    
Final Comments Avail
Board Administrator
Username: Admin
Post Number: 74
Registered: 10-2002
| | Posted on Wednesday, February 04, 2009 - 02:42 pm: | 
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Comment:
A provider requested the addition of ICD-9 codes for breast cancer and prostate cancer as the primary neoplasm with V58.69 for long term current use of high risk medications as the secondary diagnosis as an indication of a qualified individual for yearly exams. They do mention in the policy about men on hormone treatment possibly qualifying for yearly exams, but not women and neither breast nor prostate cancers are identified by ICD-9's in the policy
Response:
V58.69 is currently a covered diagnosis in LCD MS-004.
V58.61, V58.65, V58.69 Long-term (current) use of medication
Comment:
A request was made to add the following medications as indications for high risk of bone mineral loss.
Goserelin (Zoladex) - a hormone treatment for prostate cancer
Lupron - a hormone treatment for prostate cancer
Anastrazole (Arimidex) - a hormone treatment used for breast cancer
Tamoxifin (Nolvadex) - a hormone treatment used for breast cancer
Response:
ICD-9 codes V58.61, V58.65, and V58.69, which are already included in this LCD, cover this without restricting the coverage to only certain medications.
Comment:
A request was made to include site specific, detailed ICD-9 neoplasm codes.
Response:
The issue is not the specific site of the cancer, but the occurrence of the cancer. Thus, these detailed codes are not needed.
Comments:
The Bone Mass Measurement (MS-004) LCD states that a bone mass measurement is covered for an individual with a history of long term anti-convulsant, heparin, GnRH therapy or aromatase inhibitors. However we're unable to locate an ICD-9 code in the policy that supports the use of Quantitative Computed Tomography or DEXA for monitoring a patient on an aromatase inhibitor.
Response:
Any policy such as this cannot specifically cover all potential medications and their side effects. For the purpose of monitoring at risk patients, the following diagnoses will be added;
V67.2 Following chemotherapy
V67.1 Following radiotherapy
Comment:
We generate ABNs for our patients to cover both the Part A and Part B components. If we cannot summarize the policies so that they can be written as rules in our electronic order entry systems, then we don't have a way for the radiology staff to know when to generate an ABN.
The BMM LCD policy states that WPS will cover a bone mass measurement every two years for a qualified individual who meets at least one of ten criteria. The problem is that the ordering physician may have this information, but it would be quite difficult for this information to be communicated on a requisition so that the hospital knows whether or not to give an ABN.
If the requisition includes one of the diagnoses on the list of ICD-9 codes that support medical necessity, do we not need to address the narrative portion of the policy under Indications?
Response:
The purpose of this policy is not to prevent medically necessary services from occurring. Most practitioners should be readily able to determine if their services are medically necessary. However, for the purpose of enhancing clarification, the following statement has been added to the Documentation Guidelines section in the LCD and to the Coding Guidelines section of the companion Billing and Coding Guidelines document;
Documentation supporting medical necessity must be indicated in the narrative field and available upon request. |
