Anthem Central Region Clinical Claims Edit

Transcription

1 Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Subject: Screening Papanicolaou (Pap Smear) with Evaluation and Management Services Edit #: 305 Effective Date: 7/15/ /31/2099 Status: Current Last Review Date: 2/7/2013 Edit Q0091 (Screening Papanicolaou smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) bundles into (Initial outpatient evaluation and management services), (Established outpatient evaluation and management services), (Observation care discharge or initial observation care evaluation and management services), (Initial, subsequent, observation or inpatient care or hospital discharge evaluation and management services (Emergency Department, evaluation and management services), (Critical care, evaluation and management services), (Nursing facility care, new, subsequent and discharge, evaluation and management services), (Nursing facility discharge day management) (Other nursing facility services, evaluation and management services), (Domiciliary, rest home {e.g., boarding home}, or custodial care or care plan services, evaluation and management services), (Domiciliary or rest home visit for the evaluation and management of an established patient ) (Home services, new or established patient, evaluation and management services, (Physician standby service, requiring prolonged physician attendance, each 30 minutes (e.g., operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG) (Work related or Medical disability evaluation and management services), (Newborn care, initial and subsequent or in attendance, evaluation and management services), , , (Inpatient neonatal and pediatric critical care evaluation and management services), (Initial and continuing intensive care services, for neonates or low birth weight infants, evaluation and management services), (Unlisted evaluation and management), (Initial comprehensive preventive medicine, new patient age younger than 1 year), (Initial comprehensive preventive medicine, early childhood, new patient {age 1 through 4 years}), (Initial comprehensive preventive medicine, late childhood, new patient {age 5 through 11 years), (Initial comprehensive preventive medicine, adolescent, new patient {age 12 through 17 years}), (Initial comprehensive preventive medicine, new patient 18 through 39 years), (Initial comprehensive preventive medicine, new patient, years), (Initial comprehensive preventive medicine, new patient 65 years or older), (Periodic comprehensive preventive medicine, established patient age younger than 1 year), (Periodic comprehensive preventive medicine, early childhood, established patient {age 1 through 4 years}), (Periodic comprehensive Page 1 of 13

2 preventive medicine, late childhood, established patient {age 5 through 11 years}), (Periodic comprehensive preventive medicine, adolescent established patient {age 12 through 17 years}), (Periodic comprehensive preventive medicine, established patient years), (Periodic comprehensive preventive medicine established patient, years), (Periodic comprehensive preventive medicine, established patient 65 years and older), S0610 (Annual gynecological examination, new patient), S0612 (Annual gynecological examination, established patient) or S0613 (Annual gynecological examination; clinical breast examination without pelvic examination) CODE RULE CODE Q0091 Incidental S0610-S0613 Rationale for Edit: Anthem Central Region bundles Q0091 as incidental with , , , , , , , , , , 99360, , , , , , 99499, , or S0610-S0613. Anthem Central Region considers screening services are part of performing an evaluation and management services and therefore not reimbursed separately. Therefore, if Q0091 is submitted with , , , Page 2 of 13

3 99239, , , , , , , 99360, , , , , , 99499, , or S0610-S0613 only , , , , , , , , , , 99360, , , , , , 99499, , or S0610-S0613 is reimbursable. References: 1. Anthem Blue Cross and Blue Shield. EPRP: #00036 Screening Services with Evaluation and Management Services. Enterprise Professional Reimbursement Policy. Pages 1-2. Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Subject: Screening Papanicolaou (Pap Smear) with Evaluation and Management Services Edit #: 305 Effective Date: 9/12/2008-7/14/2013 Status: Prior Last Review Date: 5/8/2008 Edit (Initial outpatient evaluation and management services), (Established outpatient evaluation and management services), (Observation care discharge or initial observation care evaluation and management services), (Initial, subsequent, observation or inpatient care or hospital discharge evaluation and management services), (Office consultation evaluation and management services), (Inpatient consultation evaluation and management services-new or established), (Confirmatory consultation evaluation and management services), and (Emergency Department, critical care and neonatal and pediatric critical care services) (Nursing facilities, Domiciliary, Rest Home and home care evaluation and management services) and (Work related evaluation and management services) bundles with Q0091 (Screening Papanicolaou; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) (Initial outpatient evaluation and management services), (Established outpatient evaluation and management services), (Observation care discharge or initial observation care evaluation and management services), (Initial, Page 3 of 13

