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December 2016 Texas Medicaid Provider Procedures Manual

Inpatient and Outpatient Hospital Services Handbook : 4 Outpatient Hospital (Medical and Surgical Acute Care Outpatient Facility) : 4.2 Services, Benefits, Limitations, and Prior Authorization : 4.2.15 Lung Volume Reduction Surgery (LVRS)

4.2.15
LVRS surgery must be performed in a facility that meets at least one of the following requirements:
The surgery must be both preceded and followed by a program of diagnostic and therapeutic services that are consistent with those provided in the National Emphysema Treatment Trial (NETT) and designed to maximize the client’s potential to successfully undergo and recover from surgery. The program must meet all of the following requirements:
Be consistent with the care plan that was developed by the treating physician following the performance of a comprehensive evaluation of the client’s medical, psychosocial, and nutritional needs
Be arranged, monitored, and performed under the coordination of the facility where the surgery takes placePrior authorization is required for the LVRS procedure. However; prior authorization is not required for the pre-operative and post-discharge pulmonary services
LVRS must be prior authorized and is limited to clients who have severe emphysema, disabling dyspnea, and evidence of severe air trapping. Prior authorization is not required for the associated preoperative pulmonary surgery services for preparation of LVRS (procedure codes G0302, G0303, and G0304) or the associated postdischarge pulmonary surgery services after LVRS (procedure code G0305).
LVRS and post-discharge LVRS are restricted to the following eemphysema diagnosis codes:
 
Procedure codes 32491, G0302, G0303, G0304 and G0305 are limited to one per rolling year per client any provider.
Procedure code G0305 may be reimbursed only if a claim for LVRS (procedure code 32491) has been submitted within the past 12 months.
Refer to:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.