PAYOR POLICIES

This general reference is one resource to provide guidance on MotivHealth’s reimbursement policies. This document is not intended to address every aspect of how we will reimburse a claim. Unique circumstances may necessitate departure from normal business practices. In all cases reasonable judgment and discernment are applied.

FACILITY SERVICES p. 5

CARDIAC DEVICE REPLACEMENT p. 5

Application

This policy applies to all network and non-network inpatient and outpatient facilities where Implantable Cardiac Defibrillators (ICDs), pacemakers, and their components are implanted.

Policy

This policy addresses payments when ICDs, pacemakers, and/or associated components require replacement due to recalls, manufacturer’s defects, mechanical malfunctions or prematurely failed batteries or leads. Costs for replacement of device, associated components and/or facility costs may be eligible for reimbursement as indicated below.

In order to be eligible for reimbursement, a facility must report when a member’s implanted device requires replacement. Such reporting is necessary even if the original implant was performed at another facility. All documentation, as indicated within this policy, must be provided in order to be eligible for reimbursement. There are no exceptions to this requirement.

MotivHealth conforms to CMS requirements for reimbursement of cardiac devices that require replacement. We will reduce reimbursements when a replacement cardiac device is provided to you:

At reduced cost
At no cost
With a credit of 50 percent or greater of the device’s cost

Charges for replacement devices should be related to the cost of the services and uniformly applied to all patients regardless of facility setting. Additionally, hospital medical device charges must reasonably relate to the medical device’s cost under normal circumstances.

WHAT WE WILL PAY

Device costs

When a facility receives a hospital-reportable credit from the manufacturer for the replacement of a medical device, the facility must reduce the charges of the device to MotivHealth by the amount of the credit. MotivHealth will pay the difference between the standard cost of the device and the credit. The electrical leads for most cardiac devices carry a lifetime warranty. These should qualify for a full credit or replacement at no cost.

When a facility receives a replacement medical device from the manufacturer without cost, MotivHealth will not reimburse the device costs.

Procedure costs

When a facility receives a hospital-reportable credit from the manufacturer for the procedure required to explant and/or implant the replacement device, the facility must reduce the charges of the procedure to MotivHealth by the amount of the credit. MotivHealth will pay the standard procedure costs for surgical and anesthesia services less the credit. Such reimbursement will be consistent with our anesthesia and global surgical services policies.

WHAT YOU MUST PROVIDE

To receive reimbursement, you must report the device type including manufacturer, part number, and serial number, the facility and date of initial implantation of device, the type of defect or recall, your notification to the manufacturer of the defect or the manufacturer’s notification of defect or recall, the manufacturer’s response or remedy including any hospital-reportable credits.

You must also send the physician case notes, operative report, anesthesia records.

All costs must be included on the itemized bill for the inpatient or outpatient encounter with complete and accurate coding. See Coding Guidelines below.

Requests for reimbursement for incomplete records and/or itemized bill may result in the denial of charges.

WHAT WE WILL NOT PAY

MotivHealth will not pay for items or services that the member or another insurer or party or government entity is required to pay.

MotivHealth benefit plans exclude from coverage emerging medical technologies. Devices that are not approved by the FDA or procedures that are considered investigational are not covered. This includes Investigational Device

Exemptions (IDE). These exclusions apply to replacement devices. There are no exceptions.

Coding Guidelines

Facilities receiving replacement devices at no cost or with a hospital-reportable credit must use the correct coding when submitting a claim.

Code Type Inpatient Outpatient

49: Replaced within lifecycle

Condition Code

50: Recalled and replaced

53: Initially placed in clinical trial

FD: Dollar amount of price reduction or credit

Report on claim the replaced device credit amount in the amount section for value code FD when hospital gets a credit 50% or greater than device’s cost.

Value Code

FB: Item was provided without cost to the provider or full credit was received for the replacement.

Modifier

FC: Partial credit was received for the replacement

Reporting a no-cost item charge If your system allows, use $0.00.

If your system allows, use $0.00.

If $0.00 isn’t allowed, use $1.00.

DEFINITIONS

Charges: The regular rates published by the provider on their Charge Master for services rendered before the application of contractual allowances and/or discounts.

CMS: Centers for Medicare and Medicaid Services

FDA: Federal Drug Administration IDE: An Investigational Device Exemption (IDE) allows the investigational device to be used in a clinical study in

order to collect safety and effectiveness data.An approved IDE permits a device to be shipped lawfully for the purpose of conducting investigations of the device without complying with other requirements of the Food, Drug, and Cosmetic Act that would apply to devices in commercial distribution.

Implantable Cardiac Defibrillators (ICD): For the purposes of this policy ICDs include defibrillators, pacemakers, and their associated components such as electrical leads, batteries, etc.

Inpatient: Admission to a hospital or skilled nursing facility on a physician’s order. This usually involves at least one overnight stay.

Itemized Bill (IB): A full listing of all the charges being billed by a provider for the services rendered.

Outpatient: Facility care that a person receives without being admitted or for a stay of less than 24 hours even if this stay occurs overnight.

Resources

Billing & Claims Administration Manual

Cardiac Device Credits: Medicare Billing

CMS Section 2202.4 of Provider Reimbursement Manual

Medicare Claims Processing Manual, Chapter 4, Section 61.3.1 - 61.3.2

OIG Report: Hospitals Did Not Comply with Medicare Requirements for Reporting Certain Cardiac Device Credits

Cross References

Anesthesia

Components of Global Surgical Package

Disclaimer

This policy outlines the basis for reimbursement of the service described herein. The information in this policy is intended to serve as a general resource. It is not intended to address every aspect of reimbursement. You are responsible for submitting accurate claims that are consistent with our member contracts, our contract with you and our medical policies. This policy does not guarantee payment. Services must meet our authorization requirements and the medical necessity guidelines that are appropriate for the member’s diagnosis and medical condition at the time of service. In addition to the requirements of this policy, you must follow all guidelines in our Billing & Claims Administration Manual. The codes that are billed must be fully supported by the medical record. If our billing guidelines or the requirements outlined in this policy are not followed, we may deny the claim or recover the claim payment.

History and Approvals

12/18/2023 Approved Dr. Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

EMERGENCY DEPARTMENT p. 8

Application

This policy applies to all network and non-network facilities, physicians and other qualified health care professionals.

Policy

Emergency Department (ED) services are reimbursed for the complexity of the interventions provided to our member. CMS stipulates that coding for services should follow the intent of the CPT code descriptor and reasonably correlate to the intensity of the care provided.

All ED services resulting in an inpatient or observation stay must be billed on the inpatient or outpatient claim, as applicable. A separate claim for ED services should not be submitted.

SITUATIONS WHERE ED SERVICES SHOULD NOT BE BILLED SEPARATELY

DRG: Do not submit reimbursement for ED services for claims where a DRG reimbursement methodology would apply. For these claims the ED services are included in the DRG rate. This also applies to claims originally billed to other reimbursement methodologies, but our review finds that the claim should be paid to a DRG. Any separate charges for ED services on the original claim will be bundled into the DRG rate.
Trauma Activation: When trauma activation (revenue code 068X) is billed with ED Evaluation and Management services (revenue code 045X) for the same facility encounter, ED services will be bundled into trauma response services.

MEDICAL RECORDS REQUIRED TO SUPPORT ED SERVICES

Medical records pertaining to the ED encounter including an itemized bill may be requested to support the level of care, procedures and medications you billed.

The medical records must contain the following to support the level of care billed:

Presenting symptoms
Diagnosis, diagnoses as applicable
Medical decision-making including complexities and co-morbidities of the member
Treatment plan
All treatments, tests, and medications must be supported by medical orders written by the physician attending to the care during the ED encounter.

The itemized bill must be consistent with the electronic bill in both units and dollar amounts for the ED services revenue codes billed.

SITUATIONS WHERE REIMBURSEMENT FOR ED SERVICES WILL BE DENIED

If we do not receive all the medical records identified above in a legible format and by the date requested, the ED services will not be paid even if records are provided for other services on the same claim form.
If our review finds that the reimbursement request is not consistent with coding and billing guidelines, charges for ED services will be denied in full. Those providers that experience such adjustments may rebill to the appropriate level of care. See Billing and Claims Administration for details on rebilling your claim.

OUT OF NETWORK PROVIDERS

If the emergency services are provided by a nonparticipating provider or a nonparticipating emergency facility, MotivHealth conforms to the stipulations of 42 CFR 149.110 § 149.110 Preventing surprise medical bills for emergency services. All the medical records, coding and claim submission requirements identified above are applicable.

Coding Guidelines

FACILITY

All ED services must be reported on the UB-04 claim form or its electronic equivalent or its successor form and billed under revenue code 045X. Trauma activation services must be billed under revenue code 068X.

Type A Emergency Departments must bill services under CPT codes 99281-99285. Modifier -25 should be appended to the ED EM code when emergency services are provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedures.

Type B Emergency Departments must bill services under CPT codes G0380-G0384.

MotivHealth conforms to the coding and billing guidelines for emergency department evaluation/management, and trauma activation set by the American Medical Association, CMS and National Uniform Billing Committee (NUBC). If we select your claim for review, the date of service of the claim and the applicable criteria set by these governing bodies will be used to evaluate your claim.

PROFESSIONAL

ED professional fees should be billed on a CMS1500 claim form or electronic equivalent or its successor form with Place of Service (POS) Code 23 (Emergency Room – Hospital).

Definitions

CMS: Centers for Medicare and Medicaid Services

CMS-1500 Claim Form: The CMS 1500 also known as the HCFA-1500 is the claim form for individual providers and charges under Medicare Part B.

CPT: Current Procedural Terminology. A medical code set maintained by the American Medical Association (AMA) that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations. CPT is included in Level I Healthcare Common Procedure Coding System (HCPCS).

Emergency Department - Type A: A Type A provider-based emergency department must meet at least one of the following requirements: (1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department and be open 24 hours a day, 7 days a week; or (2) It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment and be open 24 hours a day, 7 days a week.1

Emergency Department - Type B: A Type B provider-based emergency department must meet at least one of the following requirements: (1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department, and open less than 24 hours a day, 7 days a week; or (2) It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment, and open less than 24 hours a day, 7 days a week; or (3) During the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment, regardless of its hours of operation.1

Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in— (A) Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child; (B) Serious impairment to bodily functions; or (C) Serious dysfunction of any bodily organ or part.

EMTALA: Emergency Medical Treatment and Active Labor Act

Evaluation and Management (E/M) Services: Services that requires three key components; problem or comprehensive history examination; medical decision making; counseling and/or coordination of care with physician or other qualified health care provider.

ICU: Intensive Care Unit

Itemized Bill (IB): A full listing of all the charges being billed by a provider for the services rendered.

Medical Order: The prescription of a physician or other qualified healthcare professional regarding the treatment of a patient.

National Uniform Billing Committee (NUBC): Committees responsible for the revenue code definitions and requirements for use.

Place of Service (POS): Place of Service denotes the place where the service was rendered within the facility. MotivHealth conforms to the designations used by CMS for the Medicare program.
Revenue Code: Revenue codes are 4-digit numbers that are used on hospital bills to identify where a member was located in a facility when they received treatment or services, or what service a member received as a patient.

