CPT and HCPCS Modifiers Payment Policy

Size: px
Start display at page:

Download "CPT and HCPCS Modifiers Payment Policy"

Transcription

1 Policy Blue Cross Blue Shield of Massachusetts (Blue Cross*) accepts industry-standard modifiers to allow for clear provider reporting of services and accurate claims processing. Modifiers designate a reported service or procedure performed that has been noted by specific criteria without changing the procedure code. Some examples a modifier may be used to indicate are: A bilateral procedure An unusual circumstance The professional or technical component of a service has been performed Service performed on right or left side of the body General Benefit Information Services and subsequent payment are based on the member s benefit plan and provider Agreement. Providers and their office staff may use our electronic technologies to verify effective dates and members copayments before initiating services. Please visit our etools page to access links that provide information on member eligibility and benefits. Member liability may include, but is not limited to, copayments, deductibles, and co-insurance, and will be applied depending upon the member s benefit plan. Certain services may require prior authorization or referral. Please refer to the member s subscriber certificate for more information and Authorization Requirements by Product. Payment Information Blue Cross reimburses health care providers based on: Network provider reimbursement or contracted rates Member benefits Claims are subject to payment edits, which Blue Cross updates regularly. General reimbursement information: Modifiers may affect how claims are processed, how services are priced, and how payment is calculated. Modifiers can also affect how we apply member benefits. Claims submitted with modifiers are subject to pre and/or post-pay audit. Medical notes must support services identified by the modifier. Blue Cross accepts all standard current procedural terminology (CPT) and healthcare common procedure coding system (HCPCS) modifiers submitted in accordance with the appropriate procedure codes. Certain modifiers, when submitted appropriately, will impact reimbursement. The absence or presence of a modifier may result in a claim denial. Modifier 25: Significant, separately identifiable evaluation and management (E/M) service Modifier 25 indicates a significant, separately identifiable E/M service by the same provider or other qualified health care professional on the same day of the procedure or other service. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The submission of modifier 25 appended to a procedure code indicates that documentation is available in the patient s records that will support the distinct, significant, separately identifiable nature of the E/M service submitted with modifier 25, and that these records will be provided in a timely manner for review when requested. All surgical procedures and some non-surgical procedural services include a certain degree of provider involvement or supervision, pre-service work, and post-service work which is integral to that service. For those procedures and services, a separate E/M service is not normally reimbursed. By assigning a global days indicator of 000 or 010, CMS is indicating that the RVU for the procedure includes reimbursement for the assessment of the problem, determining that the procedure is necessary, evaluating whether 1 of 11

2 the procedure is appropriate and the patient is a good candidate, discussing the risks and benefits, and obtaining informed consent, as well as performing the procedure. To support reporting a separate E/M with modifier 25, the evaluation must extend beyond what will be treated by the procedure. Example of proper use of modifier 25: An established patient is seen in the office for a follow-up of their diabetes. While there, the patient asks the provider to address a new issue of left hip pain. The physician: Performed a problem-focused history and exam of the patient s hypertension and diabetes, and changed the patient s medications. Evaluated the hip and performed an injection/arthrocentesis. Bill and The evaluation of the hip problem is included in CPT The patient was seen for a problem other than the hip, necessitating an E/M service. Example of improper use of modifier 25: A patient sees the doctor with a complaint of multiple skin lesions in the neck and axilla area which are causing discomfort from itching and bleeding. The physician recommends removal of the lesions. 20 lesions are removed. Bill only. No E/M with modifier 25 is reported. The use of modifier 25 is not appropriate because the E/M service did not go above and beyond the usual preoperative service. Also, since CPT has a global period of 010 days, the decision for surgery E/M services on the same date of service as the minor surgical procedure are not eligible to be reported with modifier 57 either, but are included in the payment for the surgical procedure. Modifiers 59, {XEPSU}: distinct and independent procedure or service Under certain circumstances, the provider may need to show that a procedure or service was distinct or independent from other non-e/m services performed on the same day. CPT modifier 59 is used to identify procedures and services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same provider. The primary purpose of CPT modifier 59 is to show that two or more procedures are performed at different anatomic sites or during different patient encounters. It should be used only if no other modifier more appropriately describes the relationship of the procedure codes. The Centers for Medicare & Medicaid Services (CMS) established four new HCPCS modifiers (XE, XS, XP, and XU) to provide greater reporting specificity in situations where modifier 59 was previously reported: Modifiers XE XP XS XU Description Separate encounter, a service that is distinct because it occurred during a separate encounter. Use this modifier only to describe separate encounters on the same date of service. Separate practitioner, a service that is distinct because it was performed by a different practitioner. Separate structure, a service that is distinct because it was performed on a separate organ or structure. Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service. o Do not report modifier 59 when a more specific X modifier is available. o Because the X{EPSU} modifiers are more selective versions of the 59 modifier, it is incorrect to include both modifiers on the same line. Do not report the 59 modifier and the X{EPSU} modifier on the same line. o Blue Cross will not stop recognizing the 59 modifier, however, note that CPT instructions state that the 59 modifier should not be used when a more descriptive modifier is available. 2 of 11

3 Examples of proper use of modifiers 59, X{EPSU} Modifier Scenario Rationale 59 Patient is having both: These are mutually exclusive procedures for CCI Paring or cutting of benign hyperkeratotic lesion purposes. (example: corn or callus); single lesion (11055) CPT modifier 59 is only appropriate in this Debridement of nails by any method; one to five (11720) situation if these procedures are performed for lesions that are anatomically separate from one another or if procedures are performed at separate patient encounters. Do not submit CPT codes through for removal of hyperkeratotic skin adjacent to nails needing debridement. XE XP Patient has an 8 a.m. surgery for one distinct procedure, and a 4 p.m. surgery for a second distinct procedure (separate surgical operative sessions on the same date of service). A patient saw her OB-GYN and oncologist on the same day (she is seen by two physicians in the practice on the same day). XS Patient receives an injection in the right hip (20605) and an injection into tendon sheath, right ankle (20550-XS). XU A diagnostic procedure is performed. Based on the findings, a therapeutic or surgical procedure is required on the same day. For example, diagnostic cardiac catheterization is followed by a medically necessary cardiac procedure. Use XE on the second (4 p.m.) procedure because it is a separate encounter. Use XP on the second encounter because it involves: Separate practitioners. Same date of service. May or may not be the same encounter. May or may not be different specialties. Use XS on because: Same encounter. Different anatomical site. Use XU because: Same encounter. Same practitioner. Same anatomical site, structure, or organ. Examples of improper use of modifier 59, X{EPSU} When another established, more descriptive modifier is available and more appropriate. When used with an E/M service. If submitted with E/M codes , E/M codes are processed as though a modifier were not present. To report a separate and distinct E/M service with a non-e/m service performed on the same date (use modifier 25, if appropriate). When a valid modifier exists to identify the services. When documentation does not support the separate and distinct status. When used to show multiple administration of injections of the same drug. Billing Information Specific billing guidelines: Submit the modifier that will impact payment in the first modifier field, followed by any informational modifiers. Use modifiers from the current CPT or HCPCS Level II manual. Medicare Advantage anesthesia claims submitted without anesthesia modifiers will deny. Report ambulance services using two individual modifier letters. The first letter shows the point of origin and the second letter shows the destination. 3 of 11

