Billing and Coding: Cervical Fusion
A59645
Refer to the Local Coverage Determination (LCD) L39762 Cervical Fusion for reasonable and necessary requirements and frequency limitations. The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to the NCCI requirements. Coding Guidance Providers should refer to the applicable AMA CPT Manual to assist with proper reporting of these services. Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. This policy applies only to cervical fusion and related procedures and does not apply to other joint procedures (such as facet, sacroiliitis, epidural or other spinal procedures). General Guidelines for Claims submitted to Part A or Part B MAC: Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported. Modifier When to Use Modifier GA Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case Report when you issue a mandatory ABN for a service as required and keep it on file. You don’t need to submit a copy of the ABN, but you must make it available on request. Use the –GA modifier when both covered and non-covered services appear on an ABN-related claim. –GX Notice of Liability Issued, Voluntary Under Payer Policy Report when you issue a voluntary ABN for a service we never cover because it’s statutorily excluded or isn’t a Medicare benefit. Use this modifier combined with modifier –GY. –GY Notice of Liability Not Issued, Not Required Under Payer Policy Report Medicare statutorily excludes the item or service, or the item or service doesn’t meet the definition of a Medicare benefit. –GZ Expect Item or Service Denied as Not Reasonable and Necessary Report when you expect we’ll deny payment of the item or service because it’s medically unnecessary and you didn’t issue an ABN. Documentation Requirements <