reimbursement resource guide pdf - cymedica orthopedics...own coding and reimbursement policies....

ReimbursementResourceGuide

CyMedica QB1®

Introducing e-vive™

Medicare Reimbursement (Part B Only)

Sample CMS-1500 Claim Form Commercial PayersSample CMS-1500 Claim Form Medicare

QB1 & e-vive Physician’s Written Order Example

ICD-10 Diagnosis Codes (Secondary)

Physician’s Prescribing Guide

2

4

9

11

5

6

10

7

3

12

13

14

8

CPT/HCPCS ModifiersICD-10 Diagnosis Codes (Primary)Coverage

Prior-Authorization ProcessCommercial PayersMedicare

Table of Contents

IntroductionReimbursement ResourceConductive Garment (E0731)

Accepted HCPCs with descriptionsNMES Device (E0745)Post-op Ajustable Knee Joints (L1833)Electrodes and Supplies (A4595)

Sample Letter of Medical Necessity

Advanced Beneficiary Notice of Noncoverage (ABN)

Introducing

Medicare BillingMedicare Documentation RequiredCommercial Billing/Reimbursement

The e-vive™ app gives patients complete control over their NMES therapy for simplified operation on virtually any smart device. Key data points are collected and sent to the cloud where providers can track patients' rehabilitation progress and engage with them remotely.

The e-vive™ App

The e-vive™ system consists of three components:

The e-vive™ conductive garment with built-in sensor technology, transmits range of motion data and steps, while precisely positioning the electrodes in place on the quadriceps.

The e-vive™ Conductive Garment

The CyMotion™ NMES controller uses our proprietary CyMotion™ Technology to monitor and control the power delivered to the muscle for maximum comfort and

The CyMotion™ Controller

PRECISELY POSITIONED ELECTRODES

INTUITIVE APP INTERFACE

2

1

3

4

5

2

INTRODUCTION

CyMedica Orthopedics®, Inc. provides

coding information based on publicly

available information as a convenience to

our customers. CyMedica Orthopedics®,

Inc. products that have been assigned

HCPCS codes by Medicare through the

coding verification process are included

in this guide. The assigned codes are the

required billing codes for these particular

products. For all other products, it is within

the sole discretion of the provider to

determine the appropriate billing code, as

well as whether the use of a product

complies with medical necessity standards

and meets all documentation requirements

of the payer.

All codes supplied in this guide are for

information purposes only and represent

no statement or guarantee by CyMedica

Orthopedics®, Inc. that these codes will be

appropriate for every patient or payer, or

that reimbursement will be made in a

particular situation. It is always the provider’s

responsibility to determine and submit

appropriate codes, charges, and modifiers

for products and services that are

rendered. All coding and reimbursement

information is subject to change without

notice, and specific payers may have their

own coding and reimbursement policies.

Before filing any claims, providers should

verify current requirements and policies

with the payer.

CyMedica Orthopedics®, Inc.(844) 296-2014

19120 N Pima Rd #135, Scottsdale, AZ 85255www.cymedicaortho.com

[email protected]

Reimbursement Resource

The patient has a medical need for rehabilitation strengthening (pursuant to a written plan of rehabilitation) following an injury where the nerve supply to the muscle is intact.

Conductive Garment (E0731)

PRECISELYPOSITIONED

ELECTRODES

INSIDE VIEW

3

Accepted (HCPCs) Healthcare Common Procedure Codes and Descriptions

A4595

L1833

E0745

E0731

Knee Orthosis, Ajustable Knee Joints ( see comment below)

Neuromuscular Stimulator, Electronic Shock Unit

Form fitting conductive garment for delivery of TENS or NMES(with conductive fibers separated from the patient’s skin by layers of fabric)

Electrodes and supplies

1 1

1Coverage of NMES to treat muscle atrophy is limited to

the treatment of disuse atrophy where nerve supply to

the muscle is intact, including brain, spinal cord and

peripheral nerves, and other non-neurological reasons

for disuse atrophy. Some examples would be casting or

splinting of a limb, contracture due to scarring of soft

tissue as in burn lesions, and hip replacement surgery

(until orthotic training begins).

