Read NC DMA: 1-O-2, Craniofacial Surgery text version

NC Division of Medical Assistance Craniofacial Surgery

Medicaid and Health Choice Clinical Coverage Policy No: 1-O-2 Revised Date: March 12, 2012

Table of Contents

1.0 2.0 Description of the Procedure, Product, or Service ........................................................................... 1 Eligible Recipients ........................................................................................................................... 1 2.1 General Provisions .............................................................................................................. 1 2.2 EPSDT Special Provision: Exception to Policy Limitations for Recipients under 21 Years of Age ................................................................................................................................. 1 2.3 Health Choice Special Provision: Exceptions to Policy Limitations for Health Choice Recipients ages 6 through 18 years of age .......................................................................... 2 When the Procedure, Product, or Service Is Covered ...................................................................... 3 3.1 General Criteria................................................................................................................... 3 3.2 Specific Criteria .................................................................................................................. 3 When the Procedure, Product, or Service Is Not Covered ............................................................... 4 4.1 General Criteria................................................................................................................... 4 4.2 Specific Non-Covered Criteria ........................................................................................... 4 4.3 NCHC Non-Covered Criteria ............................................................................................. 4 4.4 Medicaid Non-Covered Criteria ......................................................................................... 4 Requirements for and Limitations on Coverage .............................................................................. 4 5.1 Prior Approval .................................................................................................................... 4 5.2 Prior Approval Requirements ............................................................................................. 5 Providers Eligible to Bill for the Procedure, Product, or Service .................................................... 5 Additional Requirements ................................................................................................................. 5 7.1 Compliance ......................................................................................................................... 5 Policy Implementation/Revision Information .................................................................................. 6

3.0

4.0

5.0

6.0 7.0 8.0

Attachment A: Claims-Related Information ................................................................................................. 7 A. Claim Type ......................................................................................................................... 7 B. Diagnosis Codes ................................................................................................................. 7 C. Billing Code(s) .................................................................................................................... 7 D. Modifiers........................................................................................................................... 10 E. Billing Units...................................................................................................................... 10 F. Place of Service ................................................................................................................ 10 G. Co-payments ..................................................................................................................... 10 H. Reimbursement ................................................................................................................. 10

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NC Division of Medical Assistance Craniofacial Surgery

Medicaid and Health Choice Clinical Coverage Policy No: 1-O-2 Revised Date: March 12, 2012

1.0

Description of the Procedure, Product, or Service

Craniofacial surgery encompasses a broad spectrum of reconstructive procedures of the cranium and face. The objectives of these procedures are to correct deformities of the face and skull bones that result from birth defects, trauma, or disease and to restore craniofacial form and function by medical and surgical means. Some examples of conditions that may require craniofacial surgery are clefts of the lip and palate, craniosynotosis, hemifacial microsomia, microtia, Pierre Robin syndrome, Apert syndrome, and Crouzon syndrome.

2.0

Eligible Recipients

2.1 General Provisions

NC Medicaid (Medicaid) recipients shall be enrolled on the date of service and may have service restrictions due to their eligibility category that would make them ineligible for this service. NC Health Choice (NCHC) recipients, ages 6 through 18 years of age, shall be enrolled on the date of service to be eligible, and shall meet policy coverage criteria, unless otherwise specified.

2.2

EPSDT Special Provision: Exception to Policy Limitations for Recipients under 21 Years of Age

42 U.S.C. § 1396d(r) [1905(r) of the Social Security Act] Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid requirement that requires the state Medicaid agency to cover services, products, or procedures for Medicaid recipients under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination** (includes any evaluation by a physician or other licensed clinician). This means EPSDT covers most of the medical or remedial care a child needs to improve or maintain his/her health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. Medically necessary services will be provided in the most economic mode, as long as the treatment made available is similarly efficacious to the service requested by the recipient's physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the recipient's right to a free choice of providers.