4 When submitting claims for reimbursement, providers should report all services: Using the most up-to-date industry-standard procedure and diagnosis codes Including modifiers where applicable For your convenience, below are tables of the most commonly used CPT standard modifiers and Blue Cross payment policies for those modifiers. Please refer to the CPT and HCPCS manuals for a complete list of CPT and HCPCS standard modifiers. Common ambulance modifiers Common anatomic modifiers Common anesthesia modifiers Common DME and orthotic modifiers Common early intervention modifiers Common standard modifiers Common standard modifiers 22 Unusual procedural services. Affects reimbursement for surgical codes only. Additional reimbursement will be considered only if the additional work is documented in the operative report submitted to support the use of modifier 22. Descriptions of additional work included in a cover letter are not considered part of the medical record and cannot be used to support additional reimbursement. Providers may or may not receive additional reimbursement when the claim is paid based on the information in the operative report. Additional reimbursement is calculated as a percentage of the allowed amount. Do not report with an evaluation and management (E/M) code. 23 Unusual anesthesia. No impact on reimbursement. 24 E/M service performed during the postoperative period for reasons unrelated to the original surgical procedure. 25 Significant, separately identifiable E/ M service by same physician on the same day as the procedure or other services Report for E/M services unrelated to the surgery. Visits for complications of surgery not requiring a return trip to the operating room are not appropriate for modifier 24. Clinical notes must support a significant, separately identifiable E/M service above and beyond the other services provided. Do not report with surgical procedure or non E/M codes. For a same-day preventive and sick E/M, the service with the lower valued resource consumption is reimbursed at 50% of the fee schedule or allowable amount. The submission of modifier 25 appended to a procedure code indicates that documentation is available in the patient s records for review upon request. This documentation must support the distinct or independent identifiable nature of the service submitted with modifier 25. All claims submitted with this modifier are subject to preand post-pay audit. See the billing guidelines section above for additional information. 26 Professional component No impact on reimbursement. 4 of 11

5 The Centers for Medicare & Medicaid (CMS) designates which procedure codes are valid for use with modifier 26 and modifier TC. Blue Cross uses these CMS designations in determining procedure code/modifier combinations that are valid for Blue Cross use. TC Technical component No impact on reimbursement. CMS designates which procedure codes are valid for use with modifier 26 and modifier TC. Blue Cross uses these CMS designations in determining procedure code/modifier combinations. 27 Multiple outpatient hospital No impact on reimbursement. E/M encounters on the same date 32 Mandated services No impact on reimbursement. 33 Preventive services This modifier allows providers to identify a service that is not inherently preventive, but was rendered for a preventive purpose and for which patient cost-sharing does not apply under the Patient Protection and Affordable Care Act. Modifier 33 may be used when a service was initiated as a preventive service, which resulted in a conversion to a therapeutic service. For Blue Cross members, modifier 33 affects reimbursement for specific colonoscopy services. 47 Anesthesia by surgeon No impact on reimbursement. Do not report on anesthesia services. 50 Bilateral procedure Reimbursement is 150% of allowed amount for specific codes. Do not use this modifier to report services with codes for which the narrative indicates bilateral. 51 Multiple procedures No impact on reimbursement. 52 Reduced services Reimbursement is 50% of the allowed amount. 53 Discontinued procedure due to extenuating circumstance Effective 9/1/17 Reimbursement is 25% of the allowed amount for all services reported with modifier 53. Prior to 9/1/17 Modifier 53 is recognized when reported with colonoscopy codes 45378, G0105, and G1021. For all other services reported with modifier 53, there is no effect on reimbursement. Blue Cross uses CMS RVU files to calculate payment for services reported with modifier Surgical care only Payment varies based on the CPT Code used to report the service being modified. On the fee schedule, payment is based on the intraoperative portion of the global fee and the inpatient postoperative services. 55 Postoperative management only Payment varies based on the CPT code used to report the service being modified. The surgeon should not report modifier of 11

6 The physician performing the outpatient postoperative care should report the surgical procedure code and modifier 55. Report postoperative care after services have been rendered. The dates of service should indicate the range from the first to the last date of service. The number of units reported should equal the number of services rendered. 56 Preoperative management only Payment varies based on the CPT code used to report the service being modified. This modifier is valid only for major surgeries (those with a 90-day global period). 57 Decision for surgery This modifier is valid only for major surgeries those with a 90-day global period. Report with E/M service code only. 58 Staged or related procedure or Recognized for certain procedures. service by the same physician For treatment of a problem that requires a return trip to the during the postoperative period operating room/procedure room, please see modifier Distinct procedural service After appropriate use of a modifier is validated, XE XS XP XU Separate encounter. A service that is distinct because it occurred during a separate encounter Separate structure. A service that is distinct because it was performed on a separate organ/structure Separate practitioner. A service that is distinct because it was performed by a different practitioner. Unusual non-overlapping service. The use of a service that is distinct because it does not overlap usual components of the main service. reimbursement will be made according to the fee schedule or allowable amount. Submission of modifier 59 or X {EPSU} modifiers appended to a procedure code indicates that documentation is available in the patient s records, for review upon request. This documentation will support the distinct or independent identifiable nature of the service submitted with the modifier. Do not report with an E/M service code. Do not report modifier 59 when a more specific X modifier is available. All claims submitted with these modifiers are subject to pre- and post-payment audit. Because the X{EPSU} modifiers are more selective versions of the 59 modifier, it would be incorrect to include both modifiers on the same line. Do not report the 59 modifier and the X{EPSU} modifier on the same line. See the billing guidelines section above for additional information. 62 Two surgeons (co-surgeons) Each surgeon is reimbursed at 62.5% of the global surgical fee. Use modifier 62 only with procedures that warrant two surgeons (co-surgeons) according to the CMS National Physician Fee Schedule Relative Value File. 63 Procedure performed on infants less than 4kg No impact on reimbursement. 66 Surgical team The operative report for each procedure is required. Reimbursement is based on the complexity of the surgery described in the operative report after individual consideration. 6 of 11

