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Contractor's Policy Number

98-1A-R1

Contractor's Name

CareFirst of Maryland Inc., Medicare Part A

Contractor Number

00190

Contractor Type

Fiscal Intermediary

LMRP Title

Radiation Carrier

AMA CPT Copyright Statement

CPT codes, descriptions, and other data only are copyright 1999 American Medical Association (or such publication of CPT). All rights reserved. Applicable FARS/DFARS clauses apply.

CMS National Coverage Policy

• Establishment of national policy supersedes all previous contractor policy statements, including Local Medical Policy coverage guidelines
• Title XVIII of the Social Security Act, section 1862 (a) (7). This section excludes routine physical examinations.
• Title XVIII of the Social Security Act, section 1862 (a) (1) (A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Primary Geographic Jurisdiction

Maryland

Washington, DC

Secondary Geographic Jurisdiction

Alabama, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Missouri, Nebraska, Nevada, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, Washington state, and Wyoming

CMS Region

Region III

CMS Consortium

Northeast

Original Policy Effective Date

02/12/1998

Original Policy Ending Date

NA

Revision Effective Date

NA

Revision Ending Date

NA

LMRP Description

Radiation carriers are safe and effective devices used to administer radiation to confined areas by means of capsules, beads, or needles of emitting radiation materials such as radium or cesium.

Indications and Limitations of Coverage and/or Medical Necessity

The function of the device is to hold the radiation source securely in the same location during the entire period of treatment. Radiation oncologists generally use these devices to achieve close approximation and controlled application of radiation to a tumor that is susceptible to radiation. Only a radiation oncologist may report the preparation and supply of radiation carriers. The radiation carriers should be included in the procedure charge. Medicare would not expect to see the radiation carriers billed separately.

CPT/HCPCS Section & Benefit Category

Surgery/Musculoskeletal System

Type of Bill Code

Not separately billable

Revenue Codes

Not separately billable

CPT/HCPCS Codes

Not Otherwise Classified (NOC)

NA

ICD-9 Codes that Support Medical Necessity

Covered for:

Diagnoses that Support Medical Necessity

As listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

ICD-9 Codes that DO NOT Support Medical Necessity

Any diagnosis codes not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

Diagnoses that DO NOT Support Medical Necessity

Conditions not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Reasons for Denial

• All other indications not listed in the "Indications and Limitations of Coverage" section of this policy,
• The service is for screening purposes,
• The service is not medically necessary,
• The medical record does not verify that the service described by the HCPCS code was provided, and;
• The service does not follow the guidelines of this policy.
• Medicare would not expect to see the radiation carriers billed separately.

Non-covered ICD-9 Codes

Any diagnosis codes not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy

Non-covered Diagnoses

Conditions not listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

Coding Guidelines

• To report this service, use the appropriate HCPCS code,
• All of the coverage criteria must be met before this service can be reimbursed by Medicare,
• Diagnosis (es) must be present on any claim submitted, and be coded to the highest level of specificity, and;
• The diagnosis codes(s) must be representative of the patient's condition.

Documentation Requirements

• Documentation supporting the medical necessity should be legible, maintained in the patient's medical record,and include the diagnosis and treatment plan.
• Documentation in the medical record should be available to Medicare upon request.
• Only a radiation oncologist may report the preparation and supply of a radiation carrier. A description of the procedure must be submitted with the claim.

Utilization Guidelines

Medicare will monitor the utilization of this laboratory test through the Medical Review process.

Other Comments

NA

Sources of Information and Basis for Decision

• Carrier Advisory Committee Meeting, February 15, 1995.
• Special Medicare Part B Newsletter No. 136, June 15, 1995.

Advisory Committee Notes

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups , which includes representatives from the appropriate specialty(ies).

Advisory Committee Meeting Date: NA

Start Date of Comment Period

11/12/1997

End Date of Comment Period

NA

Start Date of Notice Period

01/12/1998

Revision History

THIS BULLETIN SHOULD BE SHARED WITH ALL HEALTH CARE PRACTITIONERS AND MANAGERIAL MEMBERS OF THE PROVIDER/SUPPLIER STAFF. BULLETINS ISSUED AFTER OCTOBER 1, 1999 ARE AVAILABLE FROM OUR WEBSITE AT www.marylandmedicare.com

Italicized and or quoted material is excerpted from the American Medical Association Current Procedural Terminology CPT codes, descriptions and other data only are copyrighted 1999 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.