NMES Device (E0745)

Electrodes & Supplies (A4595)

Knee instability must be documented by examination of

the beneficiary and objective description of joint laxity.

Claims for L1833 will be denied as not reasonable and

necessary when the beneficiary does not meet the

above criteria for coverage. For example, they will be

denied if only pain or a subjective description of joint

instability is documented.

Post-Op Ajustable Knee Joints (L1833)

4

CyMedica QB1™ and e-vive™

Post-op brace shown with

e-vive™ Conductive Garment

NU

RR

LT

RT

KH

KI

KJ

KX

New Equipment (DME)

Rental (use when DME is a rental)

Left

Right

DMEPOS item, initial claim, purchase or first month rental

DMEPOS item, second or third month rental

DMEPOST item, parenteral enteral nutrition (PEN) pump or capped rental, months 4- 15. When using the KJ modifier, you are indication you are billing months 4 - 13/15 of a capped rental peroid.

Patient fulfills medical criteria. Documentation on file.

5

CPT/HCPCS Modifiers

CPT/HCPCS Modifiers:

M62.551

M62.552

Muscle wasting and atrophy, not elsewhere classified, RIGHT thigh

Muscle wasting and atrophy, not elsewhere classified, LEFT thigh

While it may not be necessary, a payer prior-authorization

may be assessed by the provider. Ensuring payment

eligibility and allowable amounts is recommended prior to

billing.

Coverage:

Please see list of possible ICD-10 diagnosis codes that

may be appropriate for purposes of CyMedica’s QB1 or

e-vive devices. The following list is not meant to be taken

as written instruction of what to code but rather as

reference material to give a visual of what codes have

been used to justify the use of the QB1 and e-vive DME

products.

ICD-10 Diagnosis Codes:

Primary ICD-10 Codes - MUSCLE WEAKNESS / ATROPHY

Modifiers are used when billing to give more information about the procedure being performed. Modifiers give

about acceptable CPT/HCPCS codes and modifier combinations please consult a certified coder or any resources you have access to. Below are a list of common CPT/HCPCS modifiers that are used.

PRIMARY CODESKnee instability must be documented by examination of the beneficiary and objective description of joint laxity. Claims for L1833 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented.

6

International Classification of Diseases Secondary Codes

M17.0

M17.10

M17.11

M17.12

M17.2

M17.30

M17.31

M17.32

M17.4

M17.5

M17.9

Bilateral primary osteoarthritis of knee

Unilateral primary osteoarthritis, unspecified knee

Unilateral primary osteoarthritis, RIGHT knee

Unilateral primary osteoarthritis, LEFT knee

Bilateral post-traumatic osteoarthritis of knee

Unilateral post-traumatic osteoarthritis of knee

Unilateral post-traumatic osteoarthritis, RIGHT knee

Unilateral post-traumatic osteoarthritis, LEFT knee

Other bilateral secondary osteoarthritis of knee

Other unilateral secondary osteoarthritis of knee

Osteoarthritis of knee, unspecified

Secondary ICD-10 Codes - OSTEOARTHRITIS

M23.611

M23.612

M23.621

M23.622

M23.641

M23.642

S83.219A

S83.249A

S83.289A

S83.209A

S83.30XA

S83.509A

RIGHT - Spontaneous Disruption of ACL

LEFT- Spontaneous Disruption of ACL

RIGHT - Spontaneous Disruption of MCL or PCL

LEFT - Spontaneous Disruption of MCL or PCL

RIGHT - Spontaneous Disruption of LCL

LEFT - Spontaneous Disruption of LCL

Bucket-handled tear or medial meniscus, current injury, unspecified knee, initial encounter.

Other tear of medial meniscus, current injury, unspecified knee, initial encounter.

Other tear of lateral meniscus, current injury, unspecified knee, initial encounter.

Unspecified tear of unspecified meniscus, current injury, unspecified knee, initial encounter.

