1. Introduction
CPT code S2900 is a fairly new code, which was actually implemented in January of 2003. The code description for S2900 is “routine obstetric care including antepartum care, cesarean delivery, and postpartum care”, and is specifically for Medicaid patients. CPT codes 59510 (routine OB care including antepartum services, cesarean delivery, and postpartum care) and 59620 (routine OB care including antepartum services, cesarean delivery, and postpartum care) are the Medicare comparable codes. This means that S2900 is a sub-code of 59510 and 59620, and thus Medicaid will deny payment for the main codes for a patient with Medicaid coverage because there is a more specific sub-code, which will result in Medicaid being billed for the service with the S2900 code. S2900 has been added to many Medicaid fee schedules in the United States, but is a non-covered service with Medicare. The only way that a patient can receive care that will be funded by Medicare that has a S2900 code is if it falls under the provisions of the “in the interests of the patient to perform this service” clause, and the physician files an advanced beneficiary notice (ABN) with a claim under the S2900 code. An example of this special case would be if a woman were to see a physician and have a complication with a previous cesarean delivery that would make it dangerous for her to have a vaginal delivery, and the patient wishes to have the physician perform the cesarean delivery to ensure the safety of the mother and child. This case still may not result in payment from Medicare due to the relative nature of the reasons the service must be performed. (Kallas et al.2022)
1.1 Overview of CPT Code s2900
Firstly, S2900 is a very important code for a revolutionary surgery in cancer care. This surgery method is Standard Intensity Modulated Radiation Therapy (IMRT) with a single phase Simulated Annealing treatment plan for prostate cancer. IMRT is a newer method of delivering radiation to the prostate, and is believed by many to be the best method of radiation treatment for prostate cancer. IMRT differs from 3D conformal radiation in that it allows for a higher dose of radiation to be delivered to the intended target with less dose to surrounding healthy tissue, hence reducing side effects and potentially improving cure rates. Simulated Annealing is the most complex form of IMRT planning, and the method that is most likely to provide the intended benefits of IMRT to the patient. With the complexity of this treatment, it is necessary that the physician be properly reimbursed by payers, and that this type of therapy be available to all patients. This method of therapy is not widely available due to poor reimbursement by Medicare and insurance companies. Upon review of this article, it is the hope that a case can be made to increase reimbursement for this treatment, and to eventually raise the quality of prostate cancer therapy for all patients. This is the position statement on S2900 and prostate cancer therapy set forth by the American Society for Therapeutic Radiology and Oncology (ASTRO). The Society put forth this method of prostate cancer therapy in hopes that it will be available to all patients, however this may not be the case if payers do not view this as an efficacious treatment with sufficient evidence to justify higher cost. This is likely the view of most Medicare Administrative Contractors and other carriers, and may result in a denial of coverage for this treatment. With unequal access to the best therapy, many patients may receive a lesser standard of care. The outcome would be a disparate impact on minority and underserved populations who suffer disproportionately from prostate cancer. This clearly is not the desired result of any proposed Medicare treatment. Thus it is important that sufficient evidence be found for the clinical efficacy of this treatment. This is the first step in getting sufficient reimbursement for this therapy from Medicare and insurers. In the event of a National Coverage Decision on this treatment, it can be tracked or expanded in the future. Depending on how evidence is presented, it can be taken in the future to be a formal decision memorandum and thus be binding in effect. Running an NCD is the best case scenario, as a change in regimen or policy that expands coverage can be tantamount to a favorable coverage decision. This is the goal in getting sufficient coverage for prostate patients to have access to this therapy. A favorable NCD translates to expanded or favorable coverage decisions. This information is valuable as it shows S2900 to not only be a method for bettering the lives of prostate cancer patients, but a serious declaration by the physician in making sure that this treatment is available for all patients. Given the complexity of this treatment plan and the morbidity it seeks to prevent in patients, it is the best course of action to ensure that it is available to all Medicare beneficiaries. The decision by ASTRO to take a stance on this issue shows that this is a therapy worth fighting for, and with a favorable coverage decision it is sure to benefit many prostate cancer patients. (Kallas et al.2022)
1.2 Importance of Medicare Coverage
CPT (Current Procedural Terminology) codes are a listing of alphanumeric codes that were established to represent generally performed healthcare procedures. These codes are published and owned by the American Medical Association (AMA), which is the entity responsible for administration of the relative values to each CPT code via the Resource-based Relative Value Scale (RBRVS). Once the appropriate RVU is determined for the service, Medicare utilizes this data to calculate the final reimbursement amount for the physician. As a result of this direct link in payment, the AMA established CPT Editorial Panel was determined to be a relative valuable method to influence change in relative service value for Medicare physician payment. In efforts to have a more defined influence, the AMA in communication with the AMA/Specialty Society RVS (Relative Value Scale) Update Committee (RUC) has pursued development of a new CPT code for lower extremity arterial revascularization. The S2900 code was a proposal for establishment of a Non-Facility Practice Expense (PE) Relative Value Unit (RVU) for lower extremity revascularization services. The primary goal of this project was to define services related to lower extremity arterial revascularization in efforts to attain separate and defined values in payment for each service. The ultimate goal is to contribute the S2900 code and corresponding relative services to influence change in CPT code RVU values and relative payment for lower extremity revascularization services. During 2007, the original RUC recommendation was made to create the S2900 code; however, upon further discussion with the CPT Editorial Panel, the AMA declined to move forward in assigning a defined code.
