June 2011 Benefit Changes for CSHCN Services Program Mastectomy and Reconstructive or Cosmetic Procedures Information posted April 15, 2011

Note: For the purposes of this article, “advanced practice registered nurse (APRN) providers” includes nurse practitioner (NP) and clinical nurse specialist (CNS) providers only.

Effective for dates of service on or after June 1, 2011, the Children with Special Health Care Needs (CSHCN) Services Program benefit for mastectomy and reconstructive or cosmetic procedures will change.

The physician must maintain documentation of medical necessity in the client’s medical record. Services are subject to retrospective review.

Breast Prosthesis The following procedure codes for external breast prostheses will be made benefits of the CSHCN Services Program when provided by a licensed prosthetist or licensed orthotist to clients with a history of a medically necessary mastectomy procedure:

Procedure Code Restrictions Limitations L8000 Services rendered in the home setting may be

reimbursed to home health durable medical equipment (DME), prosthetist, orthotist, DME medical supplier, and CSHCN Services Program custom DME providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers.

4 per rolling year, same procedure, any provider

L8010 Services rendered in the home setting may be reimbursed to home health DME, prosthetist, orthotist, DME medical supplier, and CSHCN Services Program custom DME providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Modifier LT or RT required.

8 per rolling year, same procedure, any provider

L8015 Services rendered in the home setting may be reimbursed to home health DME, prosthetist, orthotist, DME medical supplier, and CSHCN Services Program custom DME providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers.

2 per lifetime, any provider regardless of modifier

Procedure Code Restrictions Limitations L8020 Services rendered in the home setting may be

reimbursed to home health DME, prosthetist, orthotist, DME medical supplier, and CSHCN Services Program custom DME providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Modifier LT or RT required.

1 per 6 rolling months, same procedure, any provider

L8030 Services rendered in the home setting may be reimbursed to home health DME, prosthetist, orthotist, DME medical supplier, and CSHCN Services Program custom DME providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers. Modifier LT or RT required.

1 per 2 rolling years, same procedure, any provider

L8035 Services rendered in the home setting may be reimbursed to home health DME, prosthetist, orthotist, DME medical supplier, and CSHCN Services Program custom DME providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers.

Requires prior authorization

L8039 Services rendered in the home setting may be reimbursed to home health DME, prosthetist, orthotist, DME medical supplier, and CSHCN Services Program custom DME providers. Services rendered in the outpatient hospital setting may be reimbursed to hospital providers.

Requires prior authorization

Prior Authorization will not be required for external breast prosthesis procedure codes L8000, L8010, L8015, L8020, and L8030 for services rendered within the quantity limitations defined above.

Changes will be made to the following breast prosthesis procedure codes:

Procedure Code

Limitations

L8001 4 per rolling year, same procedure, any provider Modifier LT or RT required.

L8002 4 per rolling year, same procedure, any provider L8031 1 per 2 rolling years, same procedure, any provider

Modifier LT or RT required. L8032 8 per rolling year, same procedure, any provider

Prior Authorization will no longer be required for external breast prosthesis procedure codes L8001, L8002, L8031, and L8032 for services rendered within the quantity limitations defined above.

Breast Prosthesis Prior Authorization Requirements

Prior authorization is required for the following:

• Medically necessary prostheses beyond set limitations. Procedure codes L8000, L8001, L8002, L8010, L8015, L8020, L8030, L8031, and L8032 may be prior authorized for services that exceed the limitations outlined in this article.

• Procedure codes L8035 and L8039. Prior authorization is required for procedure codes L8035 and L8039.

Prior authorization must be requested using the CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME).

Prior Authorization for Medically Necessary Prostheses Beyond Set Limitations Medically necessary prostheses beyond set limitations may be prior authorized if any of the following is met for procedure codes L8000, L8001, L8002, L8010, L8015, L8020, L8030, L8031, and L8032:

• Loss or irreparable damage. If the external breast prosthesis is lost or irreparably damaged, prior authorization for a replacement of the same type may be considered for coverage at any time.

• Change in the client’s condition. If a different external breast prosthesis is needed due to a change in the client's medical condition, prior authorization for prosthesis of a different type will be considered for coverage at any time.

Prior Authorization for Procedure Codes L8035 and L8039 Prior authorization requests for external breast prosthesis procedure codes L8035 or L8039 must include documentation of medical necessity for the requested device.