Tear of articular cartilage of unspecified knee, current, initial encounter.

Sprain of unspecified cruciate ligament of unspecified knee, initial encounter.

Secondary ICD-10 Codes - ACL / PCL / MCL / LCL / MENISCUS SURGERY

MEDICARE

7

Prior-Authorization Process: Commercial PayersPrior-authorization may need to be obtained when a patient has been identified that is a viable candidate for the CyMedica QB1 or e-vive™ product. Prior-authorizations vary from payer to payer however, the following should be done consistently to ensure uniformity with your process internally.

®

Call the payer’s prior-authorization number. This is usually listed on the members ID card or can be found online on the payer’s website.

Review the Diagnosis codes and procedure codes with the representative for coverage options and if prior authorization is needed. Be sure to note the representative’s name or extension for future reference should it be needed.

Should prior-authorization be needed, gather the Letter of Medical Necessity (LOMN), progress notes, physician’s notes, medical records pertinent to the procedure, any and all other treatment notes or findings justifying the use of the procedure being prior-authorized.

1

2

3

There is not a formal prior-authorization process with Medicare. However, to be compliant with rules and guidelines it is recommended that the patient be presented with an Advanced Beneficiary Notice (ABN) prior to any service being rendered. The ABN informs the patient of the cost of the product should Medicare deny the claim and they are responsible for the price of the product. See ABN form on the adjacent page.

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.htmlTo Download an ABN form visit: (also available in Spanish)

A. Notifier:B. Patient Name: C. Identification Number:

Advance Beneficiary Notice of Noncoverage (ABN)NOTE: If Medicare doesn’t pay for D. below, you may have to pay.

Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. below.

D. E. Reason Medicare May Not Pay: F. Estimated Cost

WHAT YOU NEED TO DO NOW:• Read this notice, so you can make an informed decision about your care.• Ask us any questions that you may have after you finish reading.• Choose an option below about whether to receive the D. listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

G. OPTIONS: Check only one box. We cannot choose a box for you.□ OPTION 1. I want the D. listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays ordeductibles.□ OPTION 2. I want the D. listed above, but do not bill Medicare. You mayask to be paid now as I am responsible for payment. I cannot appeal if Medicare is notbilled.□ OPTION 3. I don’t want the D. listed above. I understand with this choice Iam not responsible for payment, and I cannot appeal to see if Medicare wouldpay.

H. Additional Information:

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).Signing below means that you have received and understand this notice. You also receive a copy.

I. Signature: J. Date:

CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: [email protected].

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (Exp. 03/2020) Form Approved OMB No. 0938-0566

9

Reimbursement amount(s) vary by state and whether or not the patient lives in a Rural (R) or Non-Rural (NR) area.

The first three months of rental are reimbursed at 100% of the current Medicare fee schedule (F/S); the subsequent 10 months of rental are reimbursed at 75% of the current F/S.

Medicare pays 80% of the F/S amount; the patient is responsible for the remaining 20%.

Other than conductive garment, ongoing supplies for use of the device during the rental period are included in the rental rate(s).

NMES is not a competitively bid item.

The CyMedica NMES Device - E0745

Reimbursement amounts vary by state and whether or not the patient lives in a Rural (R) or Non-Rural (NR) area. Medicare pays 80% of the F/S amount; the patient is responsible for the remaining 20%. The conductive garment is considered a competitively bid item, only when utilized with a TENS device.

Other than conductive garment, ongoing supplies for use of the device during the rental period are included in the rental rate(s).

The CyMedica Conductive Garment - E0731

Electrodes & Supplies - A4595

Medicare Reimbursement - PART B (only)

The NMES device (E0745) is deemed a “Capped Rental” item. After 13 monthsof rental, the device is considered purchased.

The CyMedica Conductive Garment (E0731) is only deemed a “purchase only” item.

10

Medicare Billing

NMES Device Monthly Rental Conductive Garment RateSpecific modifiers are required for each month of

rental to ensure accurate reimbursement. The NMES

Device rental is billed with modifer “RR.”

