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HER OPTION®
1) What is the appropriate code to report when per-
5) What procedures are included in CPT 58356 and
forming endometrial cryoablation utilizing the
not separately billable?
Her Option® therapy system?
Below are some of the more commonly performed CPT 58356 (Endometrial cryoablation with ultrasonic
procedures which are not separately billable accord- guidance, including endometrial curettage, when per- ing to National Correct Coding Initiative (NCCI) edits. formed) is the appropriate CPT code to report when (Not all commercial payers follow NCCI edit guide- 2) Is prior authorization or pre-certification neces-
• 58100—Endometrial sampling (biopsy) with or sary for the endometrial cryoablation procedure?
without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure) As a rule, Medicare does not require prior authoriza- • 58120—Dilation and curettage, diagnostic and/or tion for any procedure. Commercial or private insur- ance carriers (e.g., Aetna, Blue Cross, etc.) and • 58340—Catheterization and introduction of saline some Medicare supplemental plans may require a or contrast material for infusion sonohysterography prior authorization or pre-certification for surgical pro- cedures. Therefore, it is recommended that you • 64435—Injection, anesthetic agent; paracervical check with insurers (primary and secondary) to verify coverage and pre-certification requirements prior to 6) Is the endometrial cryoablation procedure (CPT®
code 58356) payable in an Ambulatory Surgery
3) What modifier is used to report CPT® 58356 in
Center (ASC)?
the office setting to receive the global reim-
bursement rate?
Yes. As of January 2008, Medicare will pay for services provided in ASCs using a payment system based on CPT 58356 does not require the use of a modifier. the hospital outpatient prospective payment system The site of service entered on the claim showing that (OPPS). The ASC system uses the same payment the procedure was performed in the office should groups (APCs) as the OPPS but uses a conversion fac- tor that is equal to 50% of the OPPS conversion factor 4) What are the HCPCS codes for drugs which
might be used in conjunction with CPT 58356?
There are however, certain procedures that are not paid at the same 50% of the OPPS rates. Office based pro- Some common pre- or post-procedure injectables cedures previously not covered in the ASC that are per- and their associated HCPCS codes are as follows: formed in physician offices at least 50% of the time will • J2001—Injection, lidocaine HCl for intravenous be paid the lower of the ASC rate (based on the meth- infusion, 10 mg (use this for Xylocaine) odology described above) or the practice expense por- tion of the physician fee schedule payment rate that S0020—Injection, bupivacaine HCl 30 ml (use this applies when the service is furnished in a physician’s • J1885—Injection, ketorolac tromethamine, per Commercial payers will vary in coverage and payment • J9218—Leuprolide acetate, per 1 mg (use this is based upon individual contractual agreements with the ASC. Check with each payer for individual guide- MedPac Ambulatory Surgical Centers Payment System. Revised: October 2008. www.medpac.gov/documents/MedPAC_Payment_Basics_08_ASC.pdf CONTINUED ON REVERSE
HER OPTION®
7) Is it appropriate for a physician to bill for a diag-
8) How much do Medicare and commercial payers
nostic hysteroscopy when performed prior to an
pay for endometrial cryoablation procedures?
ablation procedure?
The Centers for Medicare and Medicaid Services When both procedures are done in the same surgical (CMS) publishes the Medicare payment rates for setting but as distinct procedures, it is appropriate to physicians, hospitals and ambulatory surgery cen- submit a diagnostic hysteroscopy code, CPT 58555, ters. Payment information may be accessed via the with a 59 modifier in addition to an ablation proce- CMS website — http://www.cms.hhs.gov and navi- dure code (e.g., 58353 or 58356). The 59 modifier gating to the appropriate provider center. Fee indicates that the diagnostic portion of the case is a schedules for commercial payers are contract driven distinct procedure from the ablation because they and considered proprietary information. Fee sched- use two methods. When reporting a surgical code ules may be based on a percentage of Medicare, with a 59 modifier, many payers may require docu- discounted charges, capitation or some other mentation to review the case in order to determine method. If a provider has not contracted with a par- whether or not the modifier is justified. In these ticular payer, reimbursement is typically made at U & cases, it is important for the provider to know and C (usual and customary) or billed amount. Before understand each payer’s specific requirements performing any new procedures, contact the individ- around the use of the modifier. If documentation is ual payer to obtain the fee schedule amounts and needed, any electronically submitted claim may be any requirements pertaining to prior authorization or line-item denied until the payer receives the physi- cian’s notes. In this case, it is better for the physi- cian to send a paper claim with documentation in- Disclaimer: While reasonable efforts have been made to ensure the
accuracy of the information set forth, AMS, Inc. can not guarantee reim-
stead of submitting an electronic claim. bursement for any product or procedure. Providers should report the codes that accurately describe the products and procedures furnished and the patient’s medical condition. Providers should contact their pay- ers if they have questions or need specific co-payment, coverage and billing/coding policies as well as to update the information described January 2009 American Medical Systems, Inc. Coding Resources:
1.
CPT 2009. Current Procedural Terminology, Professional Edition. American Medical Association, Chicago, IL Expert 2009: HCPCS Level II. Healthcare Common Procedure Coding System. American Medical Association. Ingenix, Salt Lake EncoderPro.com. Ingenix, Inc. 2009, Salt Lake City, UT

Source: http://www.heroption.com/resources/pdf/Reimb_Her%20Option%20FAQ_2009.pdf