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  • Ask the Expert CPT Coding Updates Coding Competency

    First Coast and Novitas Introduce New Category III Code Documentation Requirements


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    In January 2024 newsletters, First Coast and Novitas introduced a new process for submitting claims that includes certain category III code services. Effective Feb. 26 claims submitted without the following supporting documentation will be rejected:
    • History and physical examination
    • Lab/diagnostic test results, if applicable
    • Progress or office notes for the service performed
    • Operative or procedure report, if applicable
    • Full text of peer-reviewed articles
    • Society guidelines
    • Any additional documentation that supports the need for the service
    To include supporting documentation, billers will need to follow Medicare administrative contractor (MAC) steps for submitting unsolicited paperwork. 
    1. First submit an electronic claim with the appropriate paperwork indicator, reported as PWK, in loop 2300 of the 837 professional and institutional claim (item 19 of the Centers for Medicare & Medicaid Services 1500 form). PWK indicators are comprised of multiple codes that indicate the type of medical documentation that is being sent, method it will be transmitted, and an attachment control number (ACN) that matches the ACN on the coversheet accompanying the documentation.
    2. After the electronic claim has been accepted, submitters can accurately enter data on the fax/mail cover sheet as indicated in the PWK segment on the electronic claim. First Coast and Novitas provide their own cover sheets and instructions to submit medical documentation.

      Submitters must then send all relevant PWK data in one transmission within the designated timeframe (seven days or 10 business days). 

    Both MACs state they anticipate this to be a temporary situation. Visit each MAC’s website frequently for updated information.

    The affected category III codes (e.g., T codes) include but are not limited to:

    0253T Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoroidal space
    0333T  Visual evoked potential, screening of visual acuity, automated, with report
    0402T Collagen cross-linking of cornea, including removal of the corneal epithelium, when performed, and intraoperative pachymetry, when performed
    0444T Initial placement of a drug-eluting ocular insert under one or more eyelids, including fitting, training, and insertion, unilateral or bilateral
    0445T Subsequent placement of a drug-eluting ocular insert under one or more eyelids, including re-training, and removal of existing insert, unilateral or bilateral
    0450T Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; each additional device (List separately in addition to code for primary procedure)
    0469T Retinal polarization scan, ocular screening with on-site automated results, bilateral
    0474T Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space
    0506T Macular pigment optical density measurement by heterochromatic flicker photometry, unilateral or bilateral, with interpretation and report
    0509T  Electroretinography (ERG) with interpretation and report, pattern (PERG)
    0621T Laser incision of drainage tissue within eye (trabecular meshwork)
    0622T Laser incision of drainage tissue within eye (trabecular meshwork) using ocular endoscope
    0660T Implantation of drug-releasing device in front chamber of eye
    0661T Removal and reimplantation of drug-releasing device in front chamber of eye
    0687T Device supply, educational set-up, and initial session for online digital treatment of amblyopia
    0688T Assessment of patient performance and program data for online digital treatment of amblyopia by healthcare professional with report, per calendar month
    0704T Device supply, initial set-up, and patient education for remote treatment of amblyopia using eye tracking device
    0706T Health care professional interpretation and report of remote treatment of amblyopia using eye tracking device, per 30 days
    0730T Laser incision of drainage tissue within eye (trabeculotomy) using optical coherence tomography (OCT) guidance
    0810T Subretinal injection of a pharmacologic agent, including vitrectomy and 1 or more retinotomies