The garment is considered a purchase item only. The standard modifier is “NU.” An additional modifier is required to identify the item when utilized with a “competitively bid” product.

NMES (Month 1)

NMES (Month 2-3)

NMES (Month 4-13)

Conductive Garment

E0745

E0745

E0745

E0731

RR KH RT

RR KI RT

RR KJ RT

NU KX

HCPCS Medicare Billing EXAMPLE

ITEM DESCRIPTION HCPC Modifier(s)

Medicare requires that the supplier has documentation on file to support medical necessity, prior to dispense and invoicing. In general, documentation includes, but is not limited to:

Medicare Documentation Required

Commercial Billing/Reimbursement

Physician order and medical records

Medical records from a treating physical therapist

Medical records supporting surgery/discharge

Specific to NMES, the patient must have disuse atrophy (Diagnosis=M62.551 or M62.552) at the time of dispense. The physician’s record must support that the item is being prescribed for the treatment of disuse atrophy where the nerve supply to the muscle is intact.

When prescribing the conductive garment, the physician’s records must support that he/she is ordering the item because the patient has a medical need for rehabilitation strengthening pursuant to a written plan of rehabilitation, following an injury where the nerve supply to the muscle is intact.commercial payer provider

Commercial payers often pay for the rental of the garment and device. However, it is possible to negotiate a purchase price for the garment (E0731) and NMES device (E0745). Please consult your commercial payer provider relations and/or contracting representative to initiate the conversation of purchase prices if applicable.

Letter of Medical Necessity (see example on page 9)

A letter of Medical necessity should be submitted with the claim to ensure that medical necessity is met. Page 11 has an example of the format for a Letter of Medical Necessity (LOMN).

11

Sample Letter of Medical Necessity:

Date:Re: Patient Name Insurance Company:Claim Number:

To Whom It May Concern:

I am writing on behalf of my patient, (insert patient name), to document the medical necessity of (CyMedica QB1® or e-vive™) (choose one) Powered Muscle Stimulator System (NMES) This letter provides information about the patient’s diagnosis and a statement summarizing my treatment rationale.

Patient’s Diagnosis: (Patient name) presents with Disuse Atrophy of the quadriceps muscle post (surgery/injury/physical therapy/medications) (pick one or multiple). (Also include the patient’s history related to their condition, ((715.16 Osteoarthrosis localized primary leg, 719.46 Pain in joint lower leg, 836.0 Tear of Medial Cartilage or meniscus, other)). Examination shows the nerve supply to the muscle is intact.

Treatment Rationale:

strength and reactivate trophic action of muscle fibers. The NMES Controller and Conductive Garment are medically necessary because there is a large surface area to be treated, so many treatment sites and the stimulation will be delivered so frequently that the use of conventional electrodes is not feasible.

Equipment: CyMedica QB1® (QB-1000) or e-vive™ (CY-1000) (Pick one). Powered Muscle Stimulator (QB-1000 or CY-1000) (pick one) is manufactured by:

The CyMedica QB1® is a Class 2, 510(K) FDA cleared device (510(k) # K150413). The CyMedica e-vive™ is a Class 2, 510(K) FDA cleared device (510(k) #K163067). The principles of electrotherapy emulate the process observed during a voluntary muscle contraction. The (CyMedica QB1® or e-vive™) (pick one) System delivers stimulation based on the principles of NMES. NMES pulses stimulate motor points of target muscles, causing muscle contraction. This can help re-educate and strengthen muscles following an injury or surgery. As an NMES device, indications are for the following conditions: Retardation or prevention of disuse atrophy Duration: The aforementioned equipment is medically necessary for an estimated period of (# months – not to exceed 12 months). Patient will treat with equipment (2 times / day for 20 minute sessions, 5 days/week)

Summary: CyMedica QB1® Powered Muscle Stimulator System (QB-1000 – NMES, Conductive Garment, Brace) or e-vive™ Powered Muscle Stimulator System (CY-1000-NMES, Conductive Garment, Brace) (pick one) is medically necessary for this patient’s medical condition.

