WMGMA Payer Committee Meeting March 24, 2014 Commercial Payer Responses

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1 WMGMA Payer Committee Meeting March 24, 2014 Commercial Payer Responses Affinity Submitted by Kellie Scholl, CPC / Will you pay for two preventive services in a calendar year when one is performed by OB/GYN and the other by Primary Care? Dean Care Cigna would reimburse for two preventive services in a calendar year For Dean, it could depend on the service. Not all services are limited. If an adult patient were to receive two preventive E/M services within a group/calendar year, only one would be eligible for the preventive reimbursement of 100%. The second preventive code would be reimbursed like any other E/M service. No. If the member benefit states only one preventive service per calendar year, then only one will be paid., does allow one by the primary care provider and another by an OB/GYN provider in the same calendar year. PPIC allows one preventative visit per calendar year., will pay for more than one preventive service within the calendar year. The benefit includes one preventive visit per year, under most products, the preventive benefits do not have any type of limitations for Evaluation & Management and diagnostic charges. Some of our custom large group business may still have visit or dollar limits that could impact this situation, but they have started to change their product set-ups to match the PPACA requirements and limitations. 2 Anyone paying for the Transoral Incisionless Fundoplication (TIF) procedure? Currently using the unlisted CPT code? Per Medical Policy SURG.00047, this is considered to be investigational and not medically necessary in all cases. Policy link: Experimental, investigation or unproven and not covered when used to report endoscopic anti-reflux procedures performed for the treatment or management of gastroesopheageal reflux disease (GERD)/esophageal reflux. Dean Dean does not provide reimbursement for TIF at this time. There is insufficient published evidence to assess the safety and/or impact on health outcomes or patient management. Refer to policy Gastroesophageal Reflux Disease (GERD) Surgical Procedures located on humana.com. When billing with CPT code 43499, please provide medical records to support this unlisted code. The implantation of an anti-gastroesophageal reflux device is a surgical procedure for the treatment of gastroesophageal reflux, a condition in which the caustic contents of the stomach flow back into the esophagus. The procedure involves the implantation of this special device around the esophagus under the diaphragm and above the stomach which is secured in place by a circumferential tie strap. 1 P a g e

2 Care The implantation of this device may be considered reasonable and necessary in specific clinical situations where a conventional valvuloplasty procedure is contraindicated. The implantation of an anti-gastroesophageal reflux device is covered only for patients with documented severe or life threatening gastroesophageal reflux disease whose conditions have been resistant to medical treatment and who also: Have esophageal involvement with progressive systemic sclerosis; or Have foreshortening of the esophagus such that insufficient tissue exists to permit a valve reconstruction; or Are poor surgical risks for a valvuloplasty procedure; or Have failed previous attempts at surgical treatment with valvuloplasty procedures. PPIC considers this to be investigational/not proven and are not currently reimbursing for this. This technique is considered experimental and investigational; therefore, does not cover this service at this time. TIF procedure has not been proven to be safe and effective, therefore not a covered benefit. All unlisted codes are flagged in our system and manually reviewed to determine medical necessity. The Transoral Incisionless Fundoplication (TIF) procedure is currently not payable. 3 Will you accept CPT code for an annual nursing facility assessment? Pending Dean CPT is allowed by Dean. We do not have sufficient information, however, to confirm that this code is appropriate for the service performed. Per CPT, providers are to Select the name of the procedure or service that accurately identifies the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code Evaluation and management of a patient involving an annual nursing facility assessment, will accept CPT Codes (Subsequent Nursing Facility Care, per day) shall be used to report federally mandated physician visits and other medically necessary visits. These codes are effective January 1, 2006, and replace codes , which are deleted after 12/31/05., if the nursing facility stay is authorized. Care, will accept procedure code Skilled Nursing Facility services require preauthorization. Service required to be performed by a facility without medical necessity are not a covered benefit. 4 Will you accept CPT code for discharge from a nursing facility? 2 P a g e

