ATT016_SurvivorCCE_TGD011_IHE_MonitoringExams.pdf

Controlled Unclassified Information TGD 011 June 2023

General Contractor Technical Guidance Document

TGD #011

Initial Health Evaluations, Monitoring Exams, and Coding Details

ORIGINAL PUBLICATION: November 1, 2019 DATE LAST REVIEWED: June 15, 2023

Purpose This technical guidance document (TGD) provides clarification on:

1. Survivor eligibility period for Initial Health Evaluations/Survivor Screening

2. Appropriate diagnosis (ICD-10) and procedure codes (CPT) for Initial Health

Evaluations (IHE) and Annual Monitoring Exams (AME)

Stakeholders Affected Clinical Centers of Excellence (CCE) and Network Provider Network (NPN). Responsible for administering IHEs, AMEs, and screening services as well as billing claims for such services.

The NPN is also responsible for adjudicating claims.

Health Program Support Contractor or Third-Party Administrator (HPS/TPA). Responsible for maintaining benefits and adjudicating claims.

Background Providers will utilize certain ICD-10 and CPT codes in order to be reimbursed for services rendered to members in performance of IHEs and AMEs. Utilizing these codes will permit NIOSH to perform reporting and auditing of these services and will assure consistent reimbursement to all providers.

All future claims for this activity should be done in accordance with the direction in this TGD.

Technical Guidance Initial Health Evaluations, Diagnostics, & Cancer Diagnostics for Screening-Eligible Survivors Screening-Eligible Survivors have access to a IHE from the member’s date of enrollment or TSC (Terrorist Screening Center) Cleared Date, whichever is later (see #1 below).

They also have access to both Diagnostics and Cancer Diagnostics prior to the certification of a World Trade Center (WTC)-related health condition (see #2 below). During this evaluation period, diagnostic services are a covered benefit to evaluate whether the survivor member has a certifiable WTC-related health condition.

1. Screening-Eligible Survivors have access to one IHE per lifetime with no time-limit; AND

2. The Diagnostic and Cancer Diagnostic benefits are turned on from the IHE date of service (DOS) and are active for 6 months.

Initial Health Evaluations, Monitoring Exams, and Coding Details

a. IHE DOS for a member enrolled in a CCE is defined as the DOS in which roll-up code (See TGD #006) is utilized on a claim.

b. IHE DOS for a member enrolled in the NPN is defined as the DOS in which 99205 is utilized on a claim.

THEN

Diagnostics, Cancer Diagnostics, and Monitoring for Certified-Eligible Survivors If the member becomes certified (Certified-Eligible Survivor), then certified monitoring benefits turn on from date of approved certification signature and diagnostic and cancer diagnostic benefit plans turn on – neither with a time limitation.

OR

Survivor with No Certifications If a survivor member goes through their IHE and diagnostic/cancer diagnostic evaluation period (see #2 above) with zero resulting certifications, then diagnostics and cancer diagnostics end and the member will only have access to cancer screening once per lifetime and inpatient professional and emergency benefits for the remainder of their time in the Program.

Any inpatient professional and emergency claim received for a non-certified survivor who has completed their IHE and diagnostic evaluation period will be pended for review to ensure WTC related care.

Diagnosis Codes (Please refer to the WTC Health Program ICD-10 Codebook for code descriptions)

1. Initial Health Evaluation:

a. Claims for Survivors’ IHE should be submitted using Z13.9 as the primary diagnosis

b. Claims for Responders’ IHE should be submitted using Z04.9 as the primary diagnosis

2. Annual Monitoring Exams – claims should be submitted with ICD code Z04.9 as the primary diagnosis for both Survivors and Responders

Procedure Codes (Please refer to the WTC Health Program Procedure Codebook for code descriptions)

99205 -- Initial Health Evaluation (NPN only)

99215 – Follow-up Monitoring (NPN only)

Roll-Up Codes – CCEs only (See TGD #006)

36415 – Blood work

71046 -- Chest X-ray

80053 – Comprehensive Metabolic Panel

80061 -- Lipid Panel

81003 – Urinalysis

85025 - CBC Differential/Platelet

94010 -- Spirometry

96156 – Health Behavior Assessment.

93000 -- EKG

Quality Controls The use of the CPT codes mentioned above will be randomly audited by NIOSH to assure they have been used in alignment with this technical guidance and codebook guidelines.

Supplemental Material(s) N/A

Revision History Rev # Changes Made to Document Date

1 New Document 09/17/2019

2 Changed effective date to November 1, 2019 10/02/2019

This version was updated to include guidance on the use of CPT code 99091 for review of spirometric testing. The effective date for the guidance on codes 99358 and 99359 is still November 1, 2019. However, the guidance for CPT code 99091 has an effective date of March 1, 2020 (i.e., when the date of service for lab or ECG review is March 1, 2020, or later, the Program will not provide payment for that review).

02/28/2020

4 Sections 6-8 added and Title Updated 01/01/2021

Updated to 2022 TGD Template Title updated, Purpose and Background statement updated, Sections 1-4 deleted Sections 5-8 renumbered

07/01/2022

Clarified stakeholders affected. Clarified when screening-eligible survivors have access to IHE (from date of enrollment or TSC Cleared Date) with no time limit. Removed information regarding diagnostic timeframes prior to February 2019 and post-February 2019. Clarified that diagnostics and cancer diagnostics are turned on for screening-eligible survivors from the IHE date of service and are active for 6 months. Clarified that, after the 6 month diagnostic period is over, screening-eligible survivors without certifications only have access to

05/23/2023 cancer screening (one time), and inpatient professional and emergency benefits.

Added definition of IHE DOS.

Removed 99091 – review of EKG, Spirometry. This code should not be billed because the CCEs/NPN are reimbursed for this activity through their contract.

Removed 99358 – WTC-3 completion. This code should not be billed because CCE reimbursement is included in the roll-up code (See TGD #006) and NPN reimbursement is included in the contract.

06/15/2023

WTC Health Program Approval The undersigned acknowledges they have reviewed this WTC Health Program technical guidance document (TGD) and agree with the approach it presents. Changes to this TGD will be coordinated with and approved by the undersigned or their designated representative(s).

Signature: ______________________________________________ Date: ____________

Date1_af_date: 6/16/23