Supply Policy, Professional

Policy Number 2018R0006G Annual Approval Date Supply Policy, Professional 11/15/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT *), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider contracts, the enrollee s benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. *CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Application This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid Product. This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a ) or its electronic equivalent or its successor form. With the exception of Home Health Care and Durable Medical Equipment, Orthotics and Prosthetic providers billing in place of service 12, this policy applies to all products and all network and nonnetwork physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Policy Overview This policy describes the reimbursement methodology for Healthcare Common Procedure Coding System (HCPCS) codes representing supplies, drugs and other items based on the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS) Relative Value File and the Place of Service (POS) submitted. The website containing the POS code set can be accessed via this link: CMS POS Code Set. Reimbursement Guidelines Supply Reimbursement in a Physician s or Other Qualified Healthcare Professional s Office Pursuant to CMS policy, certain HCPCS supply codes are not separately reimbursable as the cost of supplies is

incorporated into the Practice Expense Relative Value Unit (RVU) for the Evaluation and Management (E/M) service or procedure code. Consistent with CMS, UnitedHealthcare Community Plan will not separately reimburse the HCPCS supply codes when those supplies are provided on the same day as an E/M service and/or procedure performed in a physician's or other health care professional's office and other nonfacility places of service. The UnitedHealthcare Community Plan Supply Policy Codes List contains the codes that are not separately reimbursable in an office and other nonfacility places of service. It is developed based on the CMS NPFS Relative Value File and consists of codes that based on their descriptions, CMS considers part of the practice expense and not separately reimbursable. Supply Policy Code List For the purposes of this policy, an office and other nonfacility place of service is considered POS 1, 3, 4, 9, 11, 12, 13, 14, 15, 16, 17, 20, 33, 49, 50, 54, 55, 57, 60, 62, 65, 71, 72, 81 and 99. Reimbursement for Supplies, Purchased Durable Medical Equipment (DME), Orthotics, Prosthetics, Biologicals, and Drugs submitted with a J Code Reported with Facility Places of Service 19, 21, 22, 23 and 24. CMS follows a Prospective Payment System (PPS) where Medicare payment is based on a predetermined, fixed amount payable to a facility for inpatient or outpatient hospital services. In addition, CMS reimburses ambulatory surgery centers under an Ambulatory Payment Classification (APC) payment methodology. With these fixed rates all costs associated with drugs and supplies are also deemed included in the global payment to the facility and not considered separately reimbursable when reported on a claim form by a physician or other qualified health care professional. Consistent with CMS, UnitedHealthcare Community Plan will not allow separate reimbursement for specific HCPCS supplies, purchased DME, orthotics, prosthetics, biologicals, and drugs reported with a HCPCS J code when submitted on a claim form by any physician or other qualified health care professional in the following facility POS: 19, 21, 22, 23, and 24. The UnitedHealthcare Community Plan Supply Policy Code list and Supply Facility J-Code Denial Code list contains the codes that are not separately reimbursable in a facility place of service. Supply Policy Code List Supply Facility J-Code Denial Code List In addition, the purchase of certain DME, orthotics, and prosthetics will not be separately reimbursed when reported by a physician or health care professional on a claim form in POS 19, 21, 22, 23 or 24 and the services are reported with no modifier or with one of the following purchase modifiers: NU New Equipment (use the NR modifier when DME which was new at the time of rental is subsequently purchased). UE Used Equipment NR New when rented KM Replacement of facial prosthesis including new impression/moulage KN Replacement of facial prosthesis using previous master model Supply DME Codes in a Facility Setting Supply DME Codes in an Ambulatory Surgical Center For the purposes of this policy, a facility place of service is considered POS 19, 21, 22, 23, and 24. Durable Medical Equipment, Orthotics, Prosthetics, and Related Supplies Reported with Facility Places of Service 31 and 32 In alignment with the CMS PPS reimbursement methodology, UnitedHealthcare Community Plan considers payment for certain DME, orthotics, prosthetics and related supply items on the CMS Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) fee schedule to be included in the payment to a skilled nursing facility (POS 31) and nursing facility (POS 32) and not reimbursed separately when reported by a physician or other qualified health care professional on a claim form: For the purposes of this policy, skilled nursing facility and nursing facility places of service are considered POS 31 and 32.