3 Dean Pending Codes and are allowed by Dean. We do not have sufficient information, however, to confirm that this code is appropriate for the service performed. Per CPT, providers are to Select the name of the procedure or service that accurately identifies the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code Nursing facility discharge day management; 30 minutes or less Nursing facility discharge day management; more than 30 minutes, are acceptable.. Some facilities bill for the services performed by a physician that were completed around the time of discharge for pre-work (work completed prior to discharge day) and post-work (completed after discharge day). This practice results in one billing for the accumulated time it has taken to complete discharge services., if the nursing facility stay is authorized. Care, will accept procedure code Dean Care Skilled Nursing Facility services require preauthorization. Services required by a facility without medical necessity are not covered benefits. If the service provide is medical necessary, it would be considered a covered benefit. Do you reimburse separately for the Patient Questionnaire 9 (PHQ9) depression screening? If so, is the CPT (administration and interpretation of health risk assessment instrument (e.g. health hazard appraisal) appropriate to bill? this code can be billed. Depression screening is a covered benefit. CPT may be reimbursed separately or considered incidental to other codes billed. Please see s clinical claim edits for more information using specific codes. Per Cigna Behavioral, this is not reimbursable. CPT code is a covered service and would be used to report the Administration and interpretation of health risk assessment instrument (eg, health hazard appraisal). Based on the information received it would appear that is appropriate for PHQ9 depression screening. Whether or not it is separately reimbursable depends on what other service was performed on that day and how it was subsequently billed. Per CPT: Any E/M services reported on the same day must be distinct, and time spent providing these services may not be used as a basis for the E/M code selection. Still researching., may be reimbursed separately. PPLUS would accept for this screening., this is considered preventive in certain situations. Questionnaires are not separately reimbursed. No 3 P a g e

4 Submitted by Judy Papke Marshfield Clinic / Drug Screening - Will the Payers accept and reimburse providers for HCPCS codes G0431 Drug Screen, qualitative; multiple drug classes by high 6 complexity test method (e.g. immunoassay, enzyme assay) per patient encounter and G0434 Drug screen other than chromatographic, any number of drug classes, by CLIA Waived test or moderate complexity test, per patient encounter? Is prior authorization required? Drug testing or screening is considered a covered benefit subject to the Medical Necessity criteria indicated in Medical Policy CG-LAB-09: Clinical Claim Edit 770 indicates that G0434 is incidental to G0431 and not separately reimbursed. Clinical Claim Edit 791 indicates CPT 80500, 80502, and are incidental to G0431 and not separately reimbursed. Aligned with CMS in requiring the use of either G0431 or G0434 for the billing of qualitative drug screens. Both codes will be eligible for one (1) unit of reimbursement per date of service. Codes 80100, and will no longer be eligible for reimbursement; charges associated with these codes will be denied. Both G0431 and G0434 are allowed by Dean without an authorization. Dean Care 7 Dean G Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter G Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter Note that G0431/G0434 were created by Medicare to administer their own benefits. There are other drug screening CPT codes in the 801xx series. HCPCs code G0431 is accepted at. HCPCS code G0434 is not accepted for Medicare HMO. There are no prior auth requirements for these codes. At this time NHP will accept and reimburse for HCPCS Codes G0431 & G0434., we will accept and reimburse providers for G0431 and is allowable without prior authorization. Both codes are covered and a prior authorization is not required by. Per the NCCI, G0434 is considered a component of G0431, therefore not separately reimbursable. Prior authorization if not required, but we will review for medical necessity once the claim is received. Screening Lung CT - Do the payers have a policy on coverage of screening Lung CT Scans? Computed tomography, thorax; without contrast material. Lung CT Scans are currently a covered benefit subject to Medical Necessity criteria indicate in Medical Policy RAD.0043: CT scans require precertification. CPT is covered when used to report low-dose computed tomography (CT) for lung cancer screening Dean is currently developing a policy for the USPSTF recommendation for lung cancer screening. 4 P a g e

5 Care The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in persons age 55 through 80 years with a 30 pack year history of smoking who are currently smoking or have quit within the past 15 years. Screening should be discontinued once the individual has not smoked for 15 years or develops a health problem significantly limiting either life expectancy or ability or willingness to undergo curative lung surgery. All CTs should be authorized through Help does not currently have a payment policy on these types of CT scans. Computed tomography, thorax; without contrast material., all scans need preauthorization with Med Solutions at or Computed tomography, thorax; without contrast material. Our Services Department indicates is a covered benefit and we do not currently have a policy regarding coverage. This code is covered by and a prior authorization is not required., this service is considered a preventive service based on the December 2013 USPSTF recommendation for annual screening for lung cancer with low-dose computed tomography in adults ages 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. This procedure is payable under our health plans subject to the Diagnostic Radiology benefits. Essure Will the payers reimburse a provider for CPT Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by 8 placement of permanent implants in addition to HCPCS A4264 Permanent implantable contraceptive intratubal occlusion device and delivery system? According to Clinical Claim Edit 729, A4264 is considered incidental to and is not separately reimbursed. Cigna does reimburse for this following CPT in addition to HCPCS A4264. Dean Care Dean would not provide separate reimbursement for A4264 when billed with , provides reimbursement for the Essure procedure and implants if the member s benefits allow for contraceptives. Currently, HCPCS A4264 is bundled into on the professional claim; no bundling issue for facility claims. We consider this a covered benefit under current Care Reform guidelines., these are covered services by. We do reimburse code 58565; however code A4264 is bundled when billed with this code. Rationale follows: Any CPT code(s) or care Common Procedure Coding System (HCPCS) code(s) that is/are a basic step necessary to complete the primary or comprehensive service, or any code(s) included by definition, or described as an integral component of the more comprehensive procedure is/are included in the primary or more comprehensive procedure. The current National Correct Coding Initiative Policy Manual for Medicare Services Version states, ''If a HCPCS/CPT code is reported, it includes all components of the procedure defined by the descriptor. 5 P a g e