UB-04 Claim Form: The UB-04 also known as the CMS-1450 is the claim form for institutional facilities and charges under Medicare Part A.

Resources

1CMS. “OPPS Visit Codes Frequently Asked Questions.” January 2008. Last accessed April 26, 2021.

Medicare Fee-for-Service Payment Regulations | CMS (See Hospital Outpatient PPS)

242 CFR Ch. IV (10–1–05 Edition)

https://www.govinfo.gov/content/pkg/CFR-2005-title42-vol2/pdf/CFR-2005-title42-vol2-sec422-113.pdf

American Medical Association, Current Procedural Terminology (CPT®)

Centers for Medicare and Medicaid Services, CMS Manual System

Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets

Centers for Medicare and Medicaid Services, National Correct Coding Initiative (NCCI) Policy Publications

42 CFR 149.110 § 149.110 Preventing surprise medical bills for emergency services.

Cross References Billing & Claims Administration Manual
Disclaimer

This policy outlines the basis for reimbursement of the service described herein. The information in this policy is intended to serve as a general resource. It is not intended to address every aspect of reimbursement. You are responsible for submitting accurate claims that are consistent with our member contracts, our contract with you and our medical policies. This policy does not guarantee payment. Services must meet our authorization requirements and the medical necessity guidelines that are appropriate for the member’s diagnosis and medical condition at the time of service. In addition to the requirements of this policy, you must follow all guidelines in our Billing & Claims Administration Manual. The codes that are billed must be fully supported by the medical record. If our billing guidelines or the requirements outlined in this policy are not followed, we may deny the claim or recover the claim payment.

History and Approvals

2020 New policy

07/10/2023 Policy review: Clarifying content added to all sections. Approved by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

EMERGENT AND OTHER NON-ELECTIVE INPATIENT ADMISSIONS p. 12

Application

This policy applies to all network and non-network facilities, physicians and other qualified health care professionals.

Policy

Emergent and other non-elective inpatient admissions require notification as specified in the Utilization Management section of our Payor Policy.

MotivHealth will reimburse for medically necessary inpatient admissions. Decisions for admission are based on the medical judgment of physicians and other qualified health practitioners. The documentation in the medical record must support the decision-making process and the medical necessity of the inpatient admission.

In the absence of contract stipulations addressing inpatient admission determinations, MotivHealth will use evidence-based criteria provided by MCG to determine medical necessity and to ensure that consistent and clinically valid decision making was used to determine the reasonableness of an inpatient admission. MotivHealth does not use time as the deciding factor when making a determination of the appropriateness of admission or the place of service (inpatient vs. outpatient status). All claims for reimbursement for an inpatient admission are subject to medical review.

Our determination of the appropriateness of an inpatient admission will be based on the information available at the time of discharge from the emergency setting. MotivHealth recognizes that some events may eclipse standard MCG guidelines, and, in such cases, inpatient admission may be considered justified. These events may include patient death during the inpatient stay, transfer from another inpatient facility for services not performed by the admitting facility, decision to transfer to hospice during the inpatient stay, and the self-discharge of a patient from a healthcare facility against medical advice (AMA).

Every inpatient admission must have an order stipulating an inpatient admission and orders must meet MotivHealth’s requirements for medical orders. Inpatient claims submitted without an inpatient order as specified in the Medical Order of our Payor Policy will be denied.

REBILLING DENIED INPATIENT CLAIMS

Claims denied for inpatient admission and where an observation setting would have been more appropriate may be rebilled. Claims denied for lack of a valid inpatient order may not be rebilled. See Billing and Claims Administration Manual for details on rebilling your claim.

Coding Guidelines

Not applicable

Definitions Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in— (A) Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child; (B) Serious impairment to bodily functions; or (C) Serious dysfunction of any bodily organ or part.

Inpatient: Admission to a hospital or skilled nursing facility on a physician’s order. Medical Necessity: Any health care services, supplies or treatment provided for an illness or injury which is consistent with the Member’s symptoms or diagnosis provided in the most appropriate setting that can be used safely, without regard for the convenience of a member or provider. However, such health care services must be appropriate with regard to standards of good medical practice in the state of Utah and could not have been omitted without adversely affecting the Member’s condition or the quality of medical care the Member received as determined by established medical review mechanisms, within the scope of the Provider’s licensure, and/or consistent with and included in policies established and recognized by MotivHealth. Any medical condition, treatment, service, equipment, etc. specifically excluded in the Master Policy is not an “Eligible Benefit” regardless of Medical Necessity. Medical Order: Prescription of physician or qualified healthcare professional regarding treatment of patient. MCG: Formerly known asMilliman Care Guidelines Outpatient: Facility care a person receives without being admitted or a stay less than 24 hours even if stay occurs overnight.

Qualified Healthcare Practitioner: A ‘physician or other qualified health care professional’ is an individual who is qualified by education, training, licensure/regulation and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.

Rebilled Claim: These are claims we receive from the provider prior to our payment of a clean claim.

Resources

https://www.aapc.com/blog/28964-define-a-qualified-healthcare-professional/

Cross References Medical Orders Billing & Claims Administration Manual
Disclaimer

History and Approvals

11/21/2023 New policy: Approved by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

HOSPITAL-BASED PHYSICIAN SERVICES p. 14

Application

This policy applies to all network and non-network physicians and other qualified healthcare providers who perform both inpatient and outpatient services as a hospitalist.

Policy

Services performed by hospitalists are reimbursed based on the level of care provided for evaluation and management services. Services in addition to evaluation and management may also be eligible for reimbursement.

Payments are based on the fee schedules that have been negotiated with facility providers.

OUT OF NETWORK PROVIDERS

If the emergency services are provided by a nonparticipating provider MotivHealth conforms to the stipulations of 42 CFR 149.110 § 149.110 Preventing surprise medical bills for emergency services. All the medical records, coding and claim submission requirements identified within our reimbursement policies are applicable.

If non-emergency services are provided by a nonparticipating provider, MotivHealth conforms to the stipulations of the Requirements Related to Surprise Billing. All the medical records, coding and claim submission requirements identified within our reimbursement policies are applicable.

SITUATIONS WHERE REIMBURSEMENT FOR HOSPITAL PHYSICIAN BASED SERVICES WILL BE DENIED

It is the responsibility of the physician requesting payment to obtain requested records. MotivHealth will not contact the facility for records for Hospitalists services. If we do not receive all the medical records requested in a legible format by the date requested, the services will not be paid.
If critical care time is billed and complete documentation consistent with the requirements of the code(s) billed is not available.
If our review finds that the reimbursement request is not consistent with coding and billing guidelines, charges for services will be denied in full. Those providers that experience such adjustments may rebill to the appropriate level of care. See Billing and Claims Administration Manual for details on rebilling your claim.

Coding Guidelines

Professional fees should be billed on a CMS-1500 claim form or electronic equivalent or its successor form. Ensure that all services billed have complete supporting documentation and accurate assignment of ICD-10 and CPT codes.

Definitions

CMS: Centers for Medicare and Medicaid Services

CMS-1500 Claim Form: The CMS 1500 also known as the HCFA-1500 is the claim form for individual providers and charges under Medicare Part B.

Hospitalist: A qualified healthcare practitioner (not a house officer) who assumes responsibility for the observation and treatment of hospitalized patients and returns them to the care of their private physicians when they are discharged from the hospital. Examples include anesthesiologists, emergency department physicians, intensivists, pathologists and radiologists.

Resources

42 CFR 149.110 § 149.110 Preventing surprise medical bills for emergency services.

Requirements Related to Surprise Billing

Cross References

Billing & Claims Administration Manual

Disclaimer

History and Approvals

11/21/2023 New policy: Approved by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

MEDICAL ORDERS p. 16

Application

This policy applies to all facilities and physicians and other qualified health care professionals.

Policy Every treatment, procedure or admission requires a medical order that meets the requirements below.

Criteria for an Order

Justification for the treatment, procedure or admission
Expected length of stay for inpatient admissions
Signed by practitioner with authorization to sign and sufficient knowledge of the patient’s condition at the time of treatment, procedure or admission
Date order was signed
Documented in the medical record prior to hospital discharge for inpatient admission
Documented prior to the initiation of a treatment or procedure
Orders may not be retrospective
Orders for inpatient admission may not be a standing order

Authorization to Sign

The order must be signed by any one of the following practitioners.

Doctor of medicine or osteopathy licensed by the state to perform services or admit inpatients and have been granted privileges by the facility to admit in the case of inpatient admissions,
Dentist or dental surgeon as functioning as admitting physician of record for major dental procedure performed at an inpatient facility,
Doctor of podiatric medicine (if authorized under state law) and must be responsible for the patient or have sufficient knowledge of the case and be authorized to certify.
Medical residents, physician assistants, nurse practitioners, other non-physician practitioners or practitioners without admitting privileges may act as a proxy if authorized under state law and ordering physician approves and accepts the decision and countersigns prior to initiation of the treatment/procedure or prior to discharge in the event of an inpatient admission.

Defining Sufficient Knowledge

MotivHealth considers the following hospital staff to have sufficient knowledge to write an order for an inpatient admission.

Admitting physician of record
Surgeon or physician on-call
Surgeon responsible for major procedure
Dentist functioning as admitting physician of record or surgeon for major dental procedure
Non-physician/non-dentist admitting practitioner licensed by state/ privileged by facility and on call for primary care practitioner
Emergency Department physician
Primary or covering hospitalist

Any of the above practitioners whose knowledge of the patient is solely derived from a medical record review does not suffice as a practitioner with sufficient knowledge. Claims with orders for inpatient admissions signed by such practitioners will be denied.

Verbal Orders

Healthcare workers without admitting authority i.e., registered nurses, may be permitted to accept and record verbal orders at their facility. The ordering practitioner must directly communicate the order and must countersign the order as written to authenticate it prior to the initiation of the treatment or procedure or, in the case of an inpatient admission, prior to discharge. MotivHealth will comply with state laws, hospital policies or bylaws if MotivHealth’s policies contravene any legal statutes or regulations.

Coding Guidelines

None

Definitions

Medical Order: The prescription of a physician or other qualified healthcare professional regarding the treatment of a patient.

Qualified Healthcare Professional: Physician assistant or clinical nurse specialist who is not a licensed M.D. or D.O.

Qualified Healthcare Practitioner: A ‘physician or other qualified health care professional’ is an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.

Resources

42 CFR § 424.13 - Requirements for inpatient services of hospitals other than inpatient psychiatric facilitiesCross References None

Disclaimer

History and Approvals

Policy updated: Removed Qualified Health Care Provider, updated Qualified Health Care Practitioner pursuant to new Utah state law. Approved Dr. Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

06/05/23

NEONATAL INTENSIVE CARE UNIT (NICU) p. 18

Application

This policy applies to all network and non-network inpatient facilities.

Policy

Neonatal Intensive Care Unit (NICU) services are reimbursed on the complexity of the interventions provided. See the Coding Guidelines section in this policy for additional information on billing to the appropriate level of care.

Medical records including an itemized bill may be requested to support the level of care billed. The medical records must contain the following to support the level of care billed:

Presenting symptoms
Diagnosis, diagnoses as applicable
Treatment plan
All treatments, tests, and medications must be supported by medical orders written by qualified healthcare provider.