Please contact me if any additional information is required to ensure prompt approval.

Sincerely,Physician’s name Physicians Address Physician Phone #Physician NPISign and date the letter.

CyMedica Orthopedics®, Inc.19120 N Pima Rd. Suite 135

Scottsdale, AZ 85255Telephone: (480) 664-1282

12

Sample CMS-1500 Claim Form for Commercial Payers and Medicare

When submitting claims for use of CyMedica’s QB1 or e-vive device the following should be noted to ensure accurate and correct payment from payer.

a. b.

33. BILLING PROVIDER INFO & PHONE# ( )32. SERVICE FACILITY LOCATION INFORMATION

a. b.

31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS

(I certify that the statements on the reverseapply to this bill and are made a part thereof.)

SIGNED DATE

30. Rsvd. for NUCC Use

$

29. AMOUNT PAID28. TOTAL CHARGE

$

27. ACCEPT ASSIGNMENT?(For govt. claims, see back)

YES NO

26. PATIENT’S ACCOUNT NO.25. FEDERAL TAX I.D. NUMBER SSN EIN

J.

RENDERINGPROVIDER ID. #

I.

ID.QUAL.

H.EPSDTFamilyPlan

G.DAYS

ORUNITS

F.

$CHARGES

D. PROCEDURES, SERVICES, OR SUPPLIESBox 24D (Explain Unusual Circumstances)CPT/HCPCS MODIFIER

C.

EMG

B.PLACE OFSERVICE

24. A. DATE(S) OF SERVICEFrom To

MM DD YY MM DD YY

23. PRIOR AUTHORIZATION NUMBER

ORIGINAL REF. NO.22. RESUBMISSION CODE21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E)

D. ________________

H. ________________

L. ________________

A. ________________

E. ________________

I. ________________

B. ________________

F. ________________

J. ________________

C. ________________

G. ________________

K. ________________

ICD Ind.M62.551

YES NO

20. OUTSIDE LAB? $CHARGES19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC)

MM DD YYMM DD YYFROM TO

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

17b. NPI


16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATIONMM DD YY

QUAL.

15. OTHER DATEMM DD YY

14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP)

QUAL.

SIGNED____________________________________________________

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below.

12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below.

SIGNED_______________________________________________________ DATE_____________________________

READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.

YES NO If yes, complete items 9, 9a, and 9d.

c. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN?

YES NO

c. RESERVED FOR NUCC USE c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME

YES NO

b. RESERVED FOR NUCC USE b. AUTO ACCIDENT? PLACE (State) b. OTHER CLAIM ID (Designated by NUCC)

MM DD YYM F

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

YES NO

11. INSURED’S POLICY GROUP OR FECA NUMBER10. PATIENT’S CONDITION RELATED TO:9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial)

8. RESERVED FOR NUCC USE CITY STATE

7. INSURED’S ADDRESS (No., Street)

ZIP CODE TELEPHONE (Include Area Code)

( )

6. PATIENT RELATIONSHIP TO INSURED

Self Spouse Child Other

CITY STATE

5. PATIENT’S ADDRESS (No., Street)


( )

4. INSURED’S NAME (Last Name, First Name, Middle Initial)3. PATIENT’S BIRTH DATE SEX MM DD YY

M F

2. PATIENT’S NAME (Last Name, First Name, Middle Initial)

MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER HEALTH PLAN BLKLUNG (Medicare#) (Medicaid#) (ID#/DoD#) (Member ID#) (ID#) (ID#) (ID#)

1. 1a. INSURED’S I.D.NUMBER (For Program in Item 1)

PICA PICA

APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12

HEALTH INSURANCE CLAIM FORM

Box

21

L1833 RT

E0731 NU RT

E0745 NU RT

A

A

A

1

1

1

NPI

NPI

NPI

NPI

NPI

NPI

NPI NPI

1

2

3

4

5

6

PLEASE PRINT OR TYPENUCC Instruction Manual available at: www.nucc.org APPROVED OMB-0938-1197 FORM 1500 (02-12)