Casting and Splint Supplies HCPCS codes A4570, A4580, and A4590 which were previously used for billing of splints and casts are invalid for Medicare use effective July 1, 2001, and new temporary Q codes were established to reimburse physicians and other practitioners for the supplies used in creating casts. Consistent with CMS, UnitedHealthcare Community Plan will no longer reimburse HCPCS codes A4570, A4580, and A4590 for casting and splint supplies. Physicians and other qualified health care professionals should be using the temporary Q codes (Q4001-Q4051) for reimbursement of casting and splint supplies. Implantable Tissue Markers CMS clarifies that implantable tissue markers (HCPCS code A4648) and implantable radiation dosimeters (HCPCS code A4650) are separately billable and payable when used in conjunction with CPT codes 19499, 32553, 49411 or 55876 on a claim for physician services. Consistent with CMS, UnitedHealthcare Community Plan will allow separate reimbursement for HCPCS codes A4648 and A4650 when billed on the same date of service with either CPT codes 19499, 32553, 49411 or 55876. If not reported with at least one of these CPT codes, HCPCS codes A4648 and A4650 are not separately reimbursable. Supply Code 99070 For reimbursement of covered medical and surgical supplies, an appropriate Level II HCPCS code must be submitted. The non-specific CPT code 99070 (supplies and materials, except spectacles, provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) is not reimbursable in any setting. State Exceptions Arizona The following lists do not apply to Arizona Medicaid: UnitedHealthcare Community Plan Supply DME codes in a Facility Setting and UnitedHealthcare Community Plan Supply DME codes in an Ambulatory Surgical Center. Arizona LTC allows codes E0194, E0304 and E0635 to be billed in POS 31 and 32 California Per State Regulations, CPT 99070 is covered when billed for unlisted supplies and materials used in non-surgical procedures and for supplies and materials provided by the physician over and above those routinely used during an office visit. Hawaii The following lists do not apply to Hawaii Medicaid: UnitedHealthcare Community Plan Facility J-Codes Denial Codes, UnitedHealthcare Community Plan Supply DME codes in a Facility Setting, UnitedHealthcare Community Plan Supply DME codes in an Ambulatory Surgical Center and UnitedHealthcare Community Plan Supply DME codes in a Skilled Nursing Facility. Iowa Iowa allows reimbursement for DME in a Nursing Facility POS 31 and 32. Kansas Per State Regulations, CPT code 99070 is payable within specific parameters. Kansas allows codes J0220, J0221, J0257, J1050, J3060, J3385, J7030, J7040, J7042, J7050, J7070, J7100, J7110, J7120, and J7131 to be billed in POS 19 and 22. Louisiana Louisiana allows codes J7607 to be billed in POS 21. Louisiana allows code L8614 to be billed in POS 22 and allows codes A4570 and A4590 to be billed for cast/splint supplies. Massachusetts Michigan Massachusetts allows reimbursement for custom and non-custom electric wheelchairs, oxygen equipment and related supplies in a Nursing Facility POS 31 and 32 when authorized by the Health Plan. The following lists do not apply to Michigan Medicaid: UnitedHealthcare Community Plan Supply DME codes in a Facility Setting and UnitedHealthcare Community Plan Supply

Mississippi Nebraska DME codes in an Ambulatory Surgical Center. Mississippi allows codes J7303 to be billed in POS 22 for both MSCAN and MSCHIP products. Nebraska Medicaid utilizes their own list of codes that are not separately reimbursable in a Skilled Nursing Facility (POS 31) or Nursing Facility (POS 32). See List Here. Per State Regulations, code 99070 is reimbursable with certain considerations. Please see the C&S NE Unlisted reimbursement policy. New Mexico The following lists do not apply to New Mexico Medicaid: UnitedHealthcare Community Plan Supply DME codes in a Facility Setting and UnitedHealthcare Community Plan Supply DME codes in an Ambulatory Surgical Center. New Mexico allows oxygen equipment and related supplies to be paid separately in a Nursing Facility POS 31 and 32. See List Here Ohio Texas Ohio allows custom wheelchairs and/or custom wheelchair seating and related wheelchairs and supplies to be paid separately in a Nursing Facility POS 31 and 32. Such items must meet State criteria and have appropriate authorization when applicable. The state of Ohio allows HCPCS E0465 and E0466 to be paid in POS 31 & 32. Texas allows reimbursement for custom and non-custom electric wheelchairs in Nursing Facility POS 31 and 32, when authorized by the Health Plan. Texas allows codes J2182, J2786, J7175, J7179, J7202, J7207 and J7209 to be billed in POS 19 and 22. Virginia Wisconsin Per State Regulations, CPT 99070 may be reimbursed: When billed for unlisted supplies and materials used in non-surgical procedures and for supplies and materials provided by the physician over and above those routinely used during an office visit. Documentation is required. For Family planning supplies (such as condoms, Intrauterine Devices, etc.) when billed with the FP and U2 modifier. Invoice required. Per State Regulations, codes A4550 and 99070 are payable within specific parameters. Wisconsin allows DME codes Q0163,Q0164,Q0166,Q0167,Q0169,Q0173,Q0174,Q0175,Q0177,Q0180, Q2004,Q2009,Q4101,Q4102,Q4103,Q4104,Q4105,Q4106,Q4107,Q4108, Q4110, Q4111, Q4112, Q4113, Q4114, Q4115, and Q4116 to be reimbursed in an Ambulatory Surgical Center. Wisconsin allows oxygen equipment and related supplies to be paid separately in a Nursing Facility POS 31 and 32. See List Here Codes E2402 and A6550 are payable in a Nursing Facility POS 31 and 32. Wisconsin state regulation considers POS 19 as non-facility place of service. Definitions National Physician Fee Schedule Relative Value File Practice Expense Relative Value Units Relative Value Units A public use file that contains information on services covered by the Medicare Physician Fee Schedule (MPFS). The file contains the associated Relative Value Units (RVUs), a fee schedule status indicator, and various payment policy indicators needed for payment adjustment (e.g., payment of assistant at surgery, team surgery, bilateral surgery). The assigned unit value of a particular CPT or HCPCS code for maintaining a practice including rent, equipment, supplies and nonphysician staff costs. The assigned unit value of a particular CPT or HCPCS code. The associated RVU is