The itemized bill must be consistent with the electronic bill in both units and dollar amounts for the ED services revenue codes billed.

SITUATIONS WHERE REIMBURSEMENT FOR NICU SERVICES WILL BE DENIED

If we do not receive all the medical records requested in a legible format and by the date requested, the NICU services will not be paid.
If our review finds that the reimbursement request is not consistent with coding and billing guidelines, charges for those NICU services will be denied in full. Providers that experience such adjustments may submit a corrected claim to rebill to the appropriate level of care. See Billing and Claims Administration for details on rebilling your claim.

OUT OF NETWORK PROVIDERS

Coding Guidelines

Below is an overview of the admission guidelines set by MCG Health for the following levels of neonatal care. This is not an all-inclusive list. For additional information or an in depth explanation refer to the current Careweb guidelines published by MCG.

NICU FACILITY, LEVEL I (REVENUE CODE 0171; CPT 99468 – 99469; MODIFIERS AS APPROPRIATE)

Evaluation and monitoring:

Routine laboratory testing (e.g., bilirubin, glucose, Coombs testing, CBC)
Asymptomatic abnormalities (e.g., hypoglycemia)
Weight gain and advancing oral intake
Routine care needs for infants post special care unit or higher level NICU stay

NICU FACILITY, LEVEL II (REVENUE CODE 0172; CPT 99468 – 99469; MODIFIERS AS APPROPRIATE)

Examples of the types of care required:

Respiratory abnormalities (e.g., apnea, tachypnea)
Unstable body temperature
Physiologic immaturity requiring IV fluids, enteral feeding, medication titration, transfusions, etc.
Short term ventilatory support (e.g., mechanical ventilation, CPAP, HFNC)

NICU FACILITY, LEVEL III (REVENUE CODE 0173; CPT 99468 – 99469; MODIFIERS AS APPROPRIATE)

Examples of the types of care required:

Pulmonary or cardiac arrest during delivery
Encephalopathy
Ongoing fluid resuscitation
Seizures requiring pharmacologic support
Invasive monitoring
Advanced imaging

NICU FACILITY, LEVEL III (REVENUE CODE 0174; CPT 99468 – 99469; MODIFIERS AS APPROPRIATE)

Examples of the types of care required:

Surgical care for congenital abnormalities
Subspecialty care (e.g., dialysis, ECMO)

Definitions

Corrected Claim: These are claims that we receive from the claimant after we have reviewed and paid your claim.

ECMO: Extra Corporeal Membrane Oxygenation

Itemized Bill (IB): A full listing of all the charges being billed by a provider for the services rendered.

Medical Order: The prescription of a physician or other qualified healthcare professional regarding the treatment of a patient.

Modifier: Two characters (letters or numbers) appended to a CPT® or HCPCS Level II code. The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code.

NICU: Neonatal Intensive Care Unit

Revenue Code:Revenue codes are 4-digit numbers that are used on hospital bills to identify where a member was located in a facility when they received treatment or services, or what service a member received as a patient.

Resources

1MCG Health - 27th Edition – careweb.careguidelines.com (Subscription Service)

American Medical Association, Current Procedural Terminology (CPT®)

42 CFR 149.110 § 149.110 Preventing surprise medical bills for emergency services.

Cross References

Non-Reimbursable Services and Supplies

Disclaimer

History and Approvals

12/19/2023 New policy: Approved Dr. Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

NON-REIMBURSABLE SERVICES AND SUPPLIES p. 21

Application

This policy applies to all network and non-network inpatient and outpatient facility settings, physician and other qualified healthcare professionals.

Policy

MotivHealth aligns with CMS on the practice of unbundling, or the separate submission of charges when a single code describes the service inclusive of all supplies. The following sections provide examples of services and supplies that MotivHealth considers components of room and board in any facility setting, or are integral to any professional/surgical/non-surgical procedure. Such services and supplies are not separately reimbursable. Providers shall not separately report services and supplies simply because HCPCS/CPT codes exist for them. The lists below are examples. They are not all-inclusive. SERVICES

LABORATORY

Blood draws from arterial, capillary, peripheral or vascular access devices
Collection of blood or other specimens
All point of care testing performed manually or by a mobile device
Venipunctures for the purpose of acquisition of blood for analysis

NURSING

Administration of medications including member’s own
Admission assessments
Any procedure performed by an RN in both non-intensive and intensive care settings
Assisting with bedside procedures performed by any qualified healthcare professional
Blood transfusions including MTP and IAT
Discharge planning including coordinating transfer to any facility or service
Incremental nursing care including charges for extraordinary services
Infusion or injection of fluids, nutrition, medications, TPN through peripheral and central lines
IV insertion
IV site care including assessments, infusion of fluids to keep lines patent
Patient care and monitoring in both non-intensive and intensive care settings
Point of care testing performed manually or by mobile computer devices
Recovery services in special care units even if PACU protocols were followed
Respiratory treatments performed by an RN including but not limited to:

Administration of nebulized medications (drugs are reimbursable)
Blood gas acquisition
Incentive spirometry (e.g., evaluation, monitoring and training)
Nebulizer treatment
Sputum inductions
Surfactant and mucolytic administration
Ventilator adjustments
Transports, internal and external
Tube feeding administration
Urinary catheterization and care

PHARMACY

OTC drugs
Discharge planning including coordinating transfer to any facility or service
Packing, dispensing and administration of member’s own medications
Pharmacy consultation for patient education and medication management
Preparation of medications and infusions regardless of setting
Self-administered drugs

RESPIRATORY

Administration of medications including bronchodilators and mucolytics (drugs are reimbursable)
Endotracheal suctioning when member is on a ventilator including

Sputum inductions
Incentive spirometry
Nebulizer treatment
Administration of nebulized medications
Incentive spirometry (e.g., evaluation, monitoring and training)
Oxygen, CPAP and PEEP changes when member is on ventilator support
Pressurized or non-pressurized inhalation treatments with or without aerosol may be reported once
Pulmonary diagnostic testing including breathing responses to carbon dioxide and hypoxia
Respiratory assessment including responsiveness to treatment
Transports, internal and external
Use of member’s own CPAP or BiPAP machines
Ventilator management including system checks and adjustments for current or new medical orders
Ventilator management for critical care including breathing response tests
Ventilator weaning and extubation

SPECIALTY SERVICES

Intravenous infusion/injections for hydration, therapy, prophylaxis, or diagnosis regardless of setting
Newborn blood screenings sent out to state labs are payable as one unit; it may not be unbundled
Services for which our health plan does not contract unless required by law
Social Services including AUDIT/DAST evaluations
Spiritual care
Allergen immunotherapy
Application of hot or cold packs
Chronic care case management services
Composite Measures
Computer assisted musculoskeletal procedures
Established for state Medicaid agencies
Tests, procedures and/or drugs
Genetic counseling unrelated to specific gene testing
Massage therapy
Mechanical chest wall oscillation
Medicare clinical trial codes
Medicare demonstration project codes

Non-covered service
Pneumatic Compression Device
Products that have no NDC assigned on the DOS
Quality measures
Service that is always bundled into another service
Services included in facility reimbursement
Services that are part of another service
Supervision with no direct face-to-face patient care

SURGICAL AND OTHER PROCEDURAL SERVICES

Any service including anesthesia provided by the surgeon or provider performing the service
Closure of incision or post operative repair of surgical incision
Computerized devices or equipment including programming for diagnostic or therapeutic monitoring
Intraoperative Neuromuscular Monitoring (IONM)
Intraprocedural injection(s) for angiography, imaging supervision and interpretation
Insertion of catheters including urinary
Local anesthesia provided by surgeon or anesthesia provider
Hemorrhage control or support of hemostasis peri and post operatively unless requires return to OR
Percutaneous artery interventions for implantations
Radiology regardless of mode to confirm, guide, place, interpret, treat or supervise procedures
Procedures requiring robotic assistance, add on charges for the robotic devices are not reimbursable.
SUPPLIES

EQUIPMENT AND MONITORING (ANY SETTING)

Batteries
Bladder scan equipment for post void residuals or urinary retention
Blood pressure cuffs and devices
Breast pumps
Car seats including testing
Catheters
Cautery machines
Cell saver equipment
Compression systems
Continuous blood pressure
Drainage systems
Electrodes and leads
Eye droppers
Heat lamp
Incentive spirometers
Isolation supplies/precautions
IT programming services
IV/PCA pumps and related supplies
Lasers
Monitoring equipment of any type and in any setting

Oximetry and related supplies
Perfusion equipment (does not include perfusion time)
Pneumatic compression device or intermittent pneumatic compression device (IPC)
Scopes of any type
Thermometers
Ventilators
Warming and cooling blankets

RESPIRATORY

Incentive spirometers
Irrigation supplies
Oxygen
Suction devices

ROOM AND BOARD (ADULT, PEDIATRIC, NICU)

Admission kits
Ambu bags/crash carts and all related supplies
Arm boards
Clothing of any type
Bandages/Dressings of any type and related supplies
Beds including bassinettes, incubators, Isolette, specialty, etc.
Bed linens including towels
Bedpans
Blankets including Biliblanket
Cord care supplies and cord clamp
Diapers and incontinence pads, any type or size
Diluents including heparin and saline flushes to keep lines patent
Emesis basin
Foley catheters and catheter bags
Gloves/gowns
Joint protectors
Nutrition includes meals, vitamins, supplements, drinks/shakes, baby formula, bottles, etc.
Restraints
Oxygen
Personal care items (including lozenges, creams, herbal antiemetics and supplements, etc.)
Prep or procedural kits (any type)
Procedure specific instruments/kits
Skin prep ointments including soaps and other cleansers
Urinals
Warming and cooling blankets

SURGICAL AND OTHER PROCEDURES

Alcohol and other disinfectants
Ambu bags/crash carts and all related supplies
Arm boards
Anesthesia supplies (this does not include anesthesia drugs)
Bandages, dressings and supplies
Casting and splinting supplies
Closure devices including sutures, skin glue, staples, etc.
Contrast for radiology procedures
Diluents including heparin and saline flushes to keep lines patent
Drapes and towels
Local anesthesia
Drugs that are part of a procedure (this does not include drugs)administered by anesthesia services)
Equipment and instruments of any type
Gloves/gowns/scrubs
Guidance radiology of any type
Hemostatic agents of any type (i.e., Flowseal) including vascular clips
Intermittent Pneumatic Compression (IPC)
Isolation supplies/precautions
Joint protectors
Restraints
Oxygen regardless of setting including that administered during a surgical procedure
Prep or procedural kits (any type)
Procedure specific instruments/kits
Skin prep ointments including soaps and other cleansers
Warming and cooling blankets

Supplies for denied procedures and services are not payable by association.

Coding Guidelines

See specific sections above.

Definitions

AOC:Add-on code

IAT: Intraoperative Autologous Transfusion

IPC: Intermittent Pneumatic Compression

MTP: Massive Transfusion Protocol

OTC Drugs:Medications that are safe and effective for use by the general public without seeking treatment by a health professional.

Self-administered Drugs:Medications that are normally taken by the patient independently and unassisted.

