Highmark Medicare Advantage Medical Policy in West Virginia
Section: CMS National Guidelines
Number: N-138
Topic: Microsurgery (See Reference Section)
Effective Date: July 27, 2009
Issued Date: March 29, 2010

General Policy

Microsurgical procedures are those procedures that require the use of a surgical microscope for microdissection or when the anatomical structures or pathology present is too small for normal visualization.

Indications and Limitations of Coverage

Code 69990 can be reimbursed separately only when billed with the following primary procedure codes:

61304-61546, 61550-61711, 62010-62100, 63081-63308, 63704-63710, 64831, 64834-64836, 64840-64858, 64861-64870, 64885-64898, 64905-64907

When code 69990 is reported with procedure codes other than those listed above, or if this code is reported independently, it is not covered and not billable. A provider cannot bill the member for the denied service.

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

613046130561312613136131461315
613166132061321613226132361330
613326133361334613406134361345
614406145061458614606147061480
614906150061501615106151261514
615166151761518615196152061521
615226152461526615306153161533
615346153561536615376153861539
615406154161542615436154461545
615466155061552615566155761558
615596156361564615666156761570
615716157561576615806158161582
615836158461585615866159061591
615926159561596615976159861600
616016160561606616076160861609
616106161161612616136161561616
616186161961623616246162661630
616356164061641616426168061682
616846168661690616926169761698
617006170261703617056170861710
617116201062100630816308263085
630866308763088630906309163101
631026310363170631726317363180
631826318563190631916319463195
631966319763198631996320063250
632516325263265632666326763268
632706327163272632736327563276
632776327863280632816328263283
632856328663287632906329563300
633016330263303633046330563306
633076330863704637066370763709
637106483164834648356483664840
648566485764858648616486264864
648656486664868648706488564886
648906489164892648936489564896
6489764898649056490769990 

Coding Guidelines

See “Indications and Limitations of Coverage.”

Publications

References

CMS Online Manual Pub. 100-4, Chapter 12, Section 20.4.5

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

ICD-9 Diagnosis Codes

ICD-10 Diagnosis Codes

Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.