Brad Posted Sun 12th of June, 2016 16:06:04 PM
I own a company that makes a Breathalyzer that connects to a Web Portal to monitoring alcohol use. We are used by over 100 Treatment Facilities in the United States including Hazelden/Betty Ford Center, Caron, etc...
I realize I probably have 3 questions here and if you think you can help I would be happy to pay more.
We have had a few people have success getting re imbrued with CPT Code 82075. My question is can a treatment facility use this code or does it have to be a licensed Lab?
Our product is typically used twice a day. Medicare reimburses $16.35 for CPT Code 82075 for one test. We are suggesting to our customers that they submit for reimbursement every 2 weeks for 14 tests. Any thoughts on that advice?
We also provide an appeals letter to our customers when they get denied. We have not been aggressive with this code but are going to start having a lot of our customers using this code and appeals letter. Any advice on the appeals letter would be appreciated.
CPT Codes: 82075
Re: Request for Reconsideration of Reimbursement Coverage for Remote Alcohol Breath Testing and Monitoring
Dear Medical Reviewer:
I am filing an appeal on behalf of my patient, NAME, who was denied coverage for remote alcohol breath testing and monitoring, a safe and evidence-based FDA-registered monitoring tool to improve outcomes in alcohol dependent patients. In the denial dated DATE, it was stated that the request was not authorized for the following reason: service is not covered.
Breath testing for alcohol has been widely used since the 1960s. FDA approval of breath testing surged in the 2000s both for alcohol and for use in other areas such as infectious disease and cancer risk prediction. CPT code 82075, a level 1 CPT code, has been utilized for many years.
Following a thorough initial addiction history and assessment, alcohol breath testing and monitoring was ordered for Patient’s NAME to assist in treatment planning and monitoring due to the complex nature of HIS/HER history. SUMMARIZE patient’s history with alcohol and treatment experience with emphasis on inadequate response to prior treatments, current presentation as well as how S**** monitoring is uniquely situated to provide for this patient. The addition of alcohol breath testing and monitoring was particularly helpful for this patient by SUMMARIZE key benefit(s) of S**** in the treatment planning, monitoring and accountability for this patient. Patient’s NAME has responded exceptionally well thus far to treatment as evidenced by list indicators of progress further validating S****’s role in enhancing clinical outcomes for this patient.
Using remote alcohol breath testing and monitoring to inform Patient’s NAME treatment plan was critical in changing the reality of the hijacked reward system with the new reality of an individual that sees the consequences of their use of substances, described by Dr. DuPont. Remote alcohol breath testing and monitoring was critical in breaking through Patient’s NAME denial that alcohol misuse was resulting in harmful outcomes as the consequences associated with use were more swiftly applied per the contract. [It would be helpful for the treatment centers using this to develop a 2-column chart listing various patient histories/status where S**** is presented and the second column listing the consequences for a positive or missed test. This would help to further tailor these appeal letters as well as for your marking efforts to decision makers.]
Finally, the denial of remote alcohol breath testing and monitoring for Patient’s NAME for whom it is clearly indicated may be a violation of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (“the Parity Act”). The parity law and its Interim and Final Rules preclude group health plans and issuers from applying more stringent treatment limitations on behavioral health benefits than on other medical benefits covered by the plan.
As you may know, the Parity Act states that; “The treatment limitations applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan (or coverage) and there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits.” In addition, the Parity Final Rule clarifies “that the definitions of medical/surgical benefits,” “mental health benefits,” and “substance use disorder benefits” incudes “items” as well as “services.”
Furthermore, the Parity Act regulations and guidance state that the following information must be provided in a timely manner:
1. “The reason for any denial under the plan (or coverage) of reimbursement or payment for services with respect to mental health or substance use disorder benefits in the case of any participant or beneficiary shall, on request or as otherwise required, be made available by the plan administrator (or the health insurance issuer offering such coverage) to the participant or beneficiary in accordance with regulations“ and
2. “The criteria for medical necessity determinations made under the plan with respect to mental health or substance use disorder benefits (or the health insurance coverage offered in connection with the plan with respect to such benefits) shall be made available by the plan administrator (or the health insurance issuer offering such coverage) in accordance with regulations to any current or potential participant, beneficiary, or contracting provider upon request.”
3. Documents with information on medical necessity criteria for both medical/surgical and mental health/substance use disorders as well as the processes, strategies, evidentiary standards and other factors used to apply a non-quantitative treatment limit are instruments under which the plan is established and operated and copies must be furnished within 90 days.
In accordance with the aforementioned section of the Act, I request the following information be sent to me within 10 days to enable me to evaluate INSURANCE’s compliance with the Parity Act:
1. The specific criteria (processes, strategies, evidentiary standards, or other factors) that INSURANCE used to deny coverage of remote alcohol breath testing and monitoring including the technology review that INSURANCE has performed on it as well as the policies and criteria that INSURANCE use to determine coverage of other medical testing and monitoring technologies such as blood glucose meters and testing strips and the criteria and policies used to determine reimbursement of these services; and
2. Because the Parity Act requires that a treatment limitation applied to mental health or substance use disorder benefits cannot be more restrictive than what is applied to substantially all medical/surgical benefits, I also need a copy of the criteria (processes, strategies, evidentiary standards, or other factors) that INSURANCE uses to decide what medical and surgical testing and monitoring services are reimbursable and the data which demonstrates how and to what degree these policies are used to reimburse medical and surgical spending by INSURANCE. For example, does this policy apply these criteria to more than two-thirds of all medical/surgical procedures?
SuperCoder Answered Mon 13th of June, 2016 06:20:23 AM
Code 82075 has code status “X”, which says “These codes represent an item or service that is not in the statutory definition of "physician services" for fee schedule payment purposes. No RVUS or payment amounts are shown for these codes, and no payment may be made under the physician fee schedule. (Examples are ambulance services and clinical diagnostic laboratory services.)” This means that this code should be billed by the labs and not physicians.
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