CPT codes, descriptors, and other data only are copyright 2011 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. 06.08.2012 1

NC Division of Medical Assistance Craniofacial Surgery

Medicaid and Health Choice Clinical Coverage Policy No: 1-0-2 Revised Date: March 12, 2012

EPSDT does not require the state Medicaid agency to provide any service, product, or procedure a. that is unsafe, ineffective, or experimental/investigational. b. that is not medical in nature or not generally recognized as an accepted method of medical practice or treatment. Service limitations on scope, amount, duration, frequency, location of service, and/or other specific criteria described in clinical coverage policies may be exceeded or may not apply as long as the provider's documentation shows that the requested service is medically necessary "to correct or ameliorate a defect, physical or mental illness, or a condition" [health problem]; that is, provider documentation shows how the service, product, or procedure meets all EPSDT criteria, including to correct or improve or maintain the recipient's health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. **EPSDT and Prior Approval Requirements a. If the service, product, or procedure requires prior approval, the fact that the recipient is under 21 years of age does NOT eliminate the requirement for prior approval. b. IMPORTANT ADDITIONAL INFORMATION about EPSDT and prior approval is found in the Basic Medicaid and NC Health Choice Billing Guide, sections 2 and 6, and on the EPSDT provider page. The Web addresses are specified below. Basic Medicaid and NC Health Choice Billing Guide: http://www.ncdhhs.gov/dma/basicmed/ EPSDT provider page: http://www.ncdhhs.gov/dma/epsdt/

2.3

Health Choice Special Provision: Exceptions to Policy Limitations for Health Choice Recipients ages 6 through 18 years of age

EPSDT does not apply to NCHC recipients. If a NCHC recipient does not meet the clinical coverage criteria within Section 3.0 of the clinical coverage policy, the NCHC recipient shall be denied services. Only services included under the Health Choice State Plan and the DMA clinical coverage policies, service definitions, or billing codes shall be covered for NCHC recipients.

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NC Division of Medical Assistance Craniofacial Surgery

Medicaid and Health Choice Clinical Coverage Policy No: 1-0-2 Revised Date: March 12, 2012

3.0

When the Procedure, Product, or Service Is Covered

Note: Refer to Subsection 2.2 regarding EPSDT Exception to Policy Limitations for Medicaid Recipients under 21 Years of Age.

3.1

General Criteria

Procedures, products, and services related to this policy are covered when they are medically necessary and a. the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the recipient's needs; b. the procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; and c. the procedure, product, or service is furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider.

3.2

Specific Criteria

a. For craniofacial surgery, "medical necessity" is defined as the reason the procedure is needed to raise a recipient to his or her optimal functioning level or, specific to children, to correct or ameliorate significant congenital craniofacial deformities. The need for surgery must arise from an injury, disease, birth defect, or growth and development that resulted in significant functional impairment. "Significant functional impairment" may include, but is not limited to 1. Problems with communication. 2. Problems with respiration. 3. Problems with eating. 4. Problems with swallowing. 5. Visual impairments. 6. Distortion of nearby body parts. 7. Obstruction of an orifice. Orthognathic surgery prior to craniofacial surgery is provided for persistent difficulties with mastication and swallowing, jaw posturing, temporomandibular joint problems, and malocclusion needing skeletal correction.

b.

c.

Refer to Attachment A, Claims-Related Information, for procedure codes that require prior approval.

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NC Division of Medical Assistance Craniofacial Surgery

Medicaid and Health Choice Clinical Coverage Policy No: 1-0-2 Revised Date: March 12, 2012

4.0

When the Procedure, Product, or Service Is Not Covered

Note: Refer to Subsection 2.2 regarding EPSDT Exception to Policy Limitations for Medicaid Recipients under 21 Years of Age.

4.1

General Criteria

Procedures, products, and services related to this policy are not covered when a. the recipient does not meet the eligibility requirements listed in Section 2.0; b. the recipient does not meet the medical necessity criteria listed in Section 3.0; c. the procedure, product, or service unnecessarily duplicates another provider's procedure, product, or service; or d. the procedure, product, or service is experimental, investigational, or part of a clinical trial.

4.2

Specific Non-Covered Criteria

Craniofacial surgery is not covered when it is performed for cosmetic reasons, rather than primarily to restore impairment or correct deformity in children, caused by injury, disease, birth defects, or growth and development.

4.3

NCHC Non-Covered Criteria

Except as otherwise provided for eligibility, fees, deductibles, copayments, and other cost sharing charges, health benefits coverage provided to children eligible under the Health Choice program shall be equivalent to coverage provided for dependents under the NC Medicaid Program except for the following: a. no services for long-term care; b. no non-emergency medical transportation; c. no EPSDT; and d. dental services shall be provided on a restricted basis.