TPN:Total Parenteral Nutrition

Resources
CMS Medicare Learning Network, Discharge Planning, Oct. 2014

CMS Medicare Claims Processing Manual, Chapter 16- Laboratory Services; 60.1 - Specimen Collection Fee

CMS Provider Reimbursement Manual, Chapter 22 – Determination of Cost of Services to Beneficiaries

Joint Commission International, Point of Care Testing

Utah Office of Administrative Rules, Rule R156-31b Nurse Practice Act Rule

NCQAC Advisory Opinion 13.02 Registered Nurse and Licensed Practical Nurse Scope of Practice

NCCI 2022 Coding Policy Chapter 5.§C.¶18

NCCI 2022 Coding Policy Chapter 9.§C.¶8

NCCI 2022 Coding Policy Chapter 9.§D.¶12

NCCI 2022 Coding Policy Chapter 9.§D.¶9

NCCI 2022 Coding Policy Chapter 10.§A.¶3

NCCI 2022 Coding Policy Chapter 11.§A.¶2

NCCI 2022 Coding Policy Chapter 11.§A.¶3

NCCI 2022 Coding Policy Chapter 11.§B.¶11

NCCI 2022 Coding Policy Chapter 11.§B.¶12

NCCI 2022 Coding Policy Chapter 11.§B.¶5

NCCI 2022 Coding Policy Chapter 11.§B.¶6

NCCI 2022 Coding Policy Chapter 11.§I.¶ 4

NCCI 2022 Coding Policy Chapter 11.§I.¶17

NCCI 2022 Coding Policy Chapter 11.§I.¶23

NCCI 2022 Coding Policy Chapter 11.§J.¶ 7

NCCI 2022 Coding Policy Chapter 11.§J.¶ 8

NCCI 2022 Coding Policy Chapter 11.§J.¶ 9

NCCI 2022 Coding Policy Chapter 11.§J.¶10

NCCI 2022 Coding Policy Chapter 11.§W.¶5

NCCI 2022 Coding Policy Chapter 13.§E.¶5

NCCI 2022 Coding Policy Chapter 13.§E.¶6

NCCI 2022 Coding Policy Chapter 13.§E.¶7

NCCI 2022 Coding Policy Chapter 13.§E.¶8

NCCI 2022 Coding Policy Chapter 13.§E.¶9

Cross References

Anesthesia

Interventional Radiology

Disclaimer

History and Approvals

12/03/2024 Bryan Turner, MD Medical Director; Dale Lyman, VP Cost Containment

OBSTETRICAL CARE p. 28

Application

This policy applies to all network and non-network facilities, physicians and other qualified health care professionals.

Policy

The global maternity allowance is a complete, one-time billing for the total obstetrical care package which includes all professional services for routine antepartum care, delivery services, and postpartum care when the same group, physician or other health care professional provides all components of the obstetrical package. The fee is reimbursed for all the member’s obstetric care to one provider. Global maternity billing ends with release of care during the six (6) week follow up appointment after delivery. However, global obstetrical care should be billed on or after the delivery date.

Non-global obstetrical care, or partial services, refers to maternity care not managed by a single provider or group practice.

MotivHealth conforms to the billing guidelines set forth by ACOG and AMA. See Coding Guidelines section below for the specific coding requirements of obstetrical care.

What Is Included in Care

GLOBAL OBSTETRICAL CARE

The following services are included in the global obstetrical package and not separately reimbursable.

Routine prenatal visits until delivery
Recording weight, blood pressures and fetal heart tones.
Admission to the hospital including history and physical.
Inpatient Evaluation and Management (E/M) service provided within twenty-four (24) hours of delivery.
Management of uncomplicated labor.
Vaginal or cesarean section delivery.
Delivery of placenta (CPT code 59414).
Administration/induction of intravenous oxytocin (CPT code 96365-96367).
Insertion of cervical dilator on same date as delivery (CPT code 59200).
Repair of first- or second-degree lacerations.
Simple removal of cerclage without anesthesia.
Uncomplicated inpatient visits following delivery.
Routine outpatient E/M services provided within forty-two (42) days following delivery.
Postpartum care after vaginal or cesarean section delivery (CPT code 59430).
Urinalysis by dip stick or tablet reagent (CPT codes 81000 and 81002)

High-risk monitoring that results in more than 13 antepartum visits, E/M visits may be billed. Report these services after the patient delivers. Append Modifier 25 to identify them from routine antepartum visits.

DELIVERY SERVICES ONLY

The following services are included in the delivery service and not separately reimbursable for either single gestation or twin deliveries

Admission to the hospital including admission history and physical examination.

Management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps), or cesarean delivery, external and internal fetal monitoring provided by the attending physician.
Intravenous induction of labor via oxytocin (CPT code 96365-96367).
Delivery of the placenta, any method.
Repair of first- or second-degree lacerations.
Insertion of cervical dilator (CPT 59200) to be included if performed on the same date of delivery.

DELIVERY SERVICES AND POSTPARTUM CARE

The following services are included in the delivery services and postpartum care and are not separately reimbursable:

Hospital visits related to the delivery during the delivery confinement.
Uncomplicated outpatient visits related to pregnancy.
Discussion of contraception.

Claim Reviews

Maternity claims submitted with any modifier appended to the CPT are subject to a validation review. Medical records are required if a validation review is performed. If records are not received within the timeline requested, the claim may be denied, and the funds recouped if payment was previously made.

The facility or entity submitting the billing or receiving payment for the obstetrical care is responsible for acquiring and submitting the records even if the services were provided by another provider or entity. MotivHealth will not be responsible for any fee required by any entity for the collection and/or submission of records. Any such fees are the responsibility of the billing entity or the provider receiving payment for the maternity claim. For additional details on records requests, see Billing and Claims Administration policy.

Coding Guidelines

GLOBAL OBSTETRICAL CARE

CPTDescription

59400 Routine obstetric care includes antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care. To report third and fourth degree lacerations append modifier 22.

59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care

Routine obstetric care includes antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery. To report third and fourth degree lacerations append modifier 22.

59610

59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery.

NON-GLOBAL OBSTETRICAL CARE

ANTEPARTUM CARE ONLY

CPT
Number of visits Claim Submission

Units Reported

Date Range

59425
For 4-6 visits 1 1 From/To for all services

59426
For 7 or more visits

1 1 From/To for all services

Confirmatory visit using the appropriate E/M coding may be reported separately when the antepartum records have not been initiated.

DELIVERY SERVICES ONLY

SINGLE GESTATION

CPTDescription

59409 Vaginal delivery only (with or without episiotomy and/or forceps). To report third and fourth degree lacerations append modifier 22.

59514 Cesarean delivery only.

59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps). To report third and fourth degree lacerations append modifier 22.

59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery.

TWIN GESTATION

Delivery Method Twin CPT

Vaginal Baby 159400

Baby 2 59409-59459

Vaginal birth after cesarean Baby 1 59610

Baby 2 59612-59659

Cesarean Delivery Baby 1 and Baby 2 59510*

Repeat Cesarean Delivery Baby 1 and Baby 2 59618*

Vaginal and Cesarean Delivery Baby 1 59409-59451

Baby 2 59510

Vaginal birth after cesarean and repeat cesarean delivery

Baby 1 59612-59651

Baby 2 59618

*If increased physician work is involved in the delivery of second baby, append modifier 22 to the cesarean code.

DELIVERY SERVICES AND POSTPARTUM CARE

CPTDescription

59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care. To report third and fourth degree lacerations append modifier 22.

59515 Cesarean delivery only; including postpartum care

59614 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps); including postpartum care. To report third and fourth degree lacerations append modifier 22.

59622 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; including postpartum care.

POSTPARTUM CARE ONLY Postpartum care using CPT 59430 should be billed on one claim with one unit. E/M visits related to complications related to the pregnancy are separately reimbursable.

ANTEPARTEM AND POSTPARTUM CARE WITHOUT DELIVERY SERVICES If a qualified healthcare provider performs any component of antepartum care along with postpartum care, but does not perform the delivery, then the services should be billed by using the appropriate codes as indicated in the sections above.

THREE OR FEWER VISITS WITHOUT DELIVERY SERVICES

If a provider renders care for three or fewer visits of a member’s total obstetrical care, the appropriate E/M code

should be billed after each visit.

BILLING SPECIAL SERVICES

FETAL NON-STRESS TEST ON TWIN GESTATIONS

Services related to fetal non-stress test on twin gestations may be eligible for reimbursement when coded as follows:

FetusTestCPTModifier

First Initial 59025

FirstSubsequent 59025 76 (same provider)

FirstSubsequent 59025 77 (new provider)

Second Initial 59025 59 (separate fetus)

Second Subsequent 59025 59 (separate fetus)/76 (same provider)

Second Subsequent 59025 59 (separate fetus)/77 (new provider)

ASSISTANT SURGEON FOR CESAREAN SECTIONS

Services of an assistant surgeon are only reimbursable for a non-global cesarean section delivery when the appropriate modifier is appended. For modifier and billing requirements see policy entitled Assistant-at-Surgery/Assistant Surgeon/Co-Surgeon/Team Surgeon.

The reimbursement for Assistant Surgeon is as follows:

Billed CPTReimbursed CPT

59510 59514

59515 59514

59618 59620

59622 59620

PROLONGED PHYSICIAN SERVICES

Prolonged physician services for labor and delivery management are not reimbursable services. This is consistent with ACOG coding guidelines.

MULTIPLE PROCEDURE REDUCTIONS

Multiple procedure reductions will apply to obstetrical services having a delivery component for both vaginal and cesarean sections.

INPATIENT MATERNITY STAY EXCEEDING 48/96 HOURS

Any inpatient maternity stay that exceeds forty-eight (48) hours following a vaginal delivery or ninety-six (96) hours following delivery by cesarean section requires preauthorization.

Definitions

ACOG: American College of Obstetricians and Gynecologists

AMA: American Medical Association

Assistant Surgeon: Physician (M.D. or D.O.) who actively assists the surgeon during the surgical procedure. Such an individual is usually trained in the same specialty as the surgeon.

E/M: Evaluation and Management

Evaluation and Management (E/M) Services: Services that require three key components; problem or comprehensive history examination; medical decision making; counseling and/or coordination of care with physician or other qualified health care provider.

Global allowance: the period of time and the services/supplies that are within the preoperative, intraoperative and postoperative services.

Inpatient: Admission to a hospital or skilled nursing facility on a physician’s order.

Modifier 22:Increased Procedural Services.

Qualified Healthcare Professional: Physician assistant or clinical nurse specialist who is not a licensed M.D. or D.O.

Cross References

None

Disclaimer

History and Approvals

02/26/2024 Bryan Turner, MD Medical Director and Michelle Evans, Director of Quality

PREADMISSION SERVICES p. 34

Application

This policy applies to all network and non-network facilities, physicians and other qualified health care professionals. This policy does not apply to Critical Access Hospitals (CAH) except as indicated below.

Policy

MotivHealth conforms to CMS 3-day and 1-day Payment Windows for outpatient preadmission services. Services rendered within these payment windows are not eligible for separate reimbursement. If preadmission services are billed separately from the inpatient claim, MotivHealth will bundle them into the inpatient claim.1

WHAT FACILITIES ARE SUBJECT TO THE 3-DAY PAYMENT WINDOW?

Facilities paid under the IPPS DRG payment methodology. The 3-day payment window is the 72-hour time period immediately preceding the time of an inpatient admission.