6 Monroe Clinic 9 The following additional CMS policy statements also give information about inappropriate coding combinations: ''HCPCS/CPT code(s) corresponding to component service(s) of other more comprehensive HCPCS/CPT Codes(s) should not be reported separately with the more comprehensive HCPCS/CPT code(s) that include the component service(s).'' Submitted by Leah Riesser, CPC-A leah.riesser@monroeclinic.org / If a patient receives both the Flu vaccine (90686) and the Pneumococcal vaccine (90732) should we use diagnosis code V06.6 for shots and admin when both are given on same day?, V06.6 can be used. Cigna would allow both codes with diagnosis code V06.6. If both a flu and pneumococcal vaccine were administered on the same day, it would be appropriate to report V Streptococcus pneumoniae [pneumococcus] and influenza. However, ICD-9 guidelines would allow V06.6 as a secondary diagnosis. Per the ICD-9-CM Official Guidelines for Coding and Reporting: Dean Care Inoculations and vaccinations Categories V03-V06 are for encounters for inoculations and vaccinations. They indicate that a patient is being seen to receive a prophylactic inoculation against a disease. The injection itself must be represented by the appropriate procedure code. A code from V03-V06 may be used as a secondary code if the inoculation is given as a routine part of preventive health care, such as a well-baby visit. Note that the coding rules is the same in ICD-10. Instructions are to code first any routine childhood examination. V06.6 is appropriate The Diagnosis of V06.6 is accepted for both codes when billed on the same day. We would accept either, however, coding guidelines direct us to code to the highest level of specificity and code each individually. will allow V06.6 to process within our system. Our preference would be to append the specific diagnosis to the specific vaccine V03.81 Vaccine for Hemophilus influenza B V03.82 Vaccine for Streptococcus pneumonia If that is the reason for the vaccine. 10 Do you require NDC # s for every J code? NDCs are required for any NOC J code billed. According to Professional Not Otherwise Classified (NOC) Drugs Reimbursement Policy CR.PTKPR.069.0b the following information is required: 1. Name of the drug (generic and/or brand name) 2. National Drug Code (NDC) 3. Total dosage reported (e.g. milligrams) 6 P a g e

7 4. Total units reported 5. Effective for dates of service on or after : Compound Drugs A detailed compounding pharmacy invoice, to include the name of the drug, the National Drug Code (NDC), total dose amount for each drug and total cost of the compounded drug is required. Dean Care Cigna does not require NDC # s for every J code unless specified in the contract. Dean does not require NCD numbers, please add NDC for J codes NHP doesn t require a NDC# for every J code. No NDC codes are not required, but preferred. collects the NDC information when it is submitted. We do have contracted arrangements that are contingent on receiving the appropriate J code. A NDC number is not required for every J code, however, there are times we may need additional information (such as an NDC or description for the J code used) or delay in payment may occur, especially if the J Code is an Unlisted Service or Procedure (J3490 and J9999). UW Medical Foundation 11 Submitted by David Ruff david.ruff@uwmf.wisc.edu / The CPT description for code includes first or only component of each vaccine or toxoid administered. When other vaccines are separately administered, will you pay for additional units of on a single day? If so, do you want this as a single charge line x units of service, or separate charge lines? Would modifiers be needed to prevent duplicate services denials? CPT should be billed on a single line with the multiple units. No modifier required. Dean Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component (list separately in addition to code for primary procedure). When giving a vaccine there should be a code billed for the administration of the vaccine (90460,90461, ) for each vaccine given AND a code billed for the Vaccine/toxoid with is being administered (MMR 90707, or Varicella virus vaccine 90716). Example - If Varicella virus vaccine is given to a child, the coding would be for the administration and for the toxoid. No modifiers would be needed. Example - If MMR is given to a child, the coding would be for the 1st component, for the second component and for the third component of the MMR, AND for the vaccine itself. Again no modifiers would be needed. Example - If Varicella virus and MMR are given at the same encounter to a child, the coding would be for the administration and for Varicella AND for the 1st component, for the second component and for the third component of the MMR. No modifiers are needed. I m not aware that Dean has a preference. However, we would be happy to review claim examples should you be having any payment problems. CPT can be reported more than once on a single day if being reported for more than one covered vaccine or toxoid. CPT should be reported once for the first component of a covered combination vaccine or toxoid administered and/or once for a single covered 7 P a g e