CA

RR

IER

PATI

ENT

AN

D IN

SUR

ED IN

FOR

MAT

ION

PHYS

ICIA

N O

R S

UPP

LIER

INFO

RM

ATIO

N

Box 24G DIAGNOSIS

POINTER

Box 24E

Commercial Payers: Medicare:

Box 21: Ensure that the appropriate ICD-10 diagnosiscode is noted. For example M62.551 (Muscle wasting andatrophy, not elsewhere classified, right thigh).

Box 24D: Enter the correct CPT/HCPCS code that is appropriate with the correct modifier (example L1833 RT).

Box 24E: Point the CPT/HCPCS code listed in 24D to the correct diagnosis listed in Box 21.

Box 24G: Enter the number of units (example “1”).

Box 21: Ensure that the appropriate ICD-10 diagnosiscode is noted. For example M62.551 (Muscle wasting andatrophy, not elsewhere classified, right thigh).

Box 24D: Enter the correct CPT/HCPCS code that is appropriate with the correct modifier (example L1833 RT). Please use modifiers in the following order for HCPC E0745:Rental “RR,” Month “KH, KI, or KJ,” and Laterality “LT/RT.” If using “KX” modifier: Rental “RR,” Month “KH, KI, or KJ,” Documentation on file “KX,” and Laterality “LT/RT.”

Box 24E: Point the CPT/HCPCS code listed in 24D to the correct diagnosis listed in Box 21.

Box 24G: Enter the number of units (example “1”).

a. b.


a. b.



SIGNED DATE

30. Rsvd. for NUCC Use

$


$


YES NO


J.

RENDERINGPROVIDER ID. #

I.

ID.QUAL.

H.EPSDTFamilyPlan

G.DAYS

ORUNITS

F.

$CHARGES


C.

EMG

B.PLACE OFSERVICE


MM DD YY MM DD YY


ORIGINAL REF. NO.22. RESUBMISSION CODE21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E)

D. ________________

H. ________________

L. ________________

A. ________________

E. ________________

I. ________________

B. ________________

F. ________________

J. ________________

C. ________________

G. ________________

K. ________________

ICD Ind.M62.551

YES NO



18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

17b. NPI


16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATIONMM DD YY

QUAL.



QUAL.

SIGNED____________________________________________________

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below.


SIGNED_______________________________________________________ DATE_____________________________




YES NO


YES NO


MM DD YYM F

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH SEX

YES NO


8. RESERVED FOR NUCC USE CITY STATE



( )



CITY STATE



( )

4. INSURED’S NAME (Last Name, First Name, Middle Initial)3. PATIENT’S BIRTH DATE SEX MM DD YY

M F




PICA PICA



Box

21

L1833 RT

E0731 NU RT

E0745 NU RT

A

A

A

1

1

1

NPI

NPI

NPI

NPI

NPI

NPI

NPI NPI

1

2

3

4

5

6


CA

RR

IER

PATI

ENT

AN

D IN

SUR

ED IN

FOR

MAT

ION

PHYS

ICIA

N O

R S

UPP

LIER

INFO

RM

ATIO

N

Box 24G DIAGNOSIS

POINTER

Box 24E

a. b.


a. b.



SIGNED DATE

$


$


YES NO


I.

ID.QUAL.

H.EPSDTFamilyPlan

G.DAYS

ORUNITS

F.

$CHARGES


C.

EMG

B.PLACE OFSERVICE


MM DD YY MM DD YY


ORIGINAL REF. NO22. RESUBMISSION CODE21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24E)

D. ________________

H. ________________

L. ________________

A. ________________

E. ________________

I. ________________

B. ________________

F. ________________

J. ________________

C. ________________

G. ________________

K. ________________

ICD Ind.M62.551

YES NO


MM DMM DD YYFROM TO

18. HOSPITALIZATION DATES RELATED TO CURREN17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a.

17b. NPI

MM DMM DD YYFROM TO

16. DATES PATIENT UNABLE TO WORK IN CURRENMM DD YY

QUAL.