WHAT FACILITIES ARE SUBJECT TO THE 1-DAY PAYMENT WINDOW?

The 1-day payment window is the 24-hour time period immediately preceding the time of an inpatient admission to the following facility types:1

Psychiatric hospitals and units
Inpatient rehabilitation hospitals and units
Long-term care hospitals
Children’s hospitals
Cancer hospitals

WHAT SERVICES ARE NOT SEPARATELY REIMBURSABLE?

The technical component of all outpatient diagnostic services and related non-diagnostic services such as therapies are not separately reimbursable when performed within the applicable payment window. Examples include but are not limited to hematology, chemistry, x-rays, isotope studies, EKGs, pulmonary function studies, thyroid function tests, psychological tests, and other tests to determine the nature and severity of an ailment or injury.

WHICH RENDERING PROVIDERS DOES THIS POLICY APPLY?

The provision of preadmission services during the applicable payment window applies to the admitting hospital, any entity wholly owned or operated by the admitting hospital, provider or practice group and any other entity including a CAH having an arrangement with the admitting hospital to provide preadmission services.1

Coding Guidelines

Not applicable

Definitions

CMS:Centers for Medicare and Medicaid Services

Diagnostic Service:a service is “diagnostic” if it is an exam or procedure to which you subject the patient, or which you perform on materials derived from a hospital outpatient, to get information to aid in your assessment of a medical condition or to identify a disease.2

DRG:Diagnostic Related Group

Inpatient:Admission to a hospital or skilled nursing facility on a physician’s order.

IPPS:Inpatient Prospective Payment System

Wholly Operated:Per CMSan entity is wholly operated by a hospital if the hospital has exclusive responsibility for conducting and overseeing the entity’s routine operations, regardless of whether the hospital also has policymaking authority over the entity. 1

Wholly Owned:Per CMS an entity is wholly owned by the hospital if the hospital is the sole owner of the entity. 1

Resources

1MLN Matters: 3-Day Payment Window for Services Provided to Outpatients Who Later Are Admitted As Inpatients

2Medicare Benefit Policy Manual, Chapter 6, Section 20.4.1

Federal Register/Vol. 76, No. 228/Monday, November 28, 2011/Rules and Regulations

Pub 100-04 Medicare Claims Processing Transmittal 2373

Medicare Claims Processing Manual (cms.gov) Sections 90.7 and 90.7.1

Cross References

None

Disclaimer

History and Approvals

12/10/2024 Bryan Turner, MD Medical Director; Dale Lyman, VP Cost Containment

UNBUNDLING p. 36

Application

This policy applies to all products and to all network and non-network facilities, physicians and other qualified health care professionals.

Policy

All covered charges must be reported with the code that describes the services performed or devices supplied. MotivHealth will not reimburse billings related to unbundled procedures, services, or supplies. Examples of unbundling include but are not limited to the following:

Billing multiple CPT codes when a single code describes the services

Fragmenting a procedure into its component parts

Unbundling bilateral procedures into two unilateral procedures

Billing supplies and services that are a component of the main procedure

For the purposes of this policy, the following are examples of unbundling but not limited to these situations.

Incidental procedure:

An incidental procedure is carried out at the same time as a more complex primary procedure. These procedures require little additional provider resources and are generally not considered essential to the performance of the primary procedure.

Example: Exploratory laparoscopy with an appendectomy. Provider would not bill the exploratory laparoscopy separately.

Mutually exclusive procedure

Mutually exclusive procedures are two or more procedures that are usually not performed on the same patient on the same date of service. Mutually exclusive rules may also include different procedure code descriptions for the same type of procedures for which the provider should be submitting only one of the procedure codes. Only the most clinically intense procedure will be allowed. Generally, an open procedure and a closed procedure in the same anatomic site are not separately reimbursable. If both codes accomplish the same result, the clinically more intense procedure supersedes, and the comparative code is denied as mutually exclusive.

Example: In a traumatic injury to the leg the surgeon attempts to repair the leg but then decides that an amputation is necessary. The provider would bill only the most clinically intense procedure.

Integral procedure:

Procedures considered integral occur in multiple surgery situations when one or more of the procedures are included in the major or principal procedure. Integral procedures are those commonly carried out as part of a total service. Codes should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.

Example: A diagnostic arthroscopy and surgical arthroscopy on a right knee. Provider would bill only the surgical arthroscopy.

GLOBAL ALLOWANCE:

The period of time and the services/supplies that are within the preoperative, intraoperative and postoperative services.

Example: Guidance radiology used during a cardiac ablation and an ECG was performed to determine success of procedure or issues related to the procedure. Provider would bill only the ablation procedure. The guidance radiology and ECG would not be separately reimbursable.

Coding Guidelines

CMS NCCI Coding Edits

Medicare Claims Processing Manual Chapter 12

Definitions

Global allowance: the period of time and the services/supplies that are within the preoperative, intraoperative and postoperative services.

Incidental procedure: a procedure performed at the same time as a more complex primary procedure.

Integral procedure: occurs in multiple surgery situations when one or more of the procedures are included in the principal procedure.

Mutually exclusive procedure: two or more procedures that are not usually performed on the same patient on the same date of service.

National Correct Coding Initiative (NCCI or CCI): The Centers for Medicare & Medicaid Services (CMS) developed these edits to promote consistent, correct coding and appropriate payment. These coding edits are developed based on the AMA CPT code set and the HCPCS code set, as well as analysis of standard medical and surgical practice and input from various groups, including specialty societies, other national health care organizations, Medicare contractors, providers, and consultants.

Unbundling: The use of multiple CPT/HCPCS codes to report a procedure or supply when a single comprehensive code exists that adequately describes the service or supply, either unintentionally or in an effort to maximize reimbursement.

Resources

CMS Publication 100-04, Medicare Claims Processing Manual
AAPC.com (License Required)

Cross References

Billing & Claims Administration Manual

Anesthesia

Disclaimer

History and Approvals

2016 New policy

Policy review. Statements added to policy guidelines for clarification: added statement on NCCI edits; added additional services that would constitute unbundling not eligible for separate reimbursement (incidental procedures, mutually exclusive procedures, integral procedures, global allowances). Approved by Dr. Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

06/05/2023

OUTPATIENT SERVICES p. 39

AMBULATORY SURGICAL CENTERS p. 39

Application

This policy applies to all network and non-network ambulatory surgical centers that operate exclusively to furnish outpatient surgical services.

Policy

MotivHealth conforms to Centers for Medicare and Medicaid Services (CMS) payment guidelines for Ambulatory Surgical Services (ASC) including the applicability of the surgical service performed in an ASC unless otherwise stipulated in this policy.

SERVICES INCLUDED IN THE ASC FEE (NOT SEPARATELY REIMBURSABLE)

Nursing services or any service performed by technical staff
Surgical supplies including but not limited to dressings, tools, equipment
Drugs and biologicals not on OPPS pass-through status
Blood, plasma, platelets
Point of care laboratory tests
Anesthesia supplies
Radiology services
Implantable device and implant surgery supplies
Splints, casts
Intraocular lenses
Administrative costs
Housekeeping costs

SERVICES NOT INCLUDED IN THE ASC FEE (SEPARATELY REIMBURSABLE)

Individually contracted provider services, i.e. anesthesia, physician
Ambulance services
Brachytherapy sources
Custom appliances (leg, arm, neck, back braces), (shipping/handling not separately reimbursed)
Prosthetic devices (shipping/handling not separately reimbursed)
Durable medical equipment used by the patient in their own home
Services of an independent laboratory
Emergency services
Pass-through for newly approved drugs and devices. Must be billed with CMS designated HCPCS Documentation Requirements

Medical records are an important part of patient evaluation and treatment. They provide evidence of actions and decisions made during the rendering of care and are also necessary for the appropriate administration and payment of a provider’s reimbursement requests. Adherence to the guidance in this policy will provide more efficient claims processing and expedient payment.

Our requests for records are in compliance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule which allows release of medical information for treatment, payment, and healthcare operations without the express written consent of the patient. For further information, refer to 45 CFR § 164.506

If we do not receive a response to ourrequest for records or if the records that you send us is incomplete, your claim will not be processed. For additional information on medical records standards and submission requirements, see Billing and Claims Administration Policy Manual.

The services provided and the medical necessity of the care should be documented in the medical records. Below is a listing of the minimum requirements that should be present in the medical record to support the care provided.

ASC identification
Member name
Date of service
Procedure note of the service rendered signed by a physician or qualified healthcare professional.
Supporting documentation of the medical necessity (i.e., physician office notes, history and physical, laboratory values, imaging, etc.

PAYMENT FOR TERMINATED ASC SERVICES PRIOR TO DELIVERY OF SERVICES

ASCs are eligible for reimbursement when a surgical procedure or any part of it is terminated due to medical complications which would put our member at risk if the procedure were continued. Claims for such services will only be considered when the claim is accompanied by an operative report. The operative report must contain at a minimum the following:

Reason for termination of surgery
Description of services performed, if any
Description of supplies provided, if any
Services not performed that would have been if surgery had not been terminated
Supplies that would have been provided if surgery had not been terminated
Time spent in each stage (e.g., pre-op, operative, post-op)
Time that would have been spent in each of these stages if surgery had not been terminated
CPT codes for procedures that were scheduled to be performed Append one of the following modifiers to the CPT of the terminated procedure(s).

Modifier 73: Procedure terminated before administration of anesthesia. Allows 50 percent
Modifier 74: Procedure terminated after administration of anesthesia.
Allows full payment Coding Guidelines

The Place of Service (POS) code is 24 for procedures performed in an ASC.
Append the TC modifier to the HCPCS code for codes that have both a technical and professional component.
These PTP code pair edits are applied to claims submitted by physicians, non-physician practitioners, and Ambulatory Surgery Centers.

ASC’s and physicians or other health care professionals must report the applicable HCPCS Modifier(s) with the associated charges on all lines related to the surgical error.

PA- Surgery Wrong Body Part.
PB- Surgery Wrong Patient.
PC- Wrong Surgery on Patient.
Definitions

Ambulatory Surgical Center: A distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients. An ASC is either independent (i.e., not a part of a provider of services or any other facility), or operated by a hospital (i.e., under the common ownership, licensure or control of a hospital)

CMS: Centers for Medicare and Medicaid Services

HCPCS: Healthcare Common Procedure Coding System

HCPCS Level II: A standardized coding system that is used primarily to identify medical supplies, durable medical equipment, non-physician services, and services not represented in the Level I code set CPT

Medical Necessity: Any health care services, supplies or treatment provided for an illness or injury which is consistent with the Member’s symptoms or diagnosis provided in the most appropriate setting that can be used safely, without regard for the convenience of a member or provider. However, such health care services must be appropriate with regard to standards of good medical practice in the state of Utah and could not have been omitted without adversely affecting the Member’s condition or the quality of medical care the Member received as determined by established medical review mechanisms, within the scope of the Provider’s licensure, and/or consistent with and included in policies established and recognized by MotivHealth. Any medical condition, treatment, service, equipment, etc. specifically excluded in the Master Policy is not an “Eligible Benefit” regardless of Medical Necessity.

Modifier 73: Procedure terminated before administration of anesthesia.

Modifier 74: Procedure terminated after administration of anesthesia.