7 Use modifier 66 only with procedures that warrant a surgical team according to the CMS National Physician Fee Schedule Relative Value File. 73 Discontinued outpatient/ Reimbursement is 30% of the allowed amount. ambulatory surgery center procedure (ASC) prior to anesthesia administration 74 Discontinued outpatient/ ambulatory surgery center procedure (ASC) after anesthesia administration Reimbursement is 50% of the allowed amount. 76 Repeat procedure by same physician 77 Repeat procedure by another physician 78 Unplanned return to the operating room for a related procedure during the postoperative period 79 Unrelated procedure or service by the same physician during the postoperative period No impact on reimbursement. Do not report on an E/M service code. For repeat laboratory tests performed on the same day, use modifier 91. No impact on reimbursement. Do not report on an E/M service code. For repeat laboratory tests performed on the same day, use modifier 91. Effective 9/1/17 Reimbursement is 80% of the allowed amount for all services reported with modifier 78. Prior to 9/1/17 No impact on reimbursement. Recognized on surgical procedures. No impact on reimbursement. Recognized only for surgical procedures. 80 Assistant surgeon Surgical assistant reimbursed based on 16% of the fee schedule allowable. Use modifier 80 only with procedures that warrant an assistant surgeon according to the CMS National Physician Fee Schedule Relative Value File. 81 Minimum assistant surgeon Surgical assistant reimbursed based on 16% of the fee schedule allowable. Use modifier 81 only with procedures that warrant a minimum assistant surgeon according to the CMS National Physician Fee Schedule Relative Value File. 82 Assistant surgeon (when qualified resident surgeon not available) 90 Reference (outside) laboratory No impact on reimbursement. Surgical assistant reimbursed based on 16% of the fee schedule allowable. Use modifier 82 only with procedures that warrant an assistant surgeon in accordance with the CMS National Physician Fee Schedule Relative Value File. 91 Repeat clinical diagnostic No impact on reimbursement. laboratory test 92 Alternative laboratory testing No impact on reimbursement. 95 Synchronous telemedicine service rendered via a real-time Reimbursement is calculated using 50% of the Practice Expense (PE) Relative Value Unit (RVU) for the service. 7 of 11

8 interactive audio and video telecommunications system 96 Habilitative services Use modifier SZ when submitting claims for members with a habilitation services benefit. Habilitation services are defined as health care services that help a person keep, learn, or improve skills and functioning for daily living. 97 Rehabilitative services 99 Multiple modifiers No impact on reimbursement. Other applicable modifier may be listed as part of the description of services. AM Physician billing for PA under No impact on reimbursement. direct supervision AS Physician assistant-specialty care, nurse practitioner-specialty care, for assistant at surgery Reimbursed at 16% of the fee schedule allowable. CT GA Computed tomography services furnished using equipment that does not meet each of the attributes of the national electrical manufacturers association (NEMA) xr standard Waiver of liability statement issued as required by payer policy, individual case GT Via interactive audio and video telecommunication systems GV Attending physician not employed or paid under arrangement by the patient's hospice provider GW Service not related to the hospice patient's terminal condition HE Mental health program psychiatrist nurse practitioner JG Drug or biological acquired with 340B drug pricing program discount JW PT Drug amount discarded/not administered to any patient Colorectal cancer screening test; converted to diagnostic test or other procedure Effective 6/1/2016, the technical component and the technical component of the global fee is reduced by 5%. Effective 1/1/2017, the technical component and the technical component of the global fee is reduced by 15%. Blue Cross will not reimburse for services reported and billed with the GA modifier. Use when an advance beneficiary notice (ABN) is required based on payer policy. Charges should be shown as covered. Beneficiary will be held liable. Reimbursement is calculated using 50% of the practice expense (PE) relative value unit (RVU) for the service. For physician services associated with approved hospice services delivered in a setting other than hospice, bill with the appropriate home visit CPT codes. For physician services associated with approved inpatient hospice services, bill the appropriate inpatient level of care CPT codes. For Commercial: No impact to reimbursement at this time. Report for informational purposes only. For Medicare Advantage: Base payment reduced to ASP minus 22.5% effective 1/1/2018. Providers must submit modifier JW to identify unused drug or biologicals from single use vials or single use packages for the last dose of the day for that drug or biological that is appropriately discarded. Bill with preventive/screening colonoscopies to indicate no member cost share. 8 of 11

9 SA Physician billing for nurse No impact on reimbursement. practitioner under direct supervision SB Physician billing for certified No impact on reimbursement. nurse-midwife under direct supervision SL State supplied vaccine Not reimbursed. SW Services rendered by certified diabetes educator TB Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes Modifier must be used when reporting diabetes outpatient management services. Commercial: Report for informational purposes Medicare Advantage: Report for informational purposes. TC Technical component TU Special payment rate, overtime Use to report overtime sleep studies. Common ambulance modifiers D Diagnostic or therapeutic site other than P or H when these codes are used as origin codes Report using two modifiers; E Residential, domiciliary custodial facility (other than an 1819 facility) origin and destination. G Hospital-based dialysis facility (hospital or hospital-related) H Hospital J Non hospital-based dialysis facility N Skilled nursing facility (SNF) P Physician s office (includes HMO non-hospital facility, clinic, for example) R Residence S Scene of accident of acute event Common anesthesia modifiers AA Anesthesia services personally performed by the anesthesiologist AD Medical supervision by a physician; more than four concurrent anesthesia services G8 Monitored anesthesia care (MAC) for deep, complex complicated or markedly invasive surgical procedure G9 MAC for at risk patient No impact on QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals reimbursement. QX Qualified non physician anesthetist with medical direction by a physician QY Medical direction of one qualified non physician anesthetist by an anesthesiologist QZ CRNA service: without medical direction by a physician QS Monitored anesthesiology care services (can be billed by a qualified non physician anesthetist or a physician) P1-P6 Anesthesia physical status modifiers Not reimbursed. 9 of 11

10 Common anatomic modifiers E1-E4 Anatomic modifiers associated with the eyelid FA, F1-F9 Anatomic modifiers associated with the fingers LT, RT Left side, right side (used to identify procedures performed on the left or right sides of the body) No impact on reimbursement. LC, LD, Anatomic modifiers associated with the coronary arteries LM, RC, RI TA, T1-T9 Anatomic modifiers associated with the toes Common DME and orthotic modifiers KR Rental item, partial month NU New equipment Report the NU modifier when DME is to be purchased. Reimbursed at fee schedule allowable. RR Rental Report the RR modifier when DME is to be rented. Reimbursed at fee schedule allowable. TW Back-up equipment UE Used durable medical equipment Common early intervention modifiers Modifier: Description: AH Clinical psychologist AJ Clinical social worker HN Bachelor s degree level TD Registered nurse (RN) TE Licensed practical nurse (LPN) or licensed vocational nurse (LVN) TJ Program group, child and/or adolescent Related Policies Ambulance Anesthesia Durable Medical Equipment (DME) Early Intervention Immunizations Respiratory Durable Medical Equipment (DME) Services Surgery-Professional Document History 01/19/2011 Policy effective date. 08/01/2012 Revision of existing policy with edits for clarity. 08/05/2014 Template update, annual review. 02/05/2015 Addition of information regarding CMS establishment of four new HCPCS modifiers (referred to collectively as X {EPSU} modifiers) to define specific subsets of the -59 modifier. 07/23/2015 Annual review; template update. Addition of information regarding reimbursement with GA and GT modifiers, effective 1/1/16. 06/30/2016 Annual review, template update; inclusion of documentation of existing reimbursement guidelines; addition of information regarding reimbursement of AS, SA, SB, and PT modifiers. 09/30/2016 Updates for clarity on reimbursement guidelines for modifier CT. Effective 1/1/2017, Blue Cross will apply a 15% reduction for claims billed with modifier CT. Reduction applies to the technical component and the technical component of the global fee. 10 of 11