4.4

Medicaid Non-Covered Criteria

No additional non-covered criteria.

5.0

Requirements for and Limitations on Coverage

Note: Refer to Subsection 2.2 regarding EPSDT Exception to Policy Limitations for Medicaid Recipients under 21 Years of Age.

5.1

Prior Approval

Prior approval is required for Medicaid and NCHC recipients for most procedures or related components of reconstruction. Specific procedures may require additional medical record documentation for prior approval.

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NC Division of Medical Assistance Craniofacial Surgery

Medicaid and Health Choice Clinical Coverage Policy No: 1-0-2 Revised Date: March 12, 2012

5.2

Prior Approval Requirements

The provider(s) shall submit to DMA's designee the following: a. the prior approval request; b. all health care records and any other records that support the recipient has met the specific criteria in Subsection 3.2 of this policy; and c. if the Medicaid recipient is under 21 years of age, information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available. The following information shall be submitted with each prior approval request: a. The location and cause of the defect. b. Pre-operative photographs. c. CPT codes describing the procedures to be performed. d. Supporting documentation that the treatment can reasonably be expected to improve the impairment.

6.0

Providers Eligible to Bill for the Procedure, Product, or Service

To be eligible to bill for procedures, products, and services related to this policy, providers shall a. meet Medicaid or NCHC qualifications for participation; b. be currently Medicaid - enrolled; and c. bill only for procedures, products, and services that are within the scope of their clinical practice, as defined by the appropriate licensing entity

7.0

Additional Requirements

Note: Refer to Subsection 2.2 regarding EPSDT Exception to Policy Limitations for Medicaid Recipients under 21 Years of Age.

7.1

Compliance

Providers shall comply with all applicable federal, state, and local laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA) and record retention requirements. Copies of records must be furnished upon request. The Health Insurance Portability and Accountability Act (HIPAA) does not prohibit the release of records to Medicaid (45 CFR 164.502).

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NC Division of Medical Assistance Craniofacial Surgery

Medicaid and Health Choice Clinical Coverage Policy No: 1-0-2 Revised Date: March 12, 2012

8.0

Policy Implementation/Revision Information

Original Effective Date: August 1, 1977 Revision Information: Date 7/1/2010 Section Revised Throughout Change Session Law 2009-451, Section 10.31(a) Transition of NC Health Choice Program administrative oversight from the State Health Plan to the Division of Medical Assistance (DMA) in the NC Department of Health and Human Services. To be equivalent where applicable to NC DMA's Clinical Coverage Policy # 1O-2 under Session Law 2011-145, § 10.41.(b) Removed non-covered codes 21076-21088 from policy. Technical changes to merge Medicaid and NCHC current coverage into one policy.

3/1/2012

Throughout

3/12/2012 3/12/2012

Throughout Throughout

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NC Division of Medical Assistance Craniofacial Surgery

Medicaid and Health Choice Clinical Coverage Policy No: 1-0-2 Revised Date: March 12, 2012

Attachment A: Claims-Related Information

Reimbursement requires compliance with all Medicaid or NCHC guidelines, including obtaining appropriate referrals for recipients enrolled in the Medicaid and NCHC managed care programs.

A. B.

Claim Type

Professional (CMS-1500/837P transaction)

Diagnosis Codes

Providers shall bill the ICD-9-CM diagnosis codes(s) to the highest level of specificity that supports medical necessity.

C.

Billing Code(s)

Providers are required to select the most specific billing code that accurately describes the service(s) provided. Procedure codes requiring prior approval (this list may not be all inclusive): CPT Code 21120 21121 21122 21123 21125 21127 21137 21138 21139 21141 21142 21143 21145 Description Genioplasty; augmentation (autograft, allograft, prosthetic material) Genioplasty; augmentation sliding osteotomy single Genioplasty; augmentation 2 or more osteotomies Genioplasty; sliding augmentation with interpositional bone grafts (includes obtaining autografts) Augmentation, mandibular body or angle; prosthetic material. Augmentation, mandibular body or angle; prosthetic material. With bone graft (includes obtaining autograft) Reduction forehead; contouring only Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) Reduction forehead; contouring and setback of anterior frontal sinus wall Reconstruction midface, LeFort I; single piece segment movement in any direction (eg, for Long Face Syndrome), without bone graft Reconstruction midface, LeFort I; two pieces, segment movement in any direction (eg, for Long Face Syndrome), without bone graft Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction (eg, for Long Face Syndrome), without bone graft Reconstruction midface, LeFort I; single piece segment movement in any direction (eg, for Long Face Syndrome), requiring bone grafts(includes obtaining autograft) Reconstruction midface, LeFort I; two pieces, segment movement in any direction (eg, for Long Face Syndrome), requiring bone grafts(includes obtaining autograft) (eg, ungrafted unilateral alveolar cleft)