Modifier PA: Surgery wrong body part

Modifier PB: Surgery wrong patient

Modifier PC: Wrong surgery on patient

Place of Service (POS): Place of Service denotes the place where the service was rendered within the facility. MotivHealth conforms to the coding designations used by CMS for the Medicare program.

Qualified Healthcare Professional: Physician assistant or clinical nurse specialist who is not a licensed M.D. or D.O. or nurse practitioner.

Resources

MM13216 - Ambulatory Surgical Center Payment System: July 2023 Update

Medicare Claims Processing Manual Chapter 14 Ambulatory Surgical Centers

Medicare Benefit Policy Manual Chapter 15_Covered Medical and Other Health Services

Noridian Medicare Jurisdiction F

Cross References

Billing & Claims Administration Manual

Disclaimer

History and Approvals

12/05/2024 Bryan Turner, MD, Medical Director; Dale Lyman, VP Cost Containment

BEDDED OUTPATIENT p. 43

Application

This policy applies to all network and non-network facilities.

Policy

Bedded Outpatient also known as Outpatient-In-A-Bed (OPIB), for the purposes of this policy, relates to patients whose condition does not require care in an inpatient facility due to lack of medical necessity but are placed in an acute care bed. The categorization of Bedded Outpatient or OPIB in an acute care facility maintains that a patient is a Social Admit. This situation may arise when a facility requires time to develop a transition plan for a safe discharge from a hospital unit or the Emergency Department.

MotivHealth does not recognize the designation of Bedded Outpatient for the purposes of claim payment and will not reimburse any costs for patients no longer meeting the requirements of medical necessity. This includes room and board, or any services and/or supplies used in conjunction with the stay.

OUTPATIENT SURGERIES REQUIRING POST OPERATIVE INPATIENT CARE

MotivHealth recognizes that at times outpatient surgeries require more care than originally anticipated. Such instances may necessitate an inpatient stay. In these situations the billing provider must obtain an inpatient authorization in order for the claim to be processed.

In the event an inpatient authorization was not obtained prior to discharge and/or a claim is submitted designating patient status as Bedded Outpatient or OPIB, such claims will not be reimbursed. However MotivHealth, at its sole discretion, may perform a retrospective medical necessity review for inpatient care or may deny the claim and require the billing provider to obtain a retrospective inpatient authorization through the MotivHealth system.

In the event a retrospective inpatient medical necessity review is performed on a claim where an outpatient authorization for a surgical procedure was previously obtained, our Medical Director will determine retrospectively the most appropriate patient status, and the claim will be paid accordingly. Under no circumstances will a claim, for the purposes of reimbursement, be considered both an outpatient claim and inpatient claim regardless of any prior authorizations obtained.

OUTPATIENT SURGERIES REQUIRING POST OPERATIVE OBSERVATION CARE

In the event that a patient is held in observation care post operatively and where the length of stay is expected to be less than two (2) calendar dates, the billing provider must contact MotivHealth immediately after surgery for concurrent review by our Clinical Services Team. This review will determine if an inpatient admission or extended recovery at an alternate facility is appropriate.

In the event concurrent review was not requested prior to discharge or could not be requested due to weekend or holiday closures, our Concurrent Review Team will determine, retrospectively, if observation services were medically necessary and which services/supplies are authorized for reimbursement during that interim prior to discharge.

Post operative observation care requires medical necessity in all cases. When medical necessity is no longer required, observation services will be considered complete. MotivHealth will not reimburse any costs for patients

no longer meeting the requirements of medical necessity even if a portion of the post operative period was medically necessary. Only the portion that met the requirements of medical necessity will be reimbursed. All other services after this point will be denied. This includes room and board, or any services and/or supplies used in conjunction with the stay.

MEDICAL RECORDS REQUESTS

Retrospective reviews may require additional records even if records were previously sent. Please promptly comply with any requests for additional records. Insufficient documentation may forfeit payment of some or all the claim. Additional documentation provided after our review and payment may not, at our sole discretion, be accepted for either a post payment review or for an appeal of our original decision on reimbursement. Our members may not be balanced billed for denials related to insufficient documentation. For more information on records request, please see our Billing and Claims Administration Manual.

Coding Guidelines

N/A

Definitions

Concurrent Review: Concurrent review takes place while the patient is receiving care while admitted to a facility. The purpose of the concurrent review is to put an oversight process in place that permits the scrutiny of the type of care being delivered, the necessity for that care, and the level and setting of that care. 1

Inpatient: Admission to a hospital or skilled nursing facility on a physician’s order.

Observation Care: Observation services are those services furnished by a hospital on the hospital’s premises, including use of a bed and at least periodic monitoring by a hospital’s nursing or other staff which are reasonable and necessary to evaluate an outpatient’s condition or determine the need for a possible admission to the hospital as an inpatient.

Retrospective Review: A review that occurs after the care was delivered and after the bill for that care was submitted. The retrospective review seeks to confirm that the care was appropriate and was provided at the most efficient and effective level. 1

Social Admit: Patient is admitted to an inpatient facility from the emergency department for the convenience of patient, family, or care provider while awaiting transfer to more appropriate arrangements.

Resources

1 National Institutes of Health (NIH) (.gov) https://www.ncbi.nlm.nih.gov › books › NBK560806

Cross References

Billing & Claims Administration Manual

Disclaimer

History and Approvals

12/03/2024 Bryan Turner, MD Medical Director; Dale Lyman, VP Cost Containment

HOSPICE p. 46

Application This policy applies to all network and non-network physicians and other qualified healthcare practitioners and entities providing home infusion therapy services. Infusion services should not be reported by physicians or other qualified healthcare practitioners when services are rendered in a facility setting.

Policy

Hospice is care provided to a terminally ill patient. Hospice care is subject to contract benefits, member’s coverage, and other limitations. Preauthorization is required.

Hospice care is eligible for reimbursement when the patient is no longer receiving any curative treatment, and is only receiving palliative care for pain relief, symptom control and comfort. Hospice claims must be submitted with a terminal ICD-10 diagnosis code.

SERVICES NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

24-hour a day care at home
Meals delivered to home
Homemaker services
Custodial or Personal care
Respite Care
Home Health Aides
Total Parenteral Nutrition through hospice care
Private Duty Nursing.
Coding Guidelines

CPT DESCRIPTION

0650 Hospice; General Classification

0651 Hospice; Routine Home Care

0652 Hospice Continuous Home Care

0655 Hospice Respite Care

0656 Hospice General Inpatient Care Non-Respite

0657 Hospice; Physician Services

0658 Hospice Room & Board – Nursing Facility

0659 Other Hospice Service

Definitions

Custodial Care: Non-medical care provided to assist people with daily living activities. Services may include bathing, cooking, cleaning, and other necessary functions.

Hospice: Care provided to a terminally ill patient. Also known as palliative care.

Palliative Care: Care that is focused on providing relief from the symptoms and stress of the illness. The goal is to improve quality of life for both the patient and the family.

Respite Care: Provides short-term relief for primary caregivers

Total Parenteral Nutrition: A method of feeding that bypasses the gastrointestinal tract.

Cross References

None

Disclaimer

History and Approvals

12/03/2024 Bryan Turner, MD Medical Director; Dale Lyman, VP Cost Containment

OBSERVATION p. 48

Application

This policy applies to all network and non-network facilities and other qualified health care professionals.

Policy

Observation Care for the purposes of this policy relates to evaluation and management services provided to patients designated as observation status in a hospital. This refers to the initiation of observation status, supervision of the care plan for observation and performance of periodic reassessments.

To report observation care codes, the physician must:

Indicate in the patient’s medical record that the patient is designated or admitted as observation status
Clearly document the reason for the patient to be admitted to observation status
Initiate the observation status, assess, establish, and supervise the care plan for observation and perform periodic reassessments.

Observation admission is appropriate if the patient’s condition can be evaluated or treated within 24 hours and/or rapid improvement of the patient’s condition is anticipated within 24 hours. Observation care does not require preauthorization if less than 24 hours. Any observation care 24 hours and over requires preauthorization.

INITIAL OBSERVATION CARE

CPT 99221, 99222, 99223.

Consistent with Center for Medicare and Medicaid Services (CMS) guidelines these codes should be reported for a patient admitted to Observation Care for less than eight (8) hours on the same calendar date.

The CPT codebook states that "When ‘observation status’ is initiated in the course of an encounter in another site of service (e.g., hospital emergency department, office, nursing facility) all evaluation and management services provided by the supervising physician or other qualified health care practitioner in conjunction with initiating ‘observation status’ are considered part of the initial observation care when performed on the same date and should not be bill separately. The observation care level of service reported by the supervising physician or other qualified health care practitioner should include the services related to initiating ‘observation status’ provided in the other sites of services as well as in the observation setting.”

We follow the Centers for Medicare and Medicaid Services (CMS) Claims Processing Manual which provides the instructions to “pay for initial observation care billed by only the physician who ordered hospital outpatient observation services and was responsible for the patient during his/her observation care. A physician who does not have inpatient admitting privileges but who is authorized to furnish hospital outpatient observation services may bill these codes.

For a physician to bill observation care codes, there must be a medical observation record for the patient which contains dated and timed physician’s orders regarding the observation services the patient is to receive, nursing notes, and progress notes prepared by the physician while the patient received observation services. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter."

SUBSEQUENT OBSERVATION CARE

CPT 99231, 99232, 99233

In the instance that a patient is held in observation status for more than two (2) calendar dates, the supervising physician should utilize a subsequent Observation Care CPT code, 99224 -99226. Physicians other than the supervising physician providing care to a patient designated as “observation status” should report subsequent Observation Care.

According to the CPT codebook, “All levels of subsequent observation care include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient’s status (i.e., changes in history, physical condition, and response to management) since the last assessment.

OBSERVATION CARE ADMISSION AND DISCHARGE ON THE SAME DATE

CPT 99234, 99235, 99236

The patient must be in observation status at least eight (8) hours (but less than twenty-four (24) hours since it must be on the same date) for a physician to bill same date admission and discharge code.

According to the CPT Code book, “Observation status includes the supervision of the care plan for observation as well as the periodic reassessments. The patient is not required to be physically located in a designated observation area within a hospital; however, if such an area is utilized, these codes should be reported. When a patient is admitted to the hospital from observation status on the same date of service, the clinician should only report the appropriate level of initial hospital care code. The level of care reported should reflect all of the other services from the observation status services the clinician rendered to the patient on the same date of service as well as those provided in the actual inpatient setting. Codes do not differentiate between new or established patients. Under this care category, there are three levels represented by 99234, 99235, and 99236. All of these levels require all three key components-history, exam, and medical decision making-to be documented.”

OBSERVATION CARE ADMISSION AND DISCHARGE ON DIFFERENT DATES

CPT 99238 and 99239

This code is to be reported for all services provided to a patient on discharge from outpatient hospital observation status if the discharge date is other than the initial date of observation status.

Coding Guidelines

See above

Definitions

CMS: Centers for Medicare and Medicaid Services

Inpatient: Admission to a hospital or skilled nursing facility on a physician’s order.

Qualified Healthcare Practitioner: A ‘physician or other qualified health care professional’ is an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.

Cross References

None

Disclaimer

History and Approvals

12/10/2024 Bryan Turner, MD Medical Director, Dale Lyman, VP Cost Containment

AMBULANCE p. 51

Application

This policy applies to all network and non-network providers.

