UniCare Professional Reimbursement Policy

Transcription

1 UniCare Professional Reimbursement Policy Subject: Place of Service Policy #: UniCare 0018 Committee Approved: 10/05/2018 Effective: 10/05/2018 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed below. Description A place of service code is a two-digit numeric character that is used on a professional claim to report where a service(s) was rendered. These place of service codes are maintained by The Centers for Medicare & Medicaid Services (CMS). This policy documents UniCare s reporting and reimbursement guidelines when identifying the place of service for a procedure or service rendered for CMS-1500 submitters. Policy UniCare requires the appropriate place of service to be reported for a claim to be eligible for reimbursement. There are many codes for which the appropriate setting for a procedure or service is indicated either by the description of a Current Procedural Terminology (CPT ) or Healthcare Common Procedure Coding System (HCPCS Level II) code, or by published CPT coding guidelines which may indicate that a specific procedure or service is not intended to be reported in a certain setting. For example: When an emergency department visit (e.g., 99283) is reported by a professional provider with an office place of service code (11), the claim will be denied since the verbiage of the code is specific to a particular setting (the emergency room). When intravenous hydration (e.g., 96360) is reported by a professional provider with a facility setting place of service code (e.g., 22), the service will not be eligible for reimbursement since CPT coding guidelines state that this code is not intended to be reported by the physician in the facility setting. For new and revised CPT codes and/or guidelines, UniCare will update our claims editing system to include a place of service restriction whenever the code definition or coding guideline specifies an appropriate place of service for reporting the code(s). In addition, UniCare will conduct an annual review of surgical codes with an assigned place of service restriction and update the claims editing system when we determine that a place of service restriction is no longer applicable for a particular procedure. We will also review new surgical procedure codes to determine if a place of service restriction is applicable. The following coding section provides examples of codes and code ranges that may have a place of service restriction. The inclusion or exclusion of a specific code does not indicate eligibility for coverage under all circumstances. RP0018 Place of Service Page 1 of 5

2 Coding I. Place of Service Defined Codes a) The CPT description for most Evaluation and Management (E/M) codes indicates where the particular service will be rendered. CPT describes E/M services as taking place in an office or outpatient setting, an inpatient, emergency department, nursing facility, domiciliary, or home setting. When a place of service specific E/M is reported with a place of service that does not match the place of service identified for that code, the E/M service is not eligible for reimbursement. The following table is an example of some, but not all, of the code ranges for these E/M services that have a place of service restriction: b) There are a number of CPT and HCPCS codes that are specific to services provided in a home. When a code such as H1004, Q5001, S9061, and S9810 or a code within the code ranges listed below is submitted by a professional provider with a place of service other than home, the service is not eligible for reimbursement. UniCare recognizes settings such as schools (03), homeless shelter (04), home (12), assisted living facility (13), group home (14), and temporary lodging (16) to be a home setting. The examples of procedure codes listed below are provided as an informational tool only to help identify some, but not all, of the procedures specific to a home setting: G0151-G0156 S5035-S5036 S9097-S9098 S9490-S G0398-G0400 S5180-S5181 S9122-S S0273-S0274 S5497-S5523 S9208-S9379 c) UniCare requires transportation services, including ambulance, to be reported with a place of service of 41 (land ambulance) or 42 (air or water ambulance). These services are described within the code ranges of A0021-A0999 and S0207-S0208. When a code within these code ranges is submitted by a CMS-1500 submitter with a place of service other than 41 or 42, the ambulance service is not eligible for reimbursement. d) The CPT code descriptions for Miscellaneous Services listed within the code range of indicate where the miscellaneous service will be rendered. For example: is described as Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays**, Saturday or Sunday) in addition to basic service is described as Service(s) provided in the office during regularly scheduled evening, weekend, or holiday** office hours, in addition to basic service. **UniCare does not identify specific holidays therefore holidays are not given any extra consideration outside the after-hours criteria. When either miscellaneous service code or is reported by a professional provider with a place of service other than office (11) or urgent care facility (20), the miscellaneous service is not eligible for reimbursement. Please refer to our After Hours, Emergency, and Miscellaneous E/M Services reimbursement policy for additional information on codes II. Correct Coding Guidelines RP0018 Place of Service Page 2 of 5