4 subsequent, observation or inpatient care or hospital discharge evaluation and management services), (Office consultation evaluation and management services), (Inpatient consultation evaluation and management services-new or established), (Confirmatory consultation evaluation and management services), and (Emergency Department, critical care and neonatal and pediatric critical care services) (Nursing facilities, Domiciliary, Rest home and home care evaluation and management services) and (Work related evaluation and management services) does not bundle with Q0091 (Screening Papanicolaou; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) Q (Screening Papanicolaou; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) does not bundle with (Initial outpatient evaluation and management services), (Established outpatient evaluation and management services), (Observation care discharge or initial observation care evaluation and management services), (Initial, subsequent, observation or inpatient care or hospital discharge evaluation and management services), (Office consultation evaluation and management services), (Inpatient consultation evaluation and management services-new or established), (Confirmatory consultation evaluation and management services), and (Emergency Department, critical care and neonatal and pediatric critical care services) (Nursing facilities, Domiciliary, Rest Home and home care evaluation and management services) and (Work related evaluation and management services) does not bundle with Q (Screening Papanicolaou; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) Q0091 (Screening Papanicolaou; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) bundles with (Preventive medicine services, new patient or established patient). Q0091 (Screening Papanicolaou; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) bundles with (Preventive medicine services, new patient or established patient). CODE RULE CODE Incidental Separate Reimbursement Q0091 Q0091 Page 4 of 13

5 Separate Reimbursement Q Q0091 Incidental Rationale for Edit: Anthem Central Region bundles , , , , , , , , and Based on the National Correct Coding Initiative Edits, codes , , , , , , , , and are listed as component codes to code Q0091. Therefore, if , , , , , , , , and is submitted with Q0091 only Q0091 reimburses. Anthem Central Region does not bundle , , , , , , , , and with Q0091 and does not bundle , , , , , , , , and with Q Based on the 2008 HCPCS manual, which states: Q0091 may be reported with an E/M code when a separate identifiable E/M service is provided. To identify when a separate evaluation and management service is required to be submitted along with the Q0091service, append modifier 25 to the E/M service or modifier 59 to Q0091. Therefore, if , , , , , , , , and with Q0091 both the E/M service ( , , , , , , , , and ) and Q0091 reimburses separately; or if , , Page 5 of 13

6 99220, , , , , , and is submitted with Q both E/M service ( , , , , , , , , and ) and Q reimburses separately. Anthem Central Region bundles Q0091as incidental with Based on the CPT Assistant Coding Consultation Questions and Answers article, where it states: Evaluation and Management: Preventative Medicine Services, 99381, (Q&A) Question Is a pap, pelvic, and/or breast exam included in the appropriate preventive medicine service codes performed on the same date of service? Or should the pap, pelvic, and/or breast exam be reported in addition to the preventive medicine service codes ( ). AMA Comment The codes in the preventive medicine services include the ordering of appropriate immunization(s) and laboratory or diagnostic procedures. The performance of immunization and ancillary studies involving laboratory, radiology, other procedures, or screening tests identified with a specific CPT code are reported separately. In 2005, the range of codes listed in the introductory notes for preventive medicine services referencing immunizations was revised to encompass new codes (90465, 90466, 90467, 90468) for immunization administration accompanied by counseling. The guidelines were revised strictly to identify the new immunization administration accompanied by counseling CPT codes. Codes are used to report the preventive evaluation and management (E/M) of infants, children, adolescents, and adults. The extent and focus of the services will largely depend on the age of the patient. For example, E/M preventive services for a 28-year-old adult female may include a pelvic examination including obtaining a pap smear, breast examination, and blood pressure check. Counseling is provided regarding diet and exercise, substance use, and sexual activity. Therefore, based upon this information, it would not be appropriate to separately report for a pelvic exam including obtaining of the pap smear, nor the breast exam as these services are considered part of a comprehensive preventive medicine E/M services. Therefore, if Q0091 is submitted with only reimburses. Reference Information: Page 6 of 13