Policy

Ambulance shall transport to the nearest facility that provides the appropriate care the patient requires in the shortest amount of time.

Ambulance providers are eligible for reimbursement when the ambulance service date is the same as the admission or discharge date from a medical facility. An Ambulance Trip Sheetis required with all ground and air ambulance claim submissions. All Ambulance Trip Sheets will be reviewed for Medical Necessity prior to reimbursement.

Air ambulance is eligible for reimbursement when the use of either basic or advanced life support ground ambulance is not appropriate because the patient's condition requires rapid transport to the nearest appropriate facility to treat the patient’s current medical condition. Air transport may also be reimbursable if the patient is inaccessible for a ground or water ambulance vehicle.

MotivHealth follows state administration transport code for the state where the service is rendered.

WHAT WE WILL PAY

Transportation by ambulance to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where the patient is an inpatient.
When the beneficiary is an inpatient of a long term care facility (LTCH), inpatient psychiatric facility (IPF) or inpatient rehabilitation facility (IRF) and is transported via ambulance to an acute care hospital to receive specialized services, reimbursement for transportation will be allowed if the presence of occurrence span code 74 (non-covered level of care) and the associated occurrence span code from and through dates is plus one day. The claim will be denied if the ambulance line item service date falls outside the occurrence span code 74 from and through dates plus one day.

WHAT WE WILL NOT PAY

Any claim that is not appropriately coded including modifiers
Ambulance services billed while the patient is admitted to the hospital.
Charges for any facility owned transportation.
Services and supplies including, but not limited to:

Oxygen
Drugs
Extra attendants
Any supplies
EKG
Night differential

AMBULANCE PRICING:

Licensed ground ambulance shall not charge more than the rates described by Utah Administration Code Rule R426-8.

Air Ambulance pricing is set forth in the provider agreement.

Coding Guidelines

AMBULANCE MODIFIERS FOR TRANSPORT SERVICES

Reimbursement will only be made for transport services when billed with the two-digit ambulance modifier. Any claim billed without the two-digit ambulance Modifier will be denied as a billing error. The provider may resubmit a corrected claim with applicable modifiers. Below is a list of the Modifiers eligible for reimbursement.

Each ambulance modifier consists of two digits as follows:

First digit: A single digit alpha character identifying the origin of the transport.
Second digit: A single digit alpha character identifying the destination of the transport.

Ambulance Modifier Ambulance Modifier Description

D Diagnostic or therapeutic site other than P or H when these are used as origin codes

E Residential, domiciliary, custodial facility (other than 1819 facility)

G Hospital-based ESRD facility

H Hospital

I Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport

J Free standing ESRD facility

N SNF

P Physician's office

R Residence

S Scene of accident or acute event

X Intermediate stop at physician's office on way to hospital (destination code only)

Example: SH = scene of accident or acute event to hospital

The following modifiers are second digit modifiers only. Do not bill these in the first digit position.

Ambulance Modifier Ambulance Modifier Description

GM Multiple patients on one ambulance trip. Note: Providers need to submit the appropriate origin and destination modifiers in the first modifier position and Healthcare Common Procedure Coding System (HCPCS) modifier GM in the second Modifier position.

QL Patient pronounced dead after ambulance called

QM Ambulance service provided under arrangement by a provider of services

QN Ambulance service furnished directly by a provider of services

Example: SGM = scene of accident or acute event patient pronounced dead after ambulance called

AMBULANCE MODIFIERS FOR RESPONSE AND TREATMENT, NO TRANSPORT Ambulance response and treatment, no transport (CPT A0998) - Ambulance service modifiers should not be submitted on the claim. The submission of an ambulance modifier will be denied as a billing error. The provider may resubmit a corrected claim with applicable modifiers. Below is a list of the Modifiers eligible for reimbursement.

TRANSPORTATION INDICATORS Transportation indicators below indicate the necessity of transport. The transportation indicator should be placed in the narrative field on the claim.

AIR AND GROUND

Transportation Indicator

Transportation Indicator Description

An inter-facility transport (to a higher level of care) determined necessary by the originating facility based upon The Emergency Medical Treatment and Labor Act (EMTALA) regulations and guidelines.

C1

A patient is being transported from one facility to another because a service or therapy required to treat the patient's condition is not available at the originating facility.

C2

Secondary code where a response was made to a major incident or mechanism of injury. All such responses are appropriately Advanced Level Service responses. A code that describes the patient's condition found on scene should also be included on the claim, but use of this Modifier is intended to indicate that the highest level of service available response was medically justified.

C3

Indicates that an ambulance provided a medically necessary transport, but the number of miles on the claim form appears to be excessive. This should be used only if the facility is on divert status or a particular service is not available at the time of transport only. The provider or supplier must have documentation on file clearly showing why the beneficiary was not transported to the nearest facility and may include this information in the narrative field.

C4

AIR ONLY

Transportation Indicator

Transportation Indicator Description

Long Distance: patient's condition requires rapid transportation over a long distance.

D1

Under rare and exceptional circumstances, traffic patterns preclude ground transport at the time the response is required.

D2

Time to get to the closest appropriate hospital due to the patient's condition precludes transport by ground ambulance. Unstable patient with need to minimize out of hospital time to maximize clinical benefits to the patient.

D3

D4 Pick up point not accessible by ground transportation

GROUND ONLY

Transportation Indicator

Transportation Indicator Description

Indicates situations where a patient with an ALS-level condition is encountered, treated and transported by a BLS-level ambulance with no ALS level involvement whatsoever. This situation would occur when ALS resources are not available to respond to the patient encounter.

C5

Indicates situations when an ALS-level ambulance would always be the appropriate resource chosen based upon medical dispatch protocols to respond to a request for service. Claims including this transportation indicator should contain two primary codes. The first condition will indicate the BLS-level condition corresponding to the patient's condition found on- scene and during the transport. The second condition will indicate the ALS-level condition corresponding to the information at the time of dispatch that indicated the need for an ALS- level response based upon medically appropriate dispatch protocols.

C6

C7 Indicates circumstances where IV medications were required enroute. The patient's condition should also be reported on the claim with a code selected from the list.

Definitions

Advanced Life Support (ALS): A set of life-saving protocols and skills including invasive techniques that extend beyond Basic Life Support (BLS). Examples of invasive techniques include advanced airway equipment, cardiac defibrillator, IV fluids, medications, and more. It is used to provide urgent treatment for cardiac emergencies such as cardiac arrest, stroke, myocardial infarction, and other conditions.

Ambulance Trip Sheet:Also called the Run Sheet is a record of the patient encounter and is used as a medical record for ambulance services.

Ambulance Modifier:Identifies the place of origin and destination of the ambulance trip. These must be submitted on all ambulance claims.

Basic Life Support (BLS): A level of medical skill used to treat victims experiencing life-threatening illnesses or injuries until they can be given full medical care at a hospital. A BLS provider is not authorized to perform invasive procedures, and may only administer a few select medications.

EMTALA:Emergency Medical Treatment and Labor Act. In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay.

Occurrence Span Code:Displayed on Institutional claims to identify a specific event related to a claim, which occurred for a certain span of time.

Occurrence Span Code 74: Non-Covered Level of Care. Dates represent the period at a non-covered level of care in an otherwise covered stay.

Resources

Medicare Claims Processing Manual Chapter 15 Ambulance

Cross References

None

Disclaimer

This policy outlines the basis for reimbursement of the service described herein. The information in this policy is intended to serve as a general resource. It is not intended to address every aspect of reimbursement. You are responsible for submitting accurate claims that are consistent with our member contracts, our contract with you and our medical policies. This policy does not guarantee payment. Services must meet our authorization requirements and the medical necessity guidelines that are appropriate for the member’s diagnosis and medical condition at the time of service. In addition to the requirements of this policy, you must follow all guidelines in our Billing & Claims Administration Manual. The codes that are billed must be fully supported by the medical record. If our billing guidelines or the requirements outlined in this policy are not followed, we may deny the claim or recover the claim payment.

History and Approvals

12/03/2024 Bryan Turner, MD Medical Director; Dale Lyman, VP Cost Containment

CHIROPRACTIC MANIPULATIVE TREATMENT p. 56

Application

This policy applies to all network and non-network physicians and other qualified health care professionals.

Policy

MotivHealth conforms to Centers for Medicare and Medicaid Services (CMS) guidelines unless otherwise stated in this policy for reimbursements related to chiropractic manipulative treatment (CMT). MotivHealth may require verification of the Chiropractor’s qualification. Such providers must be licensed by the state where the service was rendered and must meet the national uniform standards.

The following CPT codes are eligible for reimbursement when CMT services are rendered.

98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions
98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions
98942 Chiropractic manipulative treatment (CMT); spinal, 5 regions
98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions

The following CPT codes are not eligible for separate reimbursement when performed in a spinal region undergoing CMT:

97112 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
97124 Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
97140 Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

If the above services are performed in a different region than where the CMT was performed, these services may be eligible for reimbursement when appending modifier 59 to the CPT code.

DETERMINING MEDICAL NECESSITY: X-RAYS VS.PHYSICAL EXAMINATION

X-rays to show the subluxation are not required. If they are performed, such imaging is eligible for separate reimbursement. Imaging is not a substitute or replace the documentation requirements identified below.

When medical necessity for CMT is determined through a physical examination, two of the following four characteristics must be present, one of which must be Asymmetry/misalignment identified or Range of motion abnormality, in order for CMT to be eligible for reimbursement:

Pain/tenderness evaluated in terms of location, quality, and intensity
Asymmetry/misalignment identified on a sectional or segmental level
Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility)
Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament

The symptoms that require CMT must have a direct relationship to the level of subluxation and must relate to the spine. It is recognized that vertebral pinching of spinal nerves may cause pain or numbness in the arm, shoulder, leg and foot and can cause headaches as well. However, the subluxation must be causal to any pain or numbness experienced in other parts of the body.

One CMT per day is eligible for payment. This includes even those situations where a provider utilizes an “intensive care” chiropractic approach (multiple daily treatments are provided in a single day). Any room and board fees necessitated by this treatment approach is not eligible for reimbursement.

ITEMS AND SERVICES NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

Manual devices used or available for use during CMT
Services for devices that must be controlled manually by the chiropractor
No other diagnostic or therapeutic service or test rendered by a chiropractor even if the chiropractor holds another license for such services
X-rays taken by a chiropractor or under his/her supervision
X-ray interpretation by the chiropractor. Interpretation by another Doctor of Medicine or Osteopathy are eligible for separate reimbursement.
Evaluation and management services rendered during the CMT. Appending a modifier will not bypass the edit.

BILLING GUIDELINES The following billing guidelines are required on a CMS-1500 and at minimum must be present in order for your claim to be considered eligible for reimbursement:

Specify the precise spinal location and the level of subluxation
Date of initial visit or date of exacerbation of the existing condition
Identify the CPT code that best describes the service rendered

REQUIRED DOCUMENTATION FOR PATIENT MEDICAL RECORD Medical records are an important part of patient evaluation and treatment. They provide evidence of actions and decisions made during the rendering of care and are also necessary for the appropriate administration and payment of a provider’s reimbursement requests. Adherence to the guidance in this policy will provide more efficient claims processing and expedient payment. For detailed information on MotivHealth’s medical records standards and submission requirements, please see MotivHealth’s Billing and Claims Administration Policy.