The prior authorization request for procedure code L8039 must also include the following information:

• The client's diagnosis

• Medical records indicating prior treatment for this diagnosis and the medical necessity of the requested procedure

• A clear, concise description of the procedure to be performed

• Reason for recommending this particular procedure

• A procedure code that is comparable to the procedure being requested

• Documentation that indicates this procedure is not investigational or experimental

• The setting in which the service is to be rendered

• The physician's intended fee for this procedure

Treatment of Complications of Breast Reconstruction The following procedure codes will be made benefits of the CSHCN Services Program for the treatment of complications of breast reconstruction and may be reimbursed as follows for services rendered to female clients who are 18 years of age and older:

Procedure Code Restrictions 19328 Services rendered in the inpatient hospital setting may be reimbursed to

physician providers. Services rendered in the outpatient hospital setting may be reimbursed to APRN, physician, and ambulatory surgical center (ASC) providers. Services will be made benefits for female clients.

19330 Services rendered in the inpatient hospital setting may be reimbursed to physician providers. Services rendered in the outpatient hospital setting may be reimbursed to APRN, physician, and ASC providers. Services will be made benefits for female clients.

Other Reconstructive or Cosmetic Procedures The following procedure codes will be made benefits for acne surgeries, dermabrasion and chemical peel procedures:

Procedure Code Restrictions 10040 Services rendered in the office, outpatient hospital, or inpatient hospital

setting may be reimbursed to APRN, physician, and dentist providers. Prior authorization is required.

15782 Services rendered in the office or outpatient hospital setting may be reimbursed to APRN, physician, and podiatrist providers. Services rendered in the inpatient hospital setting may be reimbursed to physician and podiatrist providers. Prior authorization is required.

15783 Services rendered in the office or outpatient hospital setting may be reimbursed to APRN, physician, and podiatrist providers. Services rendered in the inpatient hospital setting may be reimbursed to physician and podiatrist providers. Prior authorization is required.

15792 Services rendered in the office or outpatient hospital setting may be reimbursed to APRN, physician, and podiatrist providers. Services rendered in the inpatient hospital setting may be reimbursed to physician and podiatrist providers. Prior authorization is required.

15793 Services rendered in the office or outpatient hospital setting may be reimbursed to APRN, physician, and podiatrist providers. Services rendered in the inpatient hospital setting may be reimbursed to physician and podiatrist providers. Prior authorization is required.

Acne surgeries, dermabrasion and chemical peel procedures require prior authorization. One of the following medical necessity criteria must be met and included with the prior authorization request:

• Correction or repair of severe disfigurement due to disease or accidental injury (photographic documentation is required).

• Restoration of physical function resulting from disease or accidental injury (specific function must be detailed in the prior authorization request).

The following procedure codes will be made benefits for panniculectomy and abdominoplasty procedures:

Procedure Code Restrictions 15830 Services rendered in the inpatient hospital setting may be reimbursed to

physician providers. Services rendered in the outpatient hospital setting may be reimbursed to physician and ASC providers. Prior authorization is required.

15847 Services rendered in the inpatient hospital setting may be reimbursed to physician providers. Services rendered in the outpatient hospital setting may be reimbursed to physician and ASC providers. Prior authorization is required.

Panniculectomy and abdominoplasty procedures require prior authorization. All of the following medical necessity criteria must be met and included with the prior authorization request:

• The panniculus hangs below the level of the pubis (photographic documentation is required).

• The panniculus is the result of weight loss of at least 75 pounds that has been sustained (and not subsequently regained) for longer than one year.

• There is documentation in the medical record that the panniculus directly impairs physical function. Specifically, the panniculus must do at least one of the following:

o Interfere with ambulation, urination, or other activities of daily living

o Cause recurring persistent fungal and bacterial panniculitis that is refractory to good personal hygiene and documented optimal medical management including topical anti-infectives and at least three systemic medication treatments

Additional Benefit Changes

New Benefits

The following procedure codes will be made benefits of the CSHCN Services Program:

Procedure Code Restrictions 11300 Services rendered in the office setting may be reimbursed to APRN,

physician, and podiatrist providers. Services rendered in the inpatient hospital setting may be reimbursed to physician and podiatrist providers. Services rendered in the outpatient hospital setting may be reimbursed to APRN, physician, podiatrist, and ASC providers.

11301 Services rendered in the office setting may be reimbursed to APRN, physician, and podiatrist providers. Services rendered in the inpatient hospital setting may be reimbursed to physician and podiatrist providers. Services rendered in the outpatient hospital setting may be reimbursed to APRN, physician, podiatrist, and ASC providers.

11302 Services rendered in the office setting may be reimbursed to APRN, physician, and podiatrist providers. Services rendered in the outpatient hospital setting may be reimbursed to APRN, physician, podiatrist, and ASC providers. Services rendered in the inpatient hospital setting may be reimbursed to physician and podiatrist providers.