either from the CMS NPFS Non-Facility Total value or Facility Total value. Questions and Answers Q: If a member obtains medical supplies such as blood glucose test strips or lancets from a medical supply company, what place of service should the medical supply company report? 1 A: Since the items are for home use, the medical supply company should report with a CMS Place of Service code 12 (Home). Reporting any other place of service code than 12 would be inappropriate when the items are dispensed for home use. Q: Why does this policy not address all codes with an NPFS status code indicator of B? 2 A: Codes from the NPFS with a status of "B," but otherwise addressed in other UnitedHealthcare Community Plan coverage documents or medical, reimbursement and other policies, are not included in this policy. Q: Does UnitedHealthcare Community Plan reimburse for Casting and Splint Supplies? 3 A: Yes. UnitedHealthcare Community Plan will only reimburse for Casting and Splint Supplies when billed with the temporary Q codes (Q4001-Q4051). Attachments: Please right-click on the icon to open the file UnitedHealthcare Community Plan NON REIMBURSABLE Supply Codes List UnitedHealthcare Community Plan Facility JCodes Denial Codes List UnitedHealthcare Community Plan Supply DME Codes in a Facility Setting UnitedHealthcare Community Plan Supply DME Codes in an Ambulatory Surgical Center UnitedHealthcare Community Plan Supply DME Codes in a Skilled Nursing Facility Nebraska Non Reimbursable Supply Codes in POS 31 and 32 List A List of HCPCS supply codes that are not separately reimbursable in an office, nonfacility or facility place of service. A list of HCPCS drug codes not separately reimbursable in POS 19, 21, 22, 23 and 24. A list of DME codes for purchase only not separately reimbursable in POS 19, 21, 22 or 23. A list of DME codes for purchase only not separately reimbursable in POS 24. A list of DME, Orthotics, Prosthetics, and related supplies not separately reimbursable in POS 31 or 32. List of Supply codes not separately reimbursable for Nebraska in POS 31 and 32. Proprietary information of UnitedHealthcare Community Plan. Copyright 2018 UnitedHealthcare Services, Inc. 2018R0006G

Attachments: Please right-click on the icon to open the file UnitedHealthcare Community Plan Oxygen Codes List A list of Oxygen codes payable for New Mexico and Wisconsin in POS 31 and 32. Resources Individual state Medicaid regulations, manuals & fee schedules American Medical Association, Current Procedural Terminology ( CPT ) and associated publications and services Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets History 10/7/2018 Attachments section: Updated the Supply DME Codes in a Facility Setting and the Supply DME Codes in an Ambulatory Surgical Center 9/16/2018 Added the word Professional to the policy title Application section: Removed the verbiage and link for the provider website 6/3/2018 Attachments section: Updated the UnitedHealthcare Community Plan Supply DME Codes in a Facility Setting, the UnitedHealthcare Community Plan Supply DME Codes in an Ambulatory Surgical Center and the UnitedHealthcare Community Plan Supply DME Codes in a Skilled Nursing Facility. State Exceptions section: Updated Virginia 5/20/2018 Attachments section: Updated the UnitedHealthcare Community Plan Facility J-Codes Denial Codes List. 5/7/2018 State Exceptions section: Updated Nebraska adding the language: Per State Regulations, code 99070 is reimbursable with certain considerations. Please see the C&S NE Unlisted reimbursement policy. 3/27/2018 State Exceptions section: Updated Wisconsin adding the language: Wisconsin state regulation considers POS 19 as non-facility place of service. 1/1/2018 Annual Version Change Policy section: Removed the language Bundling HCPCS Code L8680 with CPT Code 63650 and To further align with CMS, the UnitedHealthcare Community Plan Medicare Supply Policy will deny HCPCS code L8680 (Implantable neurostimulator electrode), when billed with CPT code 63650 (Percutaneous implantation of neurostimulator electrode array, epidural) in an office or nonfacility place of service, effective for dates of service 5/1/2016 and after. Attachments section: UnitedHealthcare Community Plan Facility J-Codes Denial Codes List updated and UnitedHealthcare Community Plan Supply DME Codes in a Skilled Nursing Facility updated 11/19/2017 Annual Approval Date: Updated 11/12/2017 State Exceptions section: Updated Ohio adding the language: The state of Ohio allows HCPCS E0465 and E0466 to be paid in POS 31 & 32. Updated Louisiana adding the language: A4570 and to the statement Louisiana allows code L8614 to be billed in POS 22 and allows A4590 to be billed for cast/splint supplies. 9/17/2017 State Exceptions Section: Removed deleted code J7302 8/20/2017 State Exceptions Section: J codes for Arizona (J7297, J7298, J7300, J7301 and J7307) Kansa (J7298, J7306 and J7307) Louisiana (J7297, J7298, J7300 and J7301) Mississippi (J7300, J7301, J7306, and J7307) and Washington (J7300, J7301 andj7307) were removed Attachment Section: UnitedHealthcare Community Plan Facility J-Codes Denial Codes List updated