8 vaccine or toxoid. For combination vaccine codes, each component after the 1 st should be reported with CPT Care 12 Charges can be on a single claim line or separate claim lines. A modifier should not be needed for duplicate services as this code can be reported more than once. we do allow for multiple edits to be billed per day. Our system is set up to accept them billed on separate charge lines. No modifiers are required to allow the multiple codes. PPLUS prefers units to be listed on the line vs. separate line charges to avoid duplicate denials., a modifier will be needed if billed on separate lines to avoid duplicate denials each additional vaccine or toxoid component administered (list separately in additional to code for the primary code) should be reported in this circumstance should be billed in conjunction with the primary code line. CPT is specific to the first or only component and would not allow units. CPT Code should be reported, in addition to 90460, to identify the administration and counseling of additional vaccines. CPT Code allows units. The coding software will deny any additional units billed on code based on the description on the code itself. However we do recognize the description goes on to quantify further each vaccine. Claims would need to review after initial denial. Multiple lines billed for this code would also result in a rejected line. Are you covering the Complex Chronic Care Coordination codes , and if so, have you published any coverage and/or submission guidance? These codes are considered part of providing another service and not eligible for separate reimbursement. For more information, please see our Professional Bundled Services and Supplies Reimbursement Policy 0008 that is available on our secure My provider portal. Cigna recognizes codes , however; only and are eligible for reimbursement. Dean CPT codes have been assigned a Status Indicator of B on the Medicare Physician Fee Schedule. Dean does not reimburse separately for these codes for any line of business. No, does not cover Complex Chronic Care Coordination codes Care NHP covers these services at this time and is not aware of any published coverage/submission guidance. This is currently under review at PPLUS. covers CCCC with an approved prior authorization. We do not have any specific criteria to share at this time are not covered benefits. These procedures are payable under our health plans subject to the office visit benefits. We have not at this time published any coverage or submission guidance for the above mentioned codes. 13 UWMF is interested in knowing what Payers reference the Medicare Database for payment of Assistant Surgeon, Co-Surgeon, Team, etc. cases. The question is not clear. For information on s Assistant Surgeon Policy and the sources used, please see our Professional Assistant Surgeon Reimbursement Policy 0009 and for Co-Surgeon/Team Surgeon, please see our Professional Co-Surgeon/Team Surgeon Reimbursement Policy 0006 available on our secure My provider portal for rationale and sourcing. Pending 8 P a g e

9 Dean Care 14 Dean utilizes the Medicare Physician Fee Schedule Database for the payment of Assistant Surgeon, Co-Surgeon and Team surgeons. See Provider Manual at.co for description on how Assistant surgeon/co-surgeon reimbursement addresses. Also please refer to your provider agreement/contract for any specific contract language. NH Commercial division uses the Medicare database for payment of Assistant Surgeon, Co-Surgeon, Team, etc. cases. PPIC currently follows The American College of Surgeons guidelines to determine if payment is allowable for a surgical assistant (please see our website for a list of these codes). Our system is not currently setup to reference that Medicare Database. We use the Medicare Database as a reference. We use the Medicare status indicators to determine appropriateness for Assistant Surgeons, Co-surgeons, and Team Surgeons. We also use the Multiple Surgery indicators in conjunction with CPT. 0159T Computer-aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI (List separately in addition to code for primary procedure). CPT indicates this is an add-on code to be used in conjunction with (MRI, breast, without and/or with contrast material(s); unilateral), (MRI, breast, without and/or with contrast material(s); bilateral). Do you provide coverage of code 0159T when billed with or in either an outpatient hospital or clinic setting? MRI of the breast is a covered benefit subject to Medical Necessity as indicated in policy RAD Precertification is required via AIM Specialty is required. There is no clinical claim edit currently in place to deny 0159T. Add-on codes do not require precertification. Cigna does not cover as it is considered experimental, investigation or unproven. Dean Dean allows 0159T to be billed as an add-on code to breast MRI codes, and If performed in an outpatient hospital setting, we would expect that they physician would report the professional component only. No. CPT 0159T is not covered. has a medical policy for Commercial plans Breast Imaging. According to this medical policy, HCPCS code 0159T is a non-covered service, as the technology is considered experimental/investigational. if prior authorization is obtained. We currently do not provide coverage for 0159T. We consider this redundant technology/unproven clinical benefit and are currently denying provider liability. Care 0159T is not setup as a covered benefit as it is considered investigational. does allow for CADs reported with CPT codes and 77052, understanding that these are for mammography procedure vs. MRI procedures. No many of our certificates exclude this service and if not excluded considers it experimental Investigational. 9 P a g e