7 1. Centers for Medicare and Medicaid (April 1, 2008-June 30, 2008) National Correct Coding Initiative Edits Retrieved, April 15, 2008, from the World Wide Web: terbydid=- 99&sortByDID=2&sortOrder=ascending&itemID=CMS046553&intNumPerPage=10 2. American Medical Association. Questions and Answers-Evaluation and Management: Preventive Medicine Services, CPT Assistant, 2005 (August ): page 15. Prior Version(s), if any, of this edit can be found below {Times New Roman 14} Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Subject: Screening Papanicolaou (Pap Smear) with Evaluation and Management Services Edit #: 305 Effective Date: 3/3/2006-9/11/2008 Status: Prior Last Review Date: 4/12/2007 Edit (Initial outpatient evaluation and management services), (Established outpatient evaluation and management services), (Observation care discharge or initial observation care evaluation and management services), (Initial, subsequent, observation or inpatient care or hospital discharge evaluation and management services), (Office consultation evaluation and management services), (Inpatient consultation evaluation and management services-new or established), (Confirmatory consultation evaluation and management services), and (Emergency Department, critical care and neonatal and pediatric critical care services) (Nursing facilities and home care evaluation and management services), (Preventive evaluation and management-new and established) and (Work related evaluation and management services) bundles with Q0091 (Screening Papanicolaou; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) (Initial outpatient evaluation and management services), (Established outpatient evaluation and management services), (Observation care Page 7 of 13

8 discharge or initial observation care evaluation and management services), (Initial, subsequent, observation or inpatient care or hospital discharge evaluation and management services), (Office consultation evaluation and management services), (Inpatient consultation evaluation and management services-new or established), (Confirmatory consultation evaluation and management services), and (Emergency Department, critical care and neonatal and pediatric critical care services) (Nursing facilities and home care evaluation and management services), (Preventive evaluation and management-new and established) and (Work related evaluation and management services) does not bundle with Q0091 (Screening Papanicolaou; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory). CODE RULE CODE (Deleted Codes) (Deleted codes) (Deleted Codes) (Deleted Codes) Incidental Separate Reimbursement Q0091 Q0091 Page 8 of 13

9 Rationale for Edit: Anthem Midwest bundles , , , , , , , , , , , or as incidental with Q0091. Based on the National Correct Coding Initiative Edits, codes , , , , , , , , , and are listed as component codes to code Q0091. In a 2005 CPT Assistant, Coding Consultation-Questions and Answers, article, where it states: article, it states: Evaluation and Management: Preventative Medicine Services, 99381, (Q&A) Question Is a pap, pelvic, and/or breast exam included in the appropriate preventive medicine service codes performed on the same date of service? Or should the pap, pelvic, and/or breast exam be reported in addition to the preventive medicine service codes ( )? AMA Comment The codes in the preventive medicine services include the ordering of appropriate immunization(s) and laboratory or diagnostic procedures. The performance of immunization and ancillary studies involving laboratory, radiology, other procedures, or screening tests identified with a specific CPT code are reported separately. In 2005, the range of codes listed in the introductory notes for preventive medicine services referencing immunizations was revised to encompass new codes (90465, 90466, 90467, 90468) for immunization administration accompanied by counseling. The guidelines were revised strictly to identify the new immunization administration accompanied by counseling CPT codes. Codes are used to report the preventive evaluation and management (E/M) of infants, children, adolescents, and adults. The extent and focus of the services will largely depend on the age of the patient. For example, E/M preventive services for a 28-year-old adult female may include a pelvic examination including obtaining a pap smear, breast examination, and blood pressure check. Counseling is provided regarding diet and exercise, substance use, and sexual activity. Therefore, based upon this information, it would not be appropriate to separately report for a pelvic exam including obtaining of the pap smear, nor the breast exam as these services are considered part of a comprehensive preventive medicine E/M services. Therefore, if , , , , , , , , , , or is submitted with Q0091 only Q0091 reimburses. Page 9 of 13