11 01/01/2017 Annual review; template update; addition of information on modifier 95, modifier CT, and modifier SZ. 06/01/2017 Addition of information on reimbursement guidelines for modifiers: 53, 73, 74, and 78, effective 9/1/2017; inclusion of information on modifiers GV and GW. 09/30/2017 Updated code comments. 01/01/ /30/2018 Coding update, addition of new modifiers 96 and 97; deletion of modifier SZ. Addition of modifiers JG, JW, and TB; addition of billing guidelines for modifiers 25 and 59 {EPSU}; edits for clarity on modifiers 80, 81, 82, and AS 08/06/2018 Update to modifiers JG and TB This document is for informational purposes only and is not an authorization, an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. *Blue Cross refers to Blue Cross and Blue Shield of Massachusetts, Inc. and/or Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. based on Product participation Blue Cross and Blue Shield of Massachusetts, Inc. and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Registered marks of the Blue Cross Blue Shield Association. and SM Registered marks of Blue Cross Blue Shield of Massachusetts. and TM Registered marks of their respective owners. All rights reserved. Blue Cross and Blue Shield of Massachusetts, Inc. is an Independent Licensee of the Blue Cross and Blue Shield Association. Payment policies are intended to help providers obtain Blue Cross Blue Shield of Massachusetts payment information. Payment policy determines the rationale by which a submitted claim for service is processed and paid. Payment policy development takes into consideration a variety of factors, including: the terms of the participating provider s contract(s); scope of benefits included in a given member s benefit plan; clinical rationale, industry-standard procedure code edits, and industry-standard coding conventions. Top of the Document MPC_ K-4-PP 11 of 11

Reimbursement Policy. Subject: Modifier Usage

Reimbursement Policy. Subject: Modifier Usage https://providers.amerigroup.com Reimbursement Policy Subject: Modifier Usage Effective Date:08/01/16 Committee Approval Obtained: 08/01/16 Section: Coding ***** The most current version of our reimbursement

More information

Reimbursement Policy. Subject: Modifier Usage

Reimbursement Policy. Subject: Modifier Usage Reimbursement Policy Subject: Modifier Usage Effective Date: 09/15/17 Committee Approval Obtained: 08/31/17 Section: Coding ***** The most current version of our reimbursement policies can be found on

More information

Modifier Reference Policy

Modifier Reference Policy REIMBURSEMENT POLICY Modifier Reference Policy Policy Number 2018R0111A Annual Approval Date 11/15/2017 Approved By Payment Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You

More information

MODIFIER REFERENCE POLICY

MODIFIER REFERENCE POLICY Oxford MODIFIER REFERENCE POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: ADMINISTRATIVE 026.20 T0 Effective Date: November 1, 2017 Table of Contents Page INSTRUCTIONS FOR USE... 1 APPLICABLE

More information

Empire BlueCross BlueShield Professional Commercial Reimbursement Policy

Empire BlueCross BlueShield Professional Commercial Reimbursement Policy Subject: Modifier Rules NY Policy: 0017 Effective: 04/01/2017 07/31/2017 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria

More information

Modifier Reference Policy

Modifier Reference Policy Modifier Reference Policy Policy Number 2017R0111I Annual Approval Date 11/15/2017 Approved By Payment Policy Oversight Committee IMPORTANT NOTE ABOUT THIS You are responsible for submission of accurate

More information

Reimbursement Policy. Subject: Modifier Usage

Reimbursement Policy. Subject: Modifier Usage Subject: Reimbursement Policy Effective Date: Committee Approval Obtained: Section: Coding 08/31/17 08/31/17 *****The most current version of our reimbursement policies can be found on our provider website.

More information

Reimbursement Policy.

Reimbursement Policy. Anthem Blue Cross and Blue Shield Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Subject: Reimbursement Policy Committee Approval Obtained: Effective Date: 08/31/17 Section:

More information

MEDICAL POLICY Modifier Guidelines

MEDICAL POLICY Modifier Guidelines POLICY: PG0011 ORIGINAL EFFECTIVE: 10/30/05 LAST REVIEW: 12/12/17 MEDICAL POLICY Modifier Guidelines GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by

More information

Committee Approval Obtained: Section: Coding 01/01/18

Committee Approval Obtained: Section: Coding 01/01/18 Subject: Modifier Usage Reimbursement Policy Effective Date: Committee Approval Obtained: Section: Coding 01/01/18 12/28/17 *****The most current version of our reimbursement policies can be found on our

More information

Modifier -25 Significant, Separately Identifiable E/M Service

Modifier -25 Significant, Separately Identifiable E/M Service Manual: Policy Title: Reimbursement Policy Modifier -25 Significant, Separately Identifiable E/M Service Section: Modifiers Subsection: None Date of Origin: 1/1/2000 Policy Number: RPM028 Last Updated:

More information

Anesthesia Services INDIANA HEALTH COVERAGE PROGRAMS. Copyright 2017 DXC Technology Company. All rights reserved.

Anesthesia Services INDIANA HEALTH COVERAGE PROGRAMS. Copyright 2017 DXC Technology Company. All rights reserved. INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Anesthesia Services L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 1 9 P U B L I S H E D : D E C E M B E R 1 2, 2 0 1 7 P O

More information

Anesthesia Policy REIMBURSEMENT POLICY CMS Reimbursement Policy Oversight Committee. Policy Number. Annual Approval Date. Approved By 2018R0032B

Anesthesia Policy REIMBURSEMENT POLICY CMS Reimbursement Policy Oversight Committee. Policy Number. Annual Approval Date. Approved By 2018R0032B REIMBURSEMENT POLICY CMS-1500 Policy Number 2018R0032B Annual Approval Date Anesthesia Policy 3/14/2018 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY

More information

Anesthesia Policy. Approved By 3/08/2017

Anesthesia Policy. Approved By 3/08/2017 REIMBURSEMENT POLICY Anesthesia Policy Policy Number 2018R0032B Annual Approval Date 3/08/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are

More information

Highmark Reimbursement Policy Bulletin

Highmark Reimbursement Policy Bulletin Highmark Reimbursement Policy Bulletin Bulletin Number: Subject: RP-033 Anesthesia Services Effective Date: March 12, 2018 End Date: Issue Date: June 11, 2018 Source: Reimbursement Policy Applicable Commercial

More information

Anesthesia Services Policy

Anesthesia Services Policy Anesthesia Services Policy Policy Number Annual Approval Date 3/14/2018 Approved By Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare Medicare

More information

The ASA defines anesthesiology as the practice of medicine dealing with but not limited to:

The ASA defines anesthesiology as the practice of medicine dealing with but not limited to: 1570 Midway Pl. Menasha, WI 54952 920-720-1300 Procedure 1205- Anesthesia Lines of Business: All Purpose: This guideline describes Network Health s reimbursement of anesthesia services. Procedure: Anesthesia

More information

Empire BlueCross BlueShield Professional Reimbursement Policy

Empire BlueCross BlueShield Professional Reimbursement Policy Subject: Anesthesia Services NY Policy: 0020 Effective: 01/01/2015 11/30/2015 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria

More information

IMPORTANT NOTICE REGARDING NEW ANESTHESIA BILLING GUIDELINES AND REIMBURSEMENT PROCEDURES November 2008

IMPORTANT NOTICE REGARDING NEW ANESTHESIA BILLING GUIDELINES AND REIMBURSEMENT PROCEDURES November 2008 IMPORTANT NOTICE REGARDING NEW ANESTHESIA BILLING GUIDELINES AND REIMBURSEMENT PROCEDURES November 2008 This notice will serve as an update to the August 2007Anesthesia Billing Guidelines and Reimbursement

More information

Reimbursement Policy. Subject: Professional Anesthesia Services

Reimbursement Policy. Subject: Professional Anesthesia Services Reimbursement Policy Subject: Professional Anesthesia Services Effective Date: 01/03/17 Committee Approval Obtained: 01/03/17 Section: Anesthesia ***** The most current version of our reimbursement policies

More information

APPLIES TO: x SummaCare, Inc. x Apex Health Solutions PRODUCT LINE(S): (Check all that apply)

APPLIES TO: x SummaCare, Inc. x Apex Health Solutions PRODUCT LINE(S): (Check all that apply) POLICY NAME: ANESTHESIA PAYMENT POLICY POLICY NUMBER: ISSUING DEPT.: Claims EFFECTIVE DATE: 9/25/2017 APPROVED BY: APPLIES TO: x SummaCare, Inc. x Apex Health Solutions PRODUCT LINE(S): (Check all that

More information

UniCare Professional Reimbursement Policy

UniCare Professional Reimbursement Policy UniCare Professional Reimbursement Policy Subject: Anesthesia Services Policy #: UniCare 0020 Adopted: 02/03/2009 Effective: 02/07/2017 Coverage is subject to the terms, conditions, and limitations of

More information

Modifiers 58, 78, and 79 Staged, Related, and Unrelated Procedures

Modifiers 58, 78, and 79 Staged, Related, and Unrelated Procedures Manual: Policy Title: Reimbursement Policy Modifiers 58, 78, and 79 Staged, Related, and Unrelated Procedures Section: Modifiers Subsection: None Date of Origin: 9/22/2004 Policy Number: RPM010 Last Updated:

More information

IMPORTANT NOTICE REGARDING NEW ANESTHESIA BILLING GUIDELINES AND REIMBURSEMENT PROCEDURES AUGUST 2007

IMPORTANT NOTICE REGARDING NEW ANESTHESIA BILLING GUIDELINES AND REIMBURSEMENT PROCEDURES AUGUST 2007 IMPORTANT NOTICE REGARDING NEW ANESTHESIA BILLING GUIDELINES AND REIMBURSEMENT PROCEDURES AUGUST 2007 This notice will serve as an update to the August 2005 Anesthesia Billing Guidelines and Reimbursement

More information

LOUISIANA MEDICAID PROGRAM ISSUED: 02/01/12 REPLACED: 02/01/94 CHAPTER 5: PROFESSIONAL SERVICES SECTION 5.1: COVERED SERVICES PAGE(S) 11

LOUISIANA MEDICAID PROGRAM ISSUED: 02/01/12 REPLACED: 02/01/94 CHAPTER 5: PROFESSIONAL SERVICES SECTION 5.1: COVERED SERVICES PAGE(S) 11 Anesthesia Services Surgical anesthesia services may be provided by anesthesiologists or certified registered nurse anesthetists (CRNAs). Maternity-related anesthesia services may be provided by anesthesiologists,

More information

Reimbursement Policy. BadgerCare Plus. Subject: Professional Anesthesia Services. Committee Approval Obtained: Effective Date: 05/01/17

Reimbursement Policy. BadgerCare Plus. Subject: Professional Anesthesia Services. Committee Approval Obtained: Effective Date: 05/01/17 Subject: Professional Anesthesia Services Reimbursement Policy Committee Approval Obtained: Effective Date: 05/01/17 Section: Anesthesia 01/03/17 *****The most current version of our reimbursement policies

More information

Reimbursement Policy. BadgerCare Plus. Subject: Consultations

Reimbursement Policy. BadgerCare Plus. Subject: Consultations Subject: Reimbursement Policy Effective Date: Committee Approval Obtained: Section: Evaluation and 04/20/18 04/20/18 Management *****The most current version of our reimbursement policies can be found

More information

Understanding Modifiers. C omprehensive instruction to effective modifier application OPTUM360 LEARNING

Understanding Modifiers. C omprehensive instruction to effective modifier application OPTUM360 LEARNING OPTUM360 LEARNING 2019 Understanding Modifiers C omprehensive instruction to effective modifier application POWER UP YOUR CODING with Optum360, your trusted coding partner for 32 years. Visit optum360coding.com.

More information

Reimbursement Policy.

Reimbursement Policy. Serving Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect Subject: Professional Anesthesia Services Reimbursement Policy Committee Approval Obtained: Effective Date: 01/03/17 Section: Anesthesia

More information

Global Surgery Package

Global Surgery Package Private Property of Florida Blue. This payment policy is Copyright 2017 Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission

More information

VIRGINIA WORKERS COMPENSATION MEDICAL FEE SCHEDULES GROUND RULES JUNE 5, 2017

VIRGINIA WORKERS COMPENSATION MEDICAL FEE SCHEDULES GROUND RULES JUNE 5, 2017 VIRGINIA WORKERS COMPENSATION MEDICAL FEE SCHEDULES GROUND RULES JUNE 5, 2017 Contents Introduction... 3 Definitions... 4 General Information... 11 Application of the Medical Fee Schedules... 11 Exclusions

More information

Empire BlueCross BlueShield Professional Reimbursement Policy

Empire BlueCross BlueShield Professional Reimbursement Policy Subject: Global Surgery NY Policy: 0012 Effective: 02/01/2014 05/31/2014 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria

More information

CMS-1500 Billing and Reimbursement. HP Provider Relations/October 2013

CMS-1500 Billing and Reimbursement. HP Provider Relations/October 2013 CMS-1500 Billing and Reimbursement HP Provider Relations/October 2013 Agenda Common Denials for CMS-1500 CMS-1500 Claims Billing Types of CMS-1500 Claims Paper Claim Billing Fee Schedule Crossover Claims

More information

Cotiviti Approved Issues List as of February 26, 2018

Cotiviti Approved Issues List as of February 26, 2018 Cotiviti Approved Issues List as of February 26, 2018 All physician/npp specialties 32 Ambulance Providers 34 Ambulatory Surgery Center (ASC), Outpatient Hospital 38 Inpatient Hospital 40 Inpatient Hospital,

More information

PAYMENT POLICY. Anesthesia

PAYMENT POLICY. Anesthesia IMPORTANT REMINDER This policy is current at the time of publication. Centene Corporation retains the right to change or amend this policy at any time. While this policy provides guidance regarding reimbursement,

More information

Reimbursement Policy (EXTERNAL)

Reimbursement Policy (EXTERNAL) Subject: Consultations Reimbursement Policy (EXTERNAL) Effective Date: 01/01/15 Committee Approval Obtained: 06/06/16 Section: E&M/Medicine ***** The most current version of our reimbursement policies

More information

Anesthesia Payment & Billing Information

Anesthesia Payment & Billing Information Anesthesia Payment & Billing Information Time and Points Eligible Anesthesia Procedures Defined Blue Cross and Blue Shield of Texas has determined that certain anesthesia procedures will be reimbursed