QUAL.

SIGNED___________________________________________________

13. INSURED’S OR AUTHORIZED PERSON’S SIGN payment of medical benefits to the undersigned ph services described below.


SIGNED_______________________________________________________ DATE_____________________________




YES NO


YES NO


MM DD YYM F

a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH

YES NO


8. RESERVED FOR NUCC USE CITY


ZIP CODE TELEPHONE (Include

( )



CITY STATE



( )

4. INSURED’S NAME (Last Name, First Name, Middle3. PATIENT’S BIRTH DATE SEX MM DD YY

M F




PICA



Box

21

L1833 RT

E0731 NU KX RT

E0745 RR KH RT

A

A

A

1

1

1

NPI

NPI

NPI

NPI

NPI

NPI

NPI NPI

1

2

3

4

5

6


Box 24G DIAGNOSIS

POINTER

Box 24E

13

CyMedica QB1™ and e-vive™ Physician’s Written Order Example:

PATIENT INFORMATION: (Provide all information)Patient Name MI Last Name Date of Birth

PREVIOUS TREATMENT(S): (Check all that apply)

Surgery Physical Therapy Medications Other: _____________________________________________

MUST CHECK ONE BOX IN EACH SECTION (1 THRU 7) TO PRESCRIBE FOR DISUSE ATROPHY

PRODUCTS PRESCRIBED (check one is each section)

1. CyMedica QB1™ or e-vive™ Controller: (2 Chan NMES Controller - E0745)

2. CyMedica QB1™ or e-vive™ Conductive Garment: (E0731)

3. CyMedica QB1™ or e-vive™ Post Op ROM Brace (L1833) - Document Coverage Criterion in Medical Note

DIAGNOSIS CODES (complete both primary and secondary code sections)

4. Primary ICD-10 Code(s): (check appropriate box or boxes)

5. Secondary ICD-10 Codes(s): (reference coding guide on backside - including 7th Digit Extension for S Codes)

LENGTH OF NEED

6. Prescribed Length of Need: (check one)

JUSTIFICATION FOR CONDUCTIVE GARMENT

7. Justification: (check one)

1 Controller

Patient cannot manage without a conductive garment

because of the large surface area that has many sites to be

stimulated and the stimulation will be delivered so frequently

that the use of conventional electrodes is not feasible.

M62.551 Muscle atrophy, right thigh PT Height___________

M62.552 Muscle atrophy, left thigh Quad Circumference__________

List Code(s): __________ __________ __________

Post-Op ROM Brace

Left Garment OR Right Garment

99 - Lifetime OR # of months______ Start Date: ________________ Order Date: ________________

OR Other _________________________________

_______________________________________

_______________________________________

_______________________________________

I certify that I am the physician identified on this form and that I conducted the exam within 6 months of the date on this form. The above prescribed equipment is medically indicated and, in my opinion, is reasonable and necessary with reference to the accepted standards of medical practice and treatment of this patient’s condition and is not prescribed as “convenience” equipment. I certify that the Patient/Caregiver has successfully completed, or will be trained on, the proper us of products prescribed on this Written Order. The physician notes, product lists and other supporting documentation will be provided to CyMedica Orthopedics, LLC upon request. I ask that there be no equipment substitu-tions for the devices prescribed.