10 Anthem Midwest does not bundle , , , , , , , , , , or with Q0091. Based on the 2007 HCPCS Manual, Q0091 can be reported with an E/M code when a separately identifiable E/M service is provided. Append modifier 25 to the evaluation and management service ( , , , , , , , , , and ) to show a separate identifiable service was required along with the performance of Q0091. Therefore, if , , , , , , , , , , and is submitted with Q0091 both the evaluation and management service and the obtaining of the pap smear (Q0091) reimburses separately. Reference Information: 1. Centers for Medicare and Medicaid (July 1, 2001-September 30, 2007) National Correct Coding Initiative Edits-version Retrieved September 12, 2005 from the World Wide Web: 2. Centers for Medicare and Medicaid (January 1, 2007-March 31, 2007) National Correct Coding Initiative Edits-Version Retrieved March 29, 2007 from the World Wide Web: ydid=-99&sortbydid=2&sortorder=ascending&itemid=cms046553&intnumperpage=10 3. American Medical Association. Coding Consultation: Questions and Answers---Evaluation and Management: Preventive Medicine Services, 99381, (Q&A). CPT Assistant (August): page 15 Prior Version(s), if any, of this edit can be found below {Times New Roman 14} Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Subject: Screening Papanicolaou (Pap Smear) with Evaluation and Management Services Page 10 of 13

11 Edit #: 305 Effective Date: 09/09/ /02/2006 Status: Prior Last Review Date: 05/10/2001 Edit Q0091 (Screening Papanicolaou; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) is redundant/mutually exclusive with (Initial outpatient evaluation and management services), (Established outpatient evaluation and management services), (Observation care discharge or initial observation care evaluation and management services), (Initial, subsequent, observation or inpatient care or hospital discharge evaluation and management services), (Office consultation evaluation and management services), (Inpatient consultation evaluation and management services), (Confirmatory consultation evaluation and management services), and (Emergency Department, critical care and neonatal and pediatric critical care services) (Nursing facilities and home care evaluation and management services), (Preventive medicine evaluation and management services) and (Work related evaluation and management services). Q0091 (Screening Papanicolaou; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) does not bundle with (Initial outpatient evaluation and management services), (Established outpatient evaluation and management services), (Observation care discharge or initial observation care evaluation and management services), (Initial, subsequent, observation or inpatient care or hospital discharge evaluation and management services), (Office consultation evaluation and management services), (Inpatient consultation evaluation and management services), (Confirmatory consultation evaluation and management services), and (Emergency Department, critical care and neonatal and pediatric critical care services) (Nursing facilities and home care evaluation and management services), (Preventive medicine evaluation and management services) and (Work related evaluation and management services). CODE RULE CODE Q0091 Redundant/Mutually Exclusive Page 11 of 13

12 Rationale for Edit: Q0091 Separate Reimbursement Anthem Central Region bundles Q0091 as redundant with , , , , , , , , , , and Based on a CPT Assistant article: pelvic exams are considered to be a component of evaluation and management services: "Several procedures that do not have separate CPT codes are included when an E/M code is reported. These include, for example, gastric intubation {passage of a nasogastric tube} and a pelvic examination without anesthesia. Gastric intubation and aspiration or lavage for treatment {e.g., for ingested poisons} is reported using code Reporting indicated that the physician passes a nasogastric tube and aspirates the contents of the stomach or lavages the stomach. Placing a nasogastric tube into the stomach only is not coded separately from the E/M service. A pelvic examination under anesthesia is reported using code A pelvic examination performed without anesthesia is not coded separately, it is included in the evaluation and management code reported for the visit." Therefore, if Q0091 is submitted with evaluation and management services ( , , , , , , , , , , and )--only the evaluation and management service will reimburse. Anthem Midwest does not bundle Q0091 with , , , , , , , , , , and Based on the 2003 HCPCS Level II manual, under code Q0091, it states: "Q0091 can be reported with an E/M code when a separate identifiable E/M service is provided. Therefore, if Q0091 is submitted with Page 12 of 13

13 an E/M ( , , , , , , , , , , and )--both will reimburse separately. Reference Information: 1. American Medical Association. Procedures Included with Evaluation and Management Codes. CPT Assistant; Spring 1993; 3(1): Page 13 of 13