More information

Laboratory Services Policy, Professional

Laboratory Services Policy, Professional Laboratory Services Policy, Professional UnitedHealthcare Medicare Advantage Reimbursement Policy CMS 1500 Reimbursement Policy Policy Number Annual Approval Date 12/13/2017 Approved By Oversight Committee

More information

TELEMEDICINE POLICY. Policy Number: ADMINISTRATIVE T0 Effective Date: January 1, 2018

TELEMEDICINE POLICY. Policy Number: ADMINISTRATIVE T0 Effective Date: January 1, 2018 TELEMEDICINE POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: ADMINISTRATIVE 114.28 T0 Effective Date: January 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE... 1 APPLICABLE LINES

More information

MEDICAL POLICY No R1 TELEMEDICINE

MEDICAL POLICY No R1 TELEMEDICINE Summary of Changes MEDICAL POLICY TELEMEDICINE Effective Date: March 1, 2016 Review Dates: 12/12, 12/13, 11/14, 11/15 Date Of Origin: December 12, 2012 Status: Current Clarifications: Deletions: Pg. 4,

More information

Anthem Blue Cross and Blue Shield Commercial Professional Reimbursement Policy

Anthem Blue Cross and Blue Shield Commercial Professional Reimbursement Policy Subject: Global Surgery IN, KY, MO, OH, WI Policy: 0012 Effective: 01/01/2018 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria

More information

Anthem Blue Cross and Blue Shield Commercial Professional Reimbursement Policy

Anthem Blue Cross and Blue Shield Commercial Professional Reimbursement Policy Subject: Documentation and Reporting Guidelines for Consultations IN, KY, MO, OH, WI Policy: 0030 Effective: 12/01/2016 Coverage is subject to the terms, conditions, and limitations of an individual member

More information

MEDICAL POLICY No R2 TELEMEDICINE

MEDICAL POLICY No R2 TELEMEDICINE Summary of Changes Clarifications: Page 1, Section I. A 6, additional language added for clarification. Deletions: Additions Page 4, Section IV, Description, additional language added in regards to telemedicine.

More information

Reimbursement Policy. Subject: Professional Anesthesia Services. Effective Date: 04/01/16. Committee Approval Obtained: 08/04/15. Section: Anesthesia

Reimbursement Policy. Subject: Professional Anesthesia Services. Effective Date: 04/01/16. Committee Approval Obtained: 08/04/15. Section: Anesthesia providers.amerigroup.com Subject: Professional Anesthesia Services Effective Date: 04/01/16 Committee Approval Obtained: 08/04/15 Reimbursement Policy Section: Anesthesia ***** The most current version

More information

Medical Practitioner Reimbursement

Medical Practitioner Reimbursement INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Medical Practitioner Reimbursement LIBRARY REFERENCE NUMBER: PROMOD00016 PUBLISHED: FEBRUARY 28, 2017 POLICIES AND PROCEDURES AS OF APRIL 1,

More information

Professional Fee Schedule Instruction Set Effective July 1, 2017

Professional Fee Schedule Instruction Set Effective July 1, 2017 Professional Fee Schedule Instruction Set Table of Contents Section One: Introduction... 2 Background... 2 Conversion Factors... 2 Related Terminology... 2 Description of Columns in Montana WC Professional

More information

Payment Policy: Visits On Same Day As Surgery Reference Number: CC.PP.040 Product Types: ALL Effective Date: 03/01/2018

Payment Policy: Visits On Same Day As Surgery Reference Number: CC.PP.040 Product Types: ALL Effective Date: 03/01/2018 Payment Policy: Visits On Same Day As Surgery Reference Number: CC.PP.040 Product Types: ALL Effective Date: 03/01/2018 Revision Log See Important Reminder at the end of this policy for important regulatory

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Podiatry

KANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Podiatry Fee-for-Service Provider Manual Podiatry Updated 03.2014 PART II Introduction Section BILLING INSTRUCTIONS Page 7000 Podiatry Billing Instructions.................. 7-1 Submission of Claim..................

More information

Acromioclavicular Joint Billing

Acromioclavicular Joint Billing Acromioclavicular Joint Billing October 27, 2016 When our physician performs an injection into the acromioclavicular (AC) joint of a patient in the office, can we bill 20610 for a large joint arthrocentesis?

More information

NEW YORK STATE MEDICAID PROGRAM PHYSICIAN PROCEDURE CODES. SECTION 2 MEDICINE, DRUGS and DRUG ADMINISTRATION

NEW YORK STATE MEDICAID PROGRAM PHYSICIAN PROCEDURE CODES. SECTION 2 MEDICINE, DRUGS and DRUG ADMINISTRATION NEW YORK STATE MEDICAID PROGRAM PHYSICIAN PROCEDURE CODES SECTION 2 MEDICINE, DRUGS and DRUG ADMINISTRATION Table of Contents GENERAL RULES AND INFORMATION... 3 MMIS MODIFIERS... 13 EVALUATION AND MANAGEMENT

More information

UniCare Professional Reimbursement Policy

UniCare Professional Reimbursement Policy UniCare Professional Reimbursement Policy Subject: Global Surgery Policy #: UniCare 0012 Adopted: 07/15/2008 Effective: 08/01/2017 Coverage is subject to the terms, conditions, and limitations of an individual

More information

PECULIARITIES OF BILLING AND CODING IN LTC OCTOBER 14, 2011

PECULIARITIES OF BILLING AND CODING IN LTC OCTOBER 14, 2011 PECULIARITIES OF BILLING AND CODING IN LTC OCTOBER 14, 2011 PRESENTED BY ALVA S. BAKER, MD, CMD Maine Medical Directors Association Faculty Disclosures: Dr. Baker has disclosed that he has no relevant

More information

Global Days Policy. Approved By 7/12/2017

Global Days Policy. Approved By 7/12/2017 Global Days Policy Policy Number 2018R0005A Annual Approval Date 7/12/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS You are responsible for submission of accurate

More information

Modifier 53 Discontinued Procedure

Modifier 53 Discontinued Procedure Manual: Policy Title: Reimbursement Policy Modifier 53 Discontinued Procedure Section: Modifiers Subsection: none Date of Origin: 9/13/2007 Policy Number: RPM018 Last Updated: 5/8/2017 Last Reviewed: 5/12/2017

More information

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY Global Surgery Policy Number GLS03272013RP Approved By UnitedHealthcare Medicare Committee Current Approval Date 04/09/2014 IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare

More information

CLASSIC BLUE SECURE/BLUE CROSS BLUE SHIELD COMPLEMENTARY Monroe County Benefit Summary/Comparison (Over 65 Retirees)

CLASSIC BLUE SECURE/BLUE CROSS BLUE SHIELD COMPLEMENTARY Monroe County Benefit Summary/Comparison (Over 65 Retirees) WHO IS COVERED Enrollment Requirement Members must be enrolled in both Medicare Parts A and B Members must be enrolled in both Medicare Parts A and B Type of Tier Single only Single only Dependent/Student

More information

Chapter 1 Section 16

Chapter 1 Section 16 General Chapter 1 Section 16 Issue Date: August 26, 1985 Authority: 32 CFR 199.4(c)(2)(i), (c)(2)(ii), (c)(3)(i), (c)(3)(iii), and (c)(3)(iv) 1.0 APPLICABILITY Paragraphs 3.1 through 3.7 apply to reimbursement

More information

Chapter 5. Reimbursement

Chapter 5. Reimbursement Chapter 5. Reimbursement 5.1 Physicians and Other Professional Providers 3 5.1.1 Fee Schedule... 3 5.1.2 Immunizations, Drugs, Injectables, Biologicals, Chemotherapy Agents... 5 5.1.3 Specialty Drugs...