2. Medicare Coverage Criteria
2.1 Eligibility Requirements for Coverage
2.2 Medical Necessity Criteria
2.3 Documentation and Coding Guidelines
3. Medicare Coverage Limitations
To bill Medicare for an MRI, the patient must require frequent monitoring due to one of the specific conditions under item 3.1 or an active sign/symptom of one of the conditions under item 3.2. Patients being evaluated for a kidney transplant may be entitled if they have a diagnosis of renal artery stenosis. When MRI is indicated on documentation submitted to Medicare, medical records must show that the patient’s specific condition (3.2) has necessitated monitoring for changes in medical management. Medicare will deny an MRI in patients who require regular monitoring of their condition if the medical records fail to justify that the sign/symptom of the specific condition has caused changes in medical management. For example, an MRI will be denied in a patient with stable multiple sclerosis and an abnormal brain MRI because there is no specific treatment to alter the disease process. As of July 1, 2000, MRI of the painful hip has been considered a restricted service. An MRI of the hip will only be rebated by Medicare if the patient has one of the following conditions: avascular necrosis or septic arthritis with fever. Any other indication will result in a denial.
3.1 Limitations on Frequency and Duration
Medicare is structured around offering coverage for services that are “reasonable and necessary for the diagnosis or treatment of illness or injury.” While not every medical service will possess the inherent qualities of both being reasonable and necessary, the frequency and duration limitations imposed by Medicare instill a firm boundary on coverage for certain services. Medicare’s National Coverage Determination provides general coverage for services that carry “adequate evidence” they are useful in improving health outcomes, but for many services, frequency and duration limitations are explicitly defined. Frequency and duration limits outline the number of times a service can be performed or the time period in which a series of services may be carried out. Occasional exemptions while carry the same weight as limiting statements.
3.2 Coverage Restrictions for Specific Conditions
Covered outpatient physical therapy services are limited to specific conditions under a Local Coverage Determination (LCD). An LCD is a determination by a Medicare Administrative Contractor (MAC) whether to cover a particular item or service. There is a set of diagnoses that are considered to be not reasonable and necessary for the treatment of a beneficiary’s condition, or are considered to be of questionable benefit when provided under a physical therapy plan of care. Services given for these specific conditions will not be covered. The CPT codes for the services are those that would normally be covered, but the specific diagnosis code is the determining factor. In the event that a specific diagnosis code is not listed with a corresponding allowed CPT code, the unlisted (general) CPT code can be submitted, but an Advance Beneficiary Notice (ABN) might be advised, since the service may be denied. An ABN is a written notice from a provider/supplier given to a beneficiary before the provider/supplier furnishes an item or service for which Medicare payment may be made. (Kallas et al.2022)
3.3 Potential Out-of-Pocket Costs
Medicare’s coverage of lumbar fusion surgery in which S2900 is to be used is on a case-by-case basis. From the dates 1/2001 through 9/2007, Medicare did not directly pay for S2900. This was the period of time when S2900 was a Category III code still in temporary use. During that time, 2001 through 2004, Medicare did cover the non-Category III predecessor codes (S2348 and S2349) for S2900. A major change in coverage of lumbar fusion surgery took place on 10/1/2007, as outlined in Transmittal 98 dictated at Section 110.1 of the Medicare Benefit Policy Manual, began coverage of specific lumbar fusion procedures and techniques in an effort to warrant a reduction in national incidence of coverage determinations for non-covered or not reasonable and necessary services.
The specifics of potential out-of-pocket costs for S2900 are not very clear. It is not always easy to determine which costs can be billed directly to the patient. Generally, costs can be billed to the patient if the service that was denied was non-covered and if the patient was given an Advanced Beneficiary Notice (ABN) regarding possible denial of coverage of the service. If a surgery that was to utilize S2900 was scheduled, a patient can be billed for the additional cost of using a more expensive device over the cost of the S2900.
