent that you submit cost information to Medicare, Medicaid or any other reimbursement program to support claims for services or items, you are obligated to accurately report the actual price paid for such items, including any subsequent adjustments. CPT five-digit numeric codes, descriptions, and numeric modifiers only are Copyright AMA. All rights reserved.
The information contained in this document is provided to assist health care facilities understand reimbursement guidelines and procedures. It is intended to help obtain accurate coverage and reimbursement for medically necessary health care services provided to patients under physician orders. It is not intended to increase or maximize reimbursement. Should you have questions regarding coding and reimbursement, please contact us at DUSA@dusadelivers.com.
The information referenced is based upon coding experience and research of current coding practices and published payer policies. They are based upon commonly used codes and procedures. The final decision for coding of any procedure must be made by the provider of care considering the medical necessity of the services and supplies provided, the regulations of insurance carriers and any local, state or federal laws that apply to the supplies and services rendered.
Although a particular service or supply may be considered medically necessary, the final coverage decision is based upon a review of the available clinical information and does not mean the service or supply will be covered by any payer. Each payer and benefit plan contains its own specific provisions for coverage and exclusions. Please consult individual payers to determine policy specific guidelines and whether there is any exclusion or other benefit limitations applicable to a particular service or supply.
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WEB 1400 Rev E