Empire BlueCross BlueShield Professional Commercial Reimbursement Policy

Transcription

1 Subject: Place of Service NY Policy: 0018 Effective: 12/01/ /21/2016 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 form CMS-1500 to report where a service(s) was rendered. These place of service codes are maintained by The Centers for Medicare & Medicaid Services (CMS). POLICY The Health Plan requires the appropriate place of service to be reported on a Form CMS-1500 in order for that 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 (99283) is reported in an office setting, the claim will be denied since the verbiage of the code is specific to a particular setting (the emergency room). When intravenous hydration (96360) is reported in a facility setting, 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, the Health Plan 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, the Health Plan 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of service restriction and update the claims editing system when we determine that a place of service restriction is no longer applicable for a particular procedure.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 listed below does not indicate eligibility for coverage under all circumstances. NY 0001 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, or an inpatient, emergency department, nursing facility, domiciliary or home setting. When a place-specific E/M is reported on a Form CMS-1500 with a place of service that does not match the CPT place of service description 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 on a Form CMS-1500 with a place of service other than home, the service is not eligible for reimbursement. The examples 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. The Health Plan requires transportation services, including ambulance, to be reported with a place of service of 41 or 42. These services are described within the code ranges of A0021-A0999 and S0207-S0208. When a code within these code ranges is submitted on a Form CMS-1500 with a place of service other than 41 or 42, the 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 (eg, 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. 2 **The Health Plan does not identify specific holidays therefore holidays are not given any extra consideration outside the after-hours criteria. NY 0001 Page 2 of [5]

3 Therefore, when either miscellaneous service code or is reported on a Form CMS with a place of service other than office, the miscellaneous service is not eligible for reimbursement. Please refer to the After Hours, Emergency, and Miscellaneous E/M Services Policy for additional information on codes II. Correct Coding Guidelines 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 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. (See also our Injection & Infusion Administration and Related Services & Supplies reimbursement policy.) 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. 3 Therefore, the Health Plan 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, the Health Plan considers the stereotactic radiation, neutron and proton beam treatment delivery codes to be a technical component service only with no RVU work component. Therefore the following codes are not eligible for reimbursement when billed by a professional provider in a facility setting IV. Place of Service Restrictions for Inpatient Only NY 0001 Page 3 of [5]

4 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. The Health Plan 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) or outpatient (22), skilled nursing facility (31), or office (11) (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). b. 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. 4 c. The Health Plan considers the provision of any medication, including Propofol, to be included under the facility s charge 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 reimbursement policy.) d. The Health Plan 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. e. The Health Plan 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 NY 0001 Page 4 of [5]

5 reimbursement. Therefore, when any of these services are reported by a professional provider in a facility setting they will not be eligible for separate reimbursement. 1 Current Procedural Terminology, cpt 2015, Professional Edition,pg Ibid, pg cpt Assistant February 2006, page 14 4 cpt Assistant February 1998, page 6 CPT is a registered trademark of the American Medical Association Use of Reimbursement Policy: State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, take precedence over Reimbursement Policy and must be considered first in determining eligibility for coverage. The member s contract benefits in effect on the date that services are rendered must be used. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically Empire BlueCross BlueShield 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 Empire BlueCross BlueShield. NY 0001 Page 5 of [5]