Physician’s Signature (Required)

Physician’s Printed Name (Required)

Date of Signature (Required; date stamps not acceptable)

NPI#: Phone:

Please make sure that the above information is documented in your patient’s chart notes - reference page 12.Please fax signed form to: Fax Number: 888-972-5783 14

CyMedica QB1™ and e-vive™ Physician’s Prescribing Guide

PATIENT’S CHART NOTES MUST STATE THE FOLLOWING FOR JUSTIFICATION OF CyMedica QB1™ and e-vive™

1. Disuse atrophy of quadriceps muscles2. Nerve supply to the muscle is intact

4. Large treatment area with multiple sites requires use o conductive garment.

A = Initial Encounter - Patient is actively receiving treatment (such as surgical treatment, evaluation and treatment by a new MD).D = Subsequent Encounter - Patient is in the recovery/aftercare phase (such as cast changes and removal, physical therapy & follow up visits).S = Sequelae

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M17.11

----------

----------

----------

M17.12

----------

----------

M17.0

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M17.9

M19.90

Bilateral primary osteoarthritis of knee

Unilateral primary osteoarthritis

Osteoarthritis, unspecified knee

Unspecified Osteoarthritis, unspecified site

Secondary ICD-10 Codes: (list below is not all-inclusive)

7th Digit Extension Letters Required for S Codes:

OSTEOARTHRITISDESCRIPTIONS FOR THE KNEE RIGHT LEFT UNSPECIFIED

583.31 X 583.32 X ----------Tear of Articular Cartilage

ARTICULAR CARTILAGEDESCRIPTIONS FOR THE KNEE RIGHT LEFT UNSPECIFIED

M25.561 M25.562 ----------Pain in knee

PAIN IN JOINT (Lower Leg)DESCRIPTIONS FOR THE KNEE RIGHT LEFT UNSPECIFIED

SECONDARY ICD-10 CODES

“X” REQUIRES 7TH DIGIT EXTENSION LETTER “A”, “D” or “S”

583.501 X

583.511 X

583.521 X

583.502 X

583.512 X

583.522 X

583.519 X

583.529 X

583.202 X

Sprain, Unspecified Cruciate Ligament

Sprain, Anterior Cruciate Ligament

Sprain, Posterior Cruciate Ligament

CRUCIATE LIGAMENTDESCRIPTIONS FOR THE KNEE RIGHT LEFT UNSPECIFIED

“X” REQUIRES 7TH DIGIT EXTENSION LETTER “A”, “D”, or “S”

MENISCUSDESCRIPTIONS FOR THE KNEE RIGHT LEFT UNSPECIFIED

“X” REQUIRES 7TH DIGIT EXTENSION LETTER “A”, “D”, or “S”

Bucket-Handle Tear, Unspecified Meniscus

Bucket-Handle Tear, Medial Meniscus

Bucket-Handle Tear, Lateral Meniscus

Peripheral Tear, Medial Meniscus

Peripheral Tear, Lateral Meniscus

Complex Tear, Medial Meniscus

Complex Tear, Lateral Meniscus

Other Tear, Unspecified Meniscus

Other Tear, Medial Meniscus

Other Tear, Lateral Meniscus

Unspecified Tear, Unspecified Meniscus

583.200 X

583.211 X

583.251 X

583.221 X

583.261 X

583.231 X

583.271 X

583.203 X

583.241 X

583.281 X

583.206 X

583.201 X

583.212 X

583.252 X

583.222 X

583.262 X

583.232 X

583.272 X

583.204 X

583.242 X

583.282 X

583.207 X

583.202 X

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583.259 X

583.229 X

583.269 X

583.239 X

583.279 X

583.205 X

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CyMedica Orthopedics, Inc.(844) 296-2014

19120 N. Pima Rd. #135, Scottsdale, AZ 85255www.cymedicaortho.com

Reimbursement Resource

References: 1. Policy Education. Documentation does not support coverage criteria. Noridian Healthcare Solutions website. https://med.noridianmedicare.com/web/jddme/cert-review/mr/re-view-results/ko-quarterly-results-of-tpe-review. Accessed September 19, 2018. DISCLAIMER: CyMedica’s Authorized Distributor and CyMedica have provided the information in this guide for educational purposes only. Laws, regulations, and policies can vary and are subject to change. Providers should exercise independent clinical judgment in determining that information for governmental and private payors is both current and accurate. CY-0065-015 Rev. A

The ONLY muscle

activation therapy

and patient provider

engagement

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reimbursement resource guide pdf - cymedica orthopedics...own coding and reimbursement policies....

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