7/21/2017 State Exceptions Section: Updated language for Virginia regarding code 99070 7/14/2017 Application Section: Removed UnitedHealthcare Community Plan Medicare products as applying to this policy. Added location for UnitedHealthcare Community Plan Medicare reimbursement policies 7/3/2017 State Exceptions Section: Removed language regarding cast/splint supplies for Iowa. 5/21/2017 State Exceptions Section: Updated language regarding cast supplies for Iowa and Louisiana. Attachment Section: Updated the UnitedHealthcare Community Plan Non Reimbursable Supply Codes List. Added the Nebraska Non Reimbursable Supply Codes in POS 31 and 32 List. 3/12/2017 Policy Verbiage Change: Reimbursement Guidelines Section updated to add Bundling HCPCS Code L8680 with CPT Code 63650 verbiage for Community Plan Medicare 2/19/2017 State Exceptions Section: Updated, Texas allows codes J2182, J2786, J7175, J7179, J7202, J7207 and J7209 to be billed in POS 19 and 22. 2/12/2017 State Exceptions Section: Updated the exception for Arizona LTC, codes E0194, E0304 and E0635 is payable in a Nursing Facility POS 31 and 32 and updated exception for Kansas, added code J7298 to POS 19 and 22. 1/1/2017 Annual Version Change Attachment Section: NON REIMBURSABLE Supply Codes List, Facility J-Codes Denial Codes List, Supply DME Codes in a Facility Setting, Supply DME Codes in a Skilled Nursing Facility History Section: Entries prior to 1/1/2015 archived 11/27/2016 State Exceptions Section: Updated the exception for Louisiana, code L8607 is payable in a Nursing Facility POS 31 and 32. 11/13/2016 Policy Verbiage Change: Reimbursement Guidelines Section updated to add Bundling HCPCS Code L8680 with CPT Code 63650 verbiage. 11/9/2016 Annual Approval Date: Updated Approved by Section: Changed to Reimbursement Policy Oversight Committee 10/2/2016 State Exceptions Section: Updated the exception for Arizona and Hawaii 9/15/2016 Policy Verbiage Change: Reimbursement Guidelines Section updated to clarify POS and code lists Attachments Section: Description updated for the Supply Policy Code List 8/28/2016 State Exceptions Section: Exception updated for Massachusetts to include oxygen equipment and related supplies. 7/17/2016 State Exceptions Section: Exception updated for Louisiana 6/19/2016 State Exceptions Section: Exception updated for Louisiana 6/5/2016 State Exceptions Section: Exception added for Iowa 5/21/2016 Policy Verbiage Change: Reimbursement Guidelines Section updated to add other nonfacility places of service verbiage Attachments Section: Description updated for the UnitedHealthcare Community Plan NON REIMBURSABLE SUPPLY CODES LIST 3/22/2016 State Exceptions Section: Exception added for Washington 3/16/2016 State Exceptions Section: Exception added for Pennsylvania 2/5/2016 Policy List Change: Non Reimbursable Supply Codes List updated 1/1/2016 Annual Policy Version Change Policy Approval Date Change

Policy Verbiage Change: Reimbursement Guidelines Section updated to add POS 19 State Exceptions: Added POS 19 for Kansas Policy List Change: Supply Policy Code List, Supply Facility J-Code Denial Code List, and Supply DME Codes in a Skilled Nursing Facility List updated History Section: Entries prior to 1/1/2014 archived 1/6/2006 Policy implemented by UnitedHealthcare Community Plan Back To Top