More information

Empire BlueCross BlueShield Professional Commercial Reimbursement Policy

Empire BlueCross BlueShield Professional Commercial Reimbursement Policy Subject: Global Surgery NY Policy: 0012 Effective: 10/01/2016 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed below.

More information

Reimbursement Policy. Subject: Consultations Committee Approval Obtained: Effective Date: 11/01/13

Reimbursement Policy. Subject: Consultations Committee Approval Obtained: Effective Date: 11/01/13 Reimbursement Policy Subject: Committee Approval Obtained: Effective Date: 11/01/13 Section: E&M/Medicine 06/06/16 ***** The most current version of our reimbursement policies can be found on our provider

More information

Chapter 5. Reimbursement

Chapter 5. Reimbursement Chapter 5. Reimbursement 5.1 Physicians and Other Professional Providers 3 5.1.1 RBRVS Fee Schedule... 3 5.1.2 Immunizations, Drugs, Injectables, Biologicals, Chemotherapy Agents... 4 5.1.3 Specialty Drugs...

More information

Empire BlueCross BlueShield Professional Commercial Reimbursement Policy

Empire BlueCross BlueShield Professional Commercial Reimbursement Policy Subject: Place of Service NY Policy: 0018 Effective: 12/01/2015 02/21/2016 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria

More information

ALASKA. Official MEDICAL FEE SCHEDULE WORKERS' COMPENSATION

ALASKA. Official MEDICAL FEE SCHEDULE WORKERS' COMPENSATION Official ALASKA WORKERS' COMPENSATION MEDICAL FEE SCHEDULE Effective, 201 STATE OF ALASKA DISCLAIMER This document establishes professional medical fee reimbursement amounts for covered services rendered

More information

Summary of Benefits CCPOA (Basic) Custom Access+ HMO

Summary of Benefits CCPOA (Basic) Custom Access+ HMO Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits CCPOA (Basic) Custom Access+ HMO CCPOA Effective January 1, 2019 HMO Benefit Plan This Summary of Benefits

More information

Telemedicine and Telehealth Services

Telemedicine and Telehealth Services INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Telemedicine and Telehealth Services L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 4 8 P U B L I S H E D : J A N U A R Y 1

More information

Reimbursement Policy. Subject: Consultations Effective Date: 05/01/05

Reimbursement Policy. Subject: Consultations Effective Date: 05/01/05 Reimbursement Policy Subject: Consultations Effective Date: 05/01/05 Committee Approval Obtained: 06/06/16 Section: Evaluation and Management *****The most current version of the Reimbursement Policies

More information

Anesthesia Services Clinical Coverage Policy No.: 1L-1 Amended Date: October 1, Table of Contents

Anesthesia Services Clinical Coverage Policy No.: 1L-1 Amended Date: October 1, Table of Contents Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements... 2 2.1 Provisions... 2 2.1.1 General... 2 2.1.2 Specific... 2 2.2 Special

More information

Modifiers 54 and 55 Split Surgical Care

Modifiers 54 and 55 Split Surgical Care Manual: Policy Title: Reimbursement Policy Modifiers 54 and 55 Split Surgical Care Section: Modifiers Subsection: None Date of Origin: 7/28/2004 Policy Number: RPM030 Last Updated: 7/3/2017 Last Reviewed:

More information

Home Infusion Payment Policy

Home Infusion Payment Policy Home Infusion Payment Policy Policy Blue Cross Blue Shield of Massachusetts (Blue Cross)* reimburses contracted providers for covered, medically necessary home infusion services. General Benefit Information

More information

Corporate Reimbursement Policy

Corporate Reimbursement Policy Corporate Reimbursement Policy Code Bundling Rules Not Addressed in ClaimCheck or Correct File Name: code_bundling_rules_not_addressed_in_claim_check Origination: 6/2004 Last Review: 12/2017 Next Review:

More information

2014 HCPCS (Level II) Modifiers - Abridged

2014 HCPCS (Level II) Modifiers - Abridged 2014 HCPCS (Level II) Modifiers - Abridged A1 - Dressing for one wound A2 - Dressing for two wounds A3 - Dressing for three wounds A4 - Dressing for four wounds A5 - Dressing for five wounds A6 - Dressing

More information

2006 Clinical Coding Workout 5/3/2006 MISSING QUESTIONS Chapter 5, Intermediate Ambulatory Page 1

2006 Clinical Coding Workout 5/3/2006 MISSING QUESTIONS Chapter 5, Intermediate Ambulatory Page 1 Chapter 5, Intermediate Ambulatory Page 1 CPT Modifier Use 5.81. Dr. Raddy, staff radiologist, interprets a chest x-ray that was obtained in the hospital Radiology Department. Dr. Raddy is contracted with

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: skilled_nursing_services 07/2001 2/2018 2/2019 2/2018 Description of Procedure or Service Skilled Nursing

More information

Telehealth and Telemedicine Policy

Telehealth and Telemedicine Policy Reimbursement Policy CMS 1500 Telehealth and Telemedicine Policy Policy Number 2018R0046B Annual Approval Date 7/12/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT

More information

Outpatient Hospital Facilities

Outpatient Hospital Facilities Outpatient Hospital Facilities Chapter 6 Chapter Outline Introduce students to 1. Different outpatient facilities 2. Different departments involved in the reimbursement process 3. The Chargemaster 4. Terminology

More information

KANSAS MEDICAL ASSISTANCE PROGRAM. Provider Manual. Podiatry

KANSAS MEDICAL ASSISTANCE PROGRAM. Provider Manual. Podiatry Provider Manual Podiatry Updated 07/2012 PART II Introduction Section BILLING INSTRUCTIONS Page 7000 Podiatry Billing Instructions.................. 7-1 Submission of Claim.................. 7-1 7010 Podiatry

More information

SNF Consolidated Billing Exclusions/Inclusions

SNF Consolidated Billing Exclusions/Inclusions SNF Consolidated Billing Exclusions/Inclusions Under SNF consolidated billing rules, certain Part B services provided to SNF residents are to be billed directly by the SNF. The facility would bill the

More information

Observation Services Tool for Applying MCG Care Guidelines

Observation Services Tool for Applying MCG Care Guidelines In the event of a conflict between a Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. Plan documents include

More information

MLN Matters Number: MM6740 Revised Related Change Request (CR) #: Related CR Transmittal #: R1875CP Implementation Date: January 4, 2010