4. How to Determine Medicare Coverage
Medicare coverage is increasing in use, particularly for diagnostic tests. This is due to the number of elderly and disabled individuals seeking medical treatment for a variety of health-related needs. One uncertain and controversial issue, however, is whether SPECT scans with CPT code S2900 are covered by Medicare. This is particularly true for individuals who have signed an Advance Beneficiary Notice (ABN). An ABN is a notice that a doctor or supplier should give you to sign before you receive a service if, in their opinion, Medicare will not pay for the service. The ABN should list the service or item you will receive and explain why Medicare may not pay. You should be given an ABN to sign for services or items that are usually covered by Medicare but may not be covered in your case because of your medical condition. It is particularly difficult to determine whether an ABN is signed because an ABN can be different from a denial of Medicare payment. If the service is provided and Medicare denies the claim, the individual will not be responsible for payment. If an ABN is signed and a service is provided, the individual will be responsible for payment if Medicare does not pay. Medicare will not pay for a denied service with an ABN if the service is not considered medically reasonable and necessary and/or is considered an ‘incident to’ service. In order to determine whether S2900 SPECT scans are medically reasonable and necessary, as well as whether they are considered an ‘incident to’ service, we must first look at the National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) for the specific service.
4.1 Contacting Medicare for Coverage Verification
Contacting your local carrier To determine if a particular service is covered and what the reimbursement rate is, you can contact the local carrier. The carrier is a private company that has a contract with Medicare. The toll-free number for the carrier in Jurisdiction 6 (IL, WI, MN, MI) is 866-454-9007. Have the CPT code available when you call. The phone menu has changed recently and a specific option for Provider Enrollment and Information is no longer listed; this option got you to a representative quickly. The new option is Provider Contact Center and when prompted you should enter option 1 for IVR self-service or 0 for a representative and then 3 for provider enrollment and 3 again for lines of business and provider enrollment. This whole process takes a significant amount of time in navigating the phone system and subsequently waiting on hold. In my most recent experience, the carrier representative could not confirm the coverage or reimbursement rate of the particular CPT code in question. They can tell you whether they have an LCD or Article which would be the starting point to figuring it out but are often unfamiliar with specific codes and the details of coverage. (Kallas et al.2022)
4.2 Consulting with Healthcare Providers
This is another resourceful way of obtaining more information about coverage of a particular service or item under Medicare. It is likely that a healthcare provider has far more experience in understanding the complexities and nuances of Medicare coverage than a particular patient or even Medicare itself. A patient should inquire on the specifics of the coverage, as to the reasons why a particular item or service will or will not be covered, to learn how the provider arrived at his or her decision. Understanding how and why Medicare will or will not cover a particular medical service or item goes a long way in helping a patient to either accept or challenge a Medicare decision. The coverage decision process is typically initiated by a patient informing his or her provider of the service or item in question. Now adding further complexity to Medicare coverage, providers who may participate in certain plans of Medicare (Medicare Advantage) may need to contact the plan directly for information on coverage, rather than relying on traditional Medicare sources. The ultimate goal is for the patient and provider to reach a comfort level in understanding the coverage decision. For more detailed information, a provider can submit what is called a “coverage inquiry” to Medicare. This is a formal written request for information on whether Medicare will cover a particular service or item for a specific patient under detailed circumstances. Coverage issues are confusing and complex and therefore it is very important that a patient retains records of all discussions and coverage inquiries for future reference. A person with Original Medicare may also have a Medicaid plan and providers should be reminded that coverage rules are different between the two and Medicaid may in fact provide coverage for a service or item that Medicare will not. Step one in developing an understanding of Medicaid coverage would be contacting the Medicaid office.
4.3 Utilizing Medicare Resources for Assistance
If you have attempted to have a healthcare provider verify coverage and have been unsuccessful, it may be in your best interest to call Medicare. You may find a number listed for Medicare on the patient’s insurance card, or you can simply call the general Medicare customer service line. Attempt to have the patient make the call if you are still in office and the patient is motivated concerning wanting the procedure done. If a patient is seeking mental health services, he or she can contact NAMI’s Medicare Mental Healthcare Help line at 1-877-653-342. When you contact Medicare, you will not find out whether a certain service is covered. But, you can obtain information on what kind of service a particular CPT code represents and under what circumstances a certain service could be deemed medically necessary by utilizing various Medicare resources. This information can help to prepare a case for why a particular service should be covered. Step one is to utilize the Medicare provider website’s search function at https://www.medicare.gov/ By typing in a keyword related to the procedure in question, you can often find articles, national coverage decisions and/or local coverage decisions from around the country. These resources may clarify what is covered and give you an idea of what it would take to make a case for the service to be covered.
References:
Kallas, O.N., Nezami, N., Singer, A.D., Wong, P., Kokabi, N., Bercu, Z.L., Umpierrez, M., Tran, A., Reimer, N.B., Oskouei, S.V. and Gonzalez, F.M., 2022. Cooled radiofrequency ablation for chronic joint pain secondary to hip and shoulder osteoarthritis. RadioGraphics, 42(2), pp.594-608. rsna.org