3 The CPT codebook provides additional information and coding guidelines in the beginning of many code sections and, for reporting purposes, parenthetical comments for many specific codes. For example: CPT indicates that injection and infusion codes are not intended to be reported by the physician or other qualified health care professional in the facility setting. Therefore, a facility place of service restriction is applied to hydration, injection and infusion, and chemotherapy and complex drug or biologic agent administration codes. Excluding codes , 96440, 96450, and 96542, examples of code ranges in this category are: III. Place of Service Restrictions for Radiation Treatment Delivery Codes CPT indicates that the radiation treatment delivery codes ( ) describe technical component services only and are not intended to be reported by a professional provider in the facility setting. Therefore, when a professional provider reports one of the codes within this code range with a facility place of service, the service is not eligible for reimbursement. cpt Assistant indicates that when performed, CPT code (therapeutic radiology port films) should be reported by the facility. Therefore, UniCare also considers to be a technical component service only, and not eligible for reimbursement when reported by a professional provider with a facility place of service. Additionally, UniCare considers the stereotactic radiation, neutron and proton beam treatment delivery codes to be a technical component service only with no work component RVU. The following codes are examples of radiation treatment delivery services that are not eligible for reimbursement when reported by a professional provider in a facility setting: IV. Place of Service Restrictions for Inpatient Only Certain specific complex surgeries can only be performed in an inpatient setting due to the needed level of involvement of qualified staff and the technical equipment necessary to perform the procedure. For example, when reporting a lung transplant or coronary artery bypass, the place of service submitted on a Form CMS-1500 must be inpatient hospital (21) or the surgery will not be eligible for reimbursement. Examples of CPT and HCPCS code ranges in this category include, but are not limited to: S2053-S S2205-S2209 V. Additional Place of Service Restrictions a. UniCare does not reimburse for durable medical equipment (DME) when rented or purchased for use in an ambulatory surgical center or surgical suite setting (24), emergency room (23), hospital inpatient (21), off campus-outpatient hospital (19), on campus-outpatient hospital (22), or skilled nursing facility (31), (e.g., rental of compression devices, HCPCS codes E0673, E0675, and E0676, are not eligible for reimbursement when reported in a facility place of service). **Exceptions for skilled nursing facility: Hospital beds E0194, E0301, E0302, E0303, and E0304 RP0018 Place of Service Page 3 of 5

4 Wound care items A6550, A7000, and daily rental of E2402 b. UniCare does not reimburse for DME rental when reported with an office (11) or urgent care facility (20) place of service. c. When an attended polysomnography with/or without sleep staging ( ) is reported in a home setting, the service will not be eligible for reimbursement since this type of testing is a complex medical procedure involving overnight physiologic recording in a specialized facility. d. UniCare considers the provision of any medication, including Propofol, to be included under the facility s reimbursement when medications are provided in a facility setting. Therefore, when a medication is separately reported by a professional provider with a facility setting place of service code, the drug charge will not be eligible for separate reimbursement even when reported with an unspecified code (e.g., J3490). (See also our Anesthesia Services reimbursement policy.) e. UniCare considers the provision of contrast materials (high and/or low osmolar contrast material (HOCM/LOCM), radiopharmaceutical materials, injection of dipyridamole per 10 mg (J1245), and radioelements for brachytherapy (Q3001), to be included under the facility s reimbursement as part of the technical portion of diagnostic imaging or treatment services when provided in a facility setting. Therefore, when these materials or elements are reported by a professional provider with a facility setting place of service the charges will not be eligible for reimbursement. f. UniCare considers the provision of any vaccine and the administration of such vaccines to be included under the facility s reimbursement when the vaccines and administration are provided in a facility setting. Therefore, when a vaccine and the vaccine administration are reported by a professional provider with a facility setting place of service code, the vaccine and vaccine administration charges will not be eligible for separate reimbursement. g. UniCare considers enteral and parenteral therapy to be included under the facility s reimbursement when provided in a facility setting. Therefore, when materials, supplies, or elements for enteral and parenteral therapy services represented by HCPCS B and E codes are reported by a professional provider with a facility setting place of service the charges will not be eligible for reimbursement. h. UniCare considers CPT codes (evoked otoacoustic emissions screening), (limited auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system), and (distortion product evoked otoacoustic emissions limited evaluation) performed in a facility setting to be included under the facility s reimbursement. Therefore, when any of these hearing screening services are separately reported by a professional provider during the same timeframe of a member s inpatient stay or any facility setting, they are considered to be duplicate of reimbursement and such services will not be eligible for separate reimbursement. Related Policies Injection and Infusion Administration Bundled Supplies After Hours References and Research Materials This policy has been developed through consideration of the following: CMS Policy History 10/05/2018 Revised: Updated language in section V. Additional Place of Service Restrictions RP0018 Place of Service Page 4 of 5

5 h. Added clarifying language for providers billing hearing screenings when a member has an inpatient or other facility setting stay. 03/07/2017 Revised 05/03/2016; Revised 10/04/ /01/2015 Revised 06/02/2015 Annual Review 05/06/2014; 06/03/2014 Revised 02/04/2014 Annual Review 02/05/2013 Revised 02/07/2012, Revised 07/10/2012, 09/11/ /06/2010, Revised 11/02/ /01/2010 Reviewed 04/28/2009, Revised 06/24/ /03/2009 Adopted by Enterprise Professional Reimbursement Committee CPT is a registered trademark of the American Medical Association Use of Reimbursement Policy: This policy is subject to federal and state laws, to the extent applicable, as well as the terms, conditions, and limitations of a member s benefits on the date of service. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from UniCare Claims are administered by UniCare Life & Health Insurance Company UniCare RP0018 Place of Service Page 5 of 5