MLN Matters Number: MM6740 Revised Related Change Request (CR) #: Related CR Transmittal #: R1875CP Implementation Date: January 4, 2010 News Flash Flu Season is upon us! CMS encourages providers to begin taking advantage of each office visit to encourage your patients with Medicare to get a seasonal flu shot; it s their best defense against

More information

Meet the Presenter. HCPCS Reimbursement Impacts the Bottom Line. Welcome to PMI s Webinar Presentation. On the topic:

Meet the Presenter. HCPCS Reimbursement Impacts the Bottom Line. Welcome to PMI s Webinar Presentation. On the topic: Welcome to PMI s Webinar Presentation Brought to you by: Practice Management Institute pmimd.com Meet the Presenter Rhonda Granja CMC, CMIS, CMOM, CPC, CPM, MCS Faculty Practice Management Institute On

More information

GLOBAL DAYS POLICY. Policy Number: SURGERY T0 Effective Date: January 1, 2018

GLOBAL DAYS POLICY. Policy Number: SURGERY T0 Effective Date: January 1, 2018 GLOBAL DAYS POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: SURGERY 011.37 T0 Effective Date: January 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE... 1 APPLICABLE LINES OF BUSINESS/PRODUCTS...

More information

PHYSICIAN FEE SCHEDULE PAYMENT GROUND RULES: A COMPARISON OF THE OMFS AND MEDICARE *

PHYSICIAN FEE SCHEDULE PAYMENT GROUND RULES: A COMPARISON OF THE OMFS AND MEDICARE * PHYSICIAN FEE SCHEDULE PAYMENT GROUND RULES: A COMPARISON OF THE OMFS AND MEDICARE * Ground Rule and/or OVERALL FEE SCHEDULE DESIGN Conversion factor Separate conversion factors for: Evaluation & Management

More information

NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES

NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES Table of Contents GENERAL INFORMATION... 3 SERVICES PROVIDED IN ARTICLE 28 FACILITIES... 4 MMIS MODIFIERS... 4 MEDICINE SECTION... 7 GENERAL INFORMATION

More information

SECTION 2: TEXAS MEDICAID REIMBURSEMENT

SECTION 2: TEXAS MEDICAID REIMBURSEMENT SECTION 2: TEXAS MEDICAID REIMBURSEMENT 2.1 Payment Information............................................................. 2-2 2.2 Reimbursement Methodology....................................................

More information

Florida Medicaid. Ambulatory Surgical Center Services Coverage Policy. Agency for Health Care Administration

Florida Medicaid. Ambulatory Surgical Center Services Coverage Policy. Agency for Health Care Administration Florida Medicaid Ambulatory Surgical Center Services Coverage Policy Agency for Health Care Administration Table of Contents 1.0 Introduction... 1 1.1 Florida Medicaid Policies..1 1.2 Statewide Medicaid

More information

Provider and Clinical Updates

Provider and Clinical Updates July 2018 An Update for Highmark Health Options Providers and Clinicians An Update for Highmark Health Options Providers and Clinicians Provider and Clinical Updates National Correct Coding Corner Initiative

More information

Jill M. Young, CPC, CEDC, CIMC Young Medical Consulting, LLC East Lansing, MI 4883

Jill M. Young, CPC, CEDC, CIMC Young Medical Consulting, LLC East Lansing, MI 4883 Jill M. Young, CPC, CEDC, CIMC Young Medical Consulting, LLC East Lansing, MI 4883 This material is designed to offer basic information for coding and billing. The information presented here is based on

More information

NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES

NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES Table of Contents GENERAL INFORMATION ------------------------------------------------------------------------------------------ 2 STATE DEPARTMENT

More information

Global Surgery Fact Sheet

Global Surgery Fact Sheet DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Global Surgery Fact Sheet Definition of a Global Surgical Package This fact sheet is designed to provide education on the

More information

Presented by: Jodie Edmonds VP Medicaid Revenue Consultant Passport Health Communications

Presented by: Jodie Edmonds VP Medicaid Revenue Consultant Passport Health Communications Presented by: Jodie Edmonds VP Medicaid Revenue Consultant Passport Health Communications Complete and correct coding of claims will become more important, and will have an effect on claim payment. The

More information

Anthem Blue Cross and Blue Shield Professional Reimbursement Policy

Anthem Blue Cross and Blue Shield Professional Reimbursement Policy Subject: Anesthesia CT Policy: 0020 Effective: 08/01/2014 01/31/2015 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy File Name: Origination: Last CAP Review: Next CAP Review: Last Review: observation_room_services 2/1997 3/2013 3/2014 3/2013 Description of Procedure or Service Observation services

More information

Reimbursement Policy. Subject: Consultations. Committee Approval Obtained: Section: Evaluation and 07/01/17. Effective Date:

Reimbursement Policy. Subject: Consultations. Committee Approval Obtained: Section: Evaluation and 07/01/17. Effective Date: Subject: Consultations https://providers.amerigroup.com Reimbursement Policy Effective Date: Committee Approval Obtained: Section: Evaluation and 07/01/17 06/06/16 Management *****The most current version

More information

Place of Service Code Description Conversion

Place of Service Code Description Conversion Place of Conversion CMS Place of Code Place of Name The place of service field indicates where the services were performed Possible values include: Code Description Inpatient Outpatient Office Home 5 Independent

More information

Telehealth and Telemedicine Policy

Telehealth and Telemedicine Policy Reimbursement Policy CMS 1500 Telehealth and Telemedicine Policy Policy Number 2018R0046J Annual Approval Date 7/11/2018 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT

More information

Provider-Based RHC Billing June 8, 2018

Provider-Based RHC Billing June 8, 2018 Provider-Based RHC Billing June 8, 2018 Sharon Shover, CPC, CEMC 502.992.3511 Provider-Based RHC Billing Agenda RHC Encounters Payment for RHC Services Same Day Visits Revenue Codes CG Modifier & QVL Non-RHC

More information

Coding Guidelines for Certain Respiratory Care Services January 2018 (updates in red)

Coding Guidelines for Certain Respiratory Care Services January 2018 (updates in red) Coding Guidelines for Certain Respiratory Care Services (updates in red) Overview From time to time the AARC receives inquiries about respiratory-related coding and coverage issues through its Help Line

More information

Rural Health Clinic Overview

Rural Health Clinic Overview TrailBlazer Health Enterprises Rural Health Clinic Overview Steven W. Mildward Published March 2012 108724 2012 TrailBlazer Health Enterprises /TrailBlazer. All rights reserved. Important The information

More information

Reimbursement for Anticoagulation Services

Reimbursement for Anticoagulation Services Journal of Thrombosis and Thrombolysis 12(1), 73 79, 2001. # 2002 Kluwer Academic Publishers, Manufactured in The Netherlands. Reimbursement for Anticoagulation Services Paul W. Radensky McDermott, Will

More information

February Jean C. Russell, MS, RHIT Richard Cooley, BA, CCS

February Jean C. Russell, MS, RHIT Richard Cooley, BA, CCS February 2013 Jean C. Russell, MS, RHIT jrussell@epochhealth.com Richard Cooley, BA, CCS rcooley@epochhealth.com 518-430-1144 2 2013 E/M Codes Deleted Codes New Codes Changed Codes Agenda Documentation

More information