21146

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NC Division of Medical Assistance Craniofacial Surgery

Medicaid and Health Choice Clinical Coverage Policy No: 1-0-2 Revised Date: March 12, 2012

CPT Code 21147

Description Reconstruction midface, LeFort I; three or more pieces, segment movement in any direction (eg, for Long Face Syndrome), requiring bone grafts(includes obtaining autograft) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome) Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome) any direction, requiring bone grafts (includes obtaining autografts) Reconstruction midface, LeFort III; (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I Reconstruction midface, LeFort III; (extra and intracranial) with forehead advancement (eg, mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I Reconstruction of mandibular rami, horizontal, vertical, C, or L ostomy; without bone graft Reconstruction of mandibular rami, horizontal, vertical, C, or L ostomy; with bone graft (includes obtaining graft) Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation Osteotomy, mandible, segmental; Osteotomy, mandible, segmental; with genioglossus advancement Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) Osteoplasty, facial bones; augmentation, reduction Graft, bone; nasal, maxillary or malar areas; (includes obtaining graft) Mandible (includes obtaining graft) Graft; rib cartilage, autogenous, to face, chin, nose or ear; (includes obtaining graft) Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone plate) Reconstruction of mandible or maxilla, subperiosteal implant; partial Reconstruction of mandible or maxilla, subperiosteal implant; complete Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (eg, for hemifacial microsomia) Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) Reconstruction of orbit with osteotomies and with bone grafts (includes obtaining autografts) (eg, micro-ophthalmia) Periorbital osteotomies for orbital hypertelorism with bone grafts; extracranial approach Periorbital osteotomies for orbital hypertelorism with bone grafts; combined intra- and extracranial approach

21150 21151 21159

21160

21193 21194 21195 21196 21198 21199 21206 21208 21209 21210 21215 21230 21244 21245 21246 21247 21255 21256 21260 21261

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NC Division of Medical Assistance Craniofacial Surgery

Medicaid and Health Choice Clinical Coverage Policy No: 1-0-2 Revised Date: March 12, 2012

CPT Code 21263 21267 21268 21270 21275 21295 21296

Description Periorbital osteotomies for orbital hypertelorism with bone grafts; extracranial approach with forehead advancement Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts extracranial approach Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts combined intra- and extracranial approach Malar augmentation, prosthetic material Secondary revision of orbitocraniofacial reconstruction Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); extraoral approach Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); intraoral approach

The following CPT codes no longer require prior approval: CPT Code 21172 21175 Description Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) Reconstruction, bifrontal, superior-laterial orbital rims & lower forehead, advancement or alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or prosthetic material) Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft (includes obtaining grafts) Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), extracranial Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cm Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 40 sq cm but less than 80 sq cm Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 80 sq cm Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) Medial canthopexy (separate procedure) Lateral canthopexy

21179 21180 21181 21182

21183

21184

21188 21235 21280 21282

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NC Division of Medical Assistance Craniofacial Surgery

Medicaid and Health Choice Clinical Coverage Policy No: 1-0-2 Revised Date: March 12, 2012

D. E.

Modifiers

Providers shall follow applicable modifier guidelines.

Billing Units

The provider shall report the appropriate procedure code(s) used which determines the billing unit(s).

F. G.

Place of Service

Inpatient hospital, Outpatient hospital, Ambulatory surgery center, Office, Clinic.

Co-payments

Co-payment(s) may apply to covered services, procedures, prescription drugs and over-the-counter drugs.

H.

Reimbursement

Providers shall bill their usual and customary charges. For a schedule of rates, see: http://www.ncdhhs.gov/dma/fee/.

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NC DMA: 1-O-2, Craniofacial Surgery

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