11303 Services rendered in the office setting may be reimbursed to APRN, physician, and podiatrist providers. Services rendered in the outpatient hospital setting may be reimbursed to APRN, physician, podiatrist, and ASC providers. Services rendered in the inpatient hospital setting may be reimbursed to physician and podiatrist providers.

11760 Services rendered in the office or outpatient hospital setting may be reimbursed to APRN, physician, and podiatrist providers. Services rendered in the inpatient hospital setting may be reimbursed to physician and podiatrist providers.

11762 Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to physician and podiatrist providers.

Changes to Surgical Component

The following changes will be applied to the surgical component of the procedure codes indicated:

Procedure Code Changes 11200 Services rendered in the office, inpatient hospital, or

outpatient hospital setting may be reimbursed to APRN providers.

11201 Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to APRN providers.

Procedure Code Changes 11305, 11306, 11307, 11308 Services rendered in the office setting may be

reimbursed to APRN and podiatrist providers. Services rendered in the outpatient hospital setting may be reimbursed to APRN, podiatrist, and ASC providers. Services rendered in the inpatient hospital setting may be reimbursed to podiatrist providers.

11310, 11311, 11312, 11313 Services rendered in the office setting may be reimbursed to APRN providers. Services rendered in the outpatient hospital setting may be reimbursed to APRN and ASC providers.

11400, 11401, 11402, 11403, 11404, 11406

Services rendered in the inpatient hospital setting will not be reimbursed to APRN providers.

11420, 11440, 11440, 11441, 11442, 11443, 11444, 11446

Services rendered in the outpatient hospital setting may be reimbursed to APRN providers.

11421, 11422 Services rendered in the outpatient hospital setting may be reimbursed to APRN providers.

11423, 11424 Services rendered in the inpatient hospital setting will not be reimbursed to APRN providers. Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to dentist providers.

17000, 17003, 17004, 17106, 17107, 17108

Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to podiatrist providers. Services rendered in the office setting may be reimbursed to APRN providers.

17110, 17111 Services rendered in the office setting may be reimbursed to APRN and podiatrist providers. Services rendered in the outpatient hospital setting may be reimbursed to APRN, podiatrist, and ASC providers. Services rendered in the inpatient hospital setting may be reimbursed to podiatrist providers.

17311, 17312, 17313, 17314, 21930, 22900, 23075, 25075, 26115, 27047, 27327, 67710, 67715, 67880, 67882

Services rendered in the inpatient hospital or outpatient hospital setting will not be reimbursed to APRN providers.

19368, 19369 Services rendered in the outpatient hospital setting will not be reimbursed.

21740 Services rendered in the outpatient hospital setting will not be reimbursed. Services rendered in the inpatient hospital setting will not be reimbursed to APRN providers.

Procedure Code Changes 24075 Services rendered in the office, inpatient hospital, or

outpatient hospital setting will not be reimbursed to APRN providers.

27618, 28043, 28313 Services rendered in the office, inpatient hospital, or outpatient hospital setting may be reimbursed to podiatrist providers. Services rendered in the inpatient hospital or outpatient hospital setting will not be reimbursed to APRN providers.

67950 Services rendered in the office setting will not be reimbursed to APRN providers.

15786 Services rendered in the office or outpatient hospital setting may be reimbursed to APRN providers.

15787 Services rendered in the inpatient hospital setting will not be reimbursed. Services rendered in the office or outpatient hospital setting may be reimbursed to APRN providers.

Changes to Assistant Surgery Component

The following changes will be applied to the assistant surgery component of the procedure codes indicated:

Procedure Code Restrictions 19318, 19340, 19357, 19361, 19364, 19367, S2068

Services rendered in the inpatient hospital or outpatient hospital setting may be reimbursed to APRN providers.

21740 Services rendered in the outpatient hospital setting will not be reimbursed.

19368, 19369 Services rendered in the inpatient hospital setting may be reimbursed to APRN providers. Services rendered in the outpatient hospital setting will not be reimbursed.

19342 Services will not be benefits of the CSHCN Services Program.

Changes to ASC Provider Reimbursement

The following procedure codes will not be reimbursed to ASC providers:

Procedure Codes 19361 19364 19367 19368 19369

Noncovered Services The following cosmetic procedures are not a benefit of the CSHCN Services Program:

• Rhytidectomies

• Excisions of excessive skin and subcutaneous tissue (includes lipectomy)

• Suction assisted lipectomies

• Cryotherapy for acne

• Chemical exfoliation

• Electrolysis epilation

For more information, call the TMHP-CSHCN Services Program Contact Center at 1-800-568-2413.