Please cooperate and promptly comply with our requests for the documentation we need to assess your payment requests. Services are eligible for reimbursement when the following documentation requirements are met:

HISTORY

Symptoms causing patient to seek treatment
Family history, if relevant
Past medical history
Mechanism of trauma
Quality and character of symptoms/problem
Onset, duration, intensity, frequency, location and radiation of symptoms
Aggravating or relieving factors
Prior interventions, treatments, medications
Secondary complaints

INITIAL VISIT

History as indicated above
Symptoms causing member to seek treatment. A statement of simply “pain” is insufficient. The pain must be described and the particular vertebra that is producing the pain must be identified.
Documentation of the physical examination for the musculoskeletal and nervous systems.
Diagnosis of which the primary diagnosis must be subluxation including the level of subluxation.
Treatment plan which should include the treatment goals, objective measures to determine efficacy of treatment, and the duration and frequency of visits.
SUBSEQUENT VISITS

Review of chief complaint
Member reported changes, if any, since last visit
Physical examination of area of subluxation
Objective assessment of change in member’s condition since last visit
Evaluation of treatment effectiveness
Documentation of treatment rendered on the day of the visit

Coding Guidelines

As indicated above.

Definitions

CMS: Centers for Medicare and Medicaid Services

CMT: Chiropractic Manipulative Treatment

CMS-1500 Claim Form: The CMS 1500, also known as the HCFA-1500 is the claim form for individual providers and charges under Medicare Part B.

CPT: Current Procedural Terminology. A medical code set maintained by the American Medical Association (AMA) that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations. CPT is included in Level I Healthcare Common Procedure Coding System (HCPCS).

Diagnostic Service: a service is “diagnostic” if it is an exam or procedure to which you subject the patient, or which you perform on materials derived from a hospital outpatient, to get information to aid in your assessment of a medical condition or to identify a disease.

Intensive Care Chiropractic Treatment: Chiropractic approach where multiple daily visits (as many as four or five in a single day) are given in the office or clinic. The patient is confined to bed for the day when such an approach is used.

appropriate with regard to standards of good medical practice in the state of Utah and could not have been omitted without adversely affecting the Member’s condition or the quality of medical care the Member received as determined by established medical review mechanisms, within the scope of the Provider’s licensure, and/or consistent with and included in policies established and recognized by MotivHealth. Any medical condition, treatment, service, equipment, etc. specifically excluded in the Master Policy is not an “Eligible Benefit” regardless of Medical Necessity.

Modifier 59: Used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.

Qualified Healthcare Professional: Physician assistant or clinical nurse specialist who is not a licensed M.D. or D.O. or nurse practitioner.

Subluxation: A motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact.

Resources

Medicare Claims Processing Manual Chapter 12, Section 220.A

Medicare NCCI Policy Manual, Chapter 11

Medicare Benefit Policy Manual, Chapter 15

Cross References

None Disclaimer This policy outlines the basis for reimbursement of the service described herein. The information in this policy is intended to serve as a general resource. It is not intended to address every aspect of reimbursement. You are responsible for submitting accurate claims that are consistent with our member contracts, our contract with you and our medical policies. This policy does not guarantee payment. Services must meet our authorization requirements and the medical necessity guidelines that are appropriate for the member’s diagnosis and medical condition at the time of service. In addition to the requirements of this policy, you must follow all guidelines in our Billing & Claims Administration Manual. The codes that are billed must be fully supported by the medical record. If our billing guidelines or the requirements outlined in this policy are not followed, we may deny the claim or recover the claim payment.

History and Approvals

12/10/2024 Bryan Turner, MD Medical Director; Dale Lyman, VP Cost Containment

PREVENTATIVE SERVICES p. 60

Application

This policy applies to all network and non-network facilities, physicians and other qualified health care practitioners, and qualified healthcare professionals.

Policy

MotivHealth covers certain recommended preventive services identified by United States Preventive Services Task Force (USPSTF) and Women’s Preventive Services Initiative (WPSI).

PREVENTIVE MEDICINE SERVICES

Services such as annual physicals and other preventive services are eligible for reimbursement when supported by documentation consistent with evaluation and management (E/M) services. This includes at least three key components: problem or comprehensive history and examination, medical decision making, counseling and/or coordination of care with physician or other qualified health care professional.

IMMUNIZATIONS

MotivHealth conforms to all federal mandates for all children’s vaccinations. Vaccines are eligible for reimbursement when a provider must incur actual costs for the vaccine. Providers with access to free vaccines regardless of source, federal or state, will not be reimbursed.

Vaccinations for adults as a condition of employment or continued employment are eligible for reimbursement.

Vaccinations must be administered by an individual qualified to administer such drugs. MotivHealth will notreimburse for the administration fee of a vaccine.

Coding Guidelines

PREVENTIVE MEDICINE SERVICES

The following preventive medicine codes will be reimbursed at 100 percent of the allowable contracted rate:

CPT 99381-99387 CPT 99391-99397

The following E/M codes, when billed with Modifier 25 to identify a separately identifiable service, are eligible for reimbursement but will be subject to a 50 percent reduction. This payment reduction on the E/M visit is due to the duplication of overlapping services, such as the costs associated with maintaining a practice. These costs are already being considered in the reimbursement of the preventive service.

CPT 99201-99205 CPT 99211-99215 CPT 99241-99245

IMMUNIZATIONS The correct immunization code (90476-90749) that was administered must be billed. The administration must be supported by documentation.

Definitions

Immunization: The process whereby a person is made resistant to a disease, typically by the administration of a vaccine.

Preventive Services: Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

Qualified Healthcare Practitioner: A ‘physician or other qualified health care professional’ is an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.

Qualified Healthcare Professional: Physician assistant or clinical nurse specialist who is not a licensed M.D. or D.O. or nurse practitioner.

USPSTF: The U.S. Preventive Services Task Force works to improve the health of people nationwide by making evidence-based recommendations on effective ways to prevent disease & prolong life.

Vaccine: A preparation that is used to stimulate the body’s immune response against diseases. Vaccines are usually administered through needle injections, but some can be administered by mouth or sprayed into the nose.

Cross References

None

Disclaimer

History and Approvals

12/10/2024 Bryan Turner, MD Medical Director; Dale Lyman, VP Cost Containment

PROLONGED SERVICES p. 62

Application

This policy applies to all network and non-network facilities, physicians and other qualified health care practitioners.

Policy

Separate reimbursement will be made to physicians or other qualified health care practitioners for prolonged services when reported in conjunction with E/M codes or other services.

Prolonged Services with Direct Patient Contact: When a physician or other qualified health care professional provides prolonged services beyond the usual service in either the inpatient or outpatient setting. Direct Patient Contact is face-to-face and includes additional non-face-to-face services on the patient’s floor or unit in the hospital or nursing facility during the same session. This service is reported in addition to the designated evaluation and management services at any level and other services provided at the same session as evaluation and management services.

Prolonged Services without Direct Patient Contact: Prolonged Services without Direct Patient Contact are used when a prolonged service is provided that is neither face-to-face time in the office or outpatient setting, nor additional unit/floor time in the hospital or nursing facility setting during the same session of an evaluation and management service and is beyond the usual physician or other qualified health care professional service time.

Coding Guidelines

CODE DESCRIPTION

99358Prolonged evaluation and management service before and/or after direct patient care; first hour

99359Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes (List separately in addition to code for prolonged service)

Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service)

99415

Prolonged clinical staff service (the service beyond the highest time in the range of total time of the service) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; each additional 30 minutes (List separately in addition to code for prolonged service)

99416

Prolonged outpatient evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the outpatient Evaluation and Management service)

99417

Prolonged inpatient or observation evaluation and management service(s) time with or without direct patient contact beyond the required time of the primary service when the primary service level has been selected using total time, each 15 minutes of total time (List separately in addition to the code of the inpatient and observation Evaluation and Management service)

99418

Prolonged service codes are considered add-on codes and should not be reported without the appropriate primary code.

In accordance with CMS and the AMA, Prolonged Services without Direct Patient Contact (CPT 99358 and 99359) will not be separately reimbursed with Care Management CPT codes 99484, 99487, 99490, 99492, 99493, 99494 and Transitional Care Management CPT codes 99495 and 99496.

According to the American Congress of Obstetricians and Gynecologists (ACOG) coding guidelines, prolonged services are not separately reimbursed. Prolonged services are not reported for services that do not have a time component such as labor and delivery management.

Definitions

ACOG: American College of Obstetricians and Gynecologists

AMA: American Medical Association

CMS: Centers for Medicare and Medicaid Services

Cross References

None

Disclaimer

History and Approvals

12/10/2024 Bryan Turner, MD Medical Director; Dale Lyman, VP Cost Containment

TELEHEALTH/TELEMEDICINE SERVICES p. 64

Application

This policy applies to all network and non-network facilities, physicians and other qualified health care professionals.

Policy

The information exchanged between the reporting provider and the patient during the course of the telehealth/telemedicine visit must be of an amount and nature that would be sufficient to meet the key components/or requirements of the same service when rendered via face-to-face interaction.

Claims for professional services must be submitted using the appropriate CPT Code from Appendix P in the CPT manual. (See Coding Guidelines below). Modifier GT or 95 must be appended to the code to differentiate a telemedicine encounter from an in-person encounter with the patient. When reporting Modifier GT or Modifier 95, the practitioner is attesting that services were rendered to a patient via an interactive audio and visual telecommunications system.

All claims are subject to audit. Medical records may be requested from the provider. Failure to submit requested records will result in a denial of the claim. See Billing and Claims Administration Manual for the requirements related to medical records’ requests.

REIMBURSEMENT FOR TELEMEDICINE SERVICES

Reimbursement for claims eligible for reimbursement will be at the following rates:

PROVIDER

PLACE OF

MODIFIER REQUIRED

REIMBURSEMENT

TYPE

SERVICE

RATE

Participating Network 02 Yes Contractual facility fee schedule: 100%

Participating Network N/A Yes Contractual facility fee schedule: 70%

First Health Network N/A Yes First Health contractual rate: 100%

Out of Network N/A Yes Medicare Physician Fee Schedule: 80%

Coding Guidelines Charges for telemedicine services are eligible for reimbursement when the following coding guidelines are met.

PLACE OF SERVICE:

Place of Service 02 is required on the claim per the table above to indicate that the service was delivered via telemedicine.

MODIFIERS

MODIFIER DESCRIPTION

GT Via interactive audio and video telecommunications systems

95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system

CPT CODES THAT MAY BE USED FOR SYNCHRONOUS TELEMEDICINE SERVICES

This listing from Appendix P 1 is a summary of CPT codes that may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95. Procedures on this list involve electronic communication using interactive telecommunications equipment that includes, at a minimum, audio and video.

CPT® Code CPT® Code CPT® Code CPT® Code CPT® Code CPT® Code CPT® Code

90785 90952 92228 93268 97530 99211 99308

90791 90954 92507 93270 97535 99212 99309

90792 90955 92508 93271 97750 99213 99310

90832 90957 92521 93272 97755 99214 99406

90833 90958 92522 96040 97760 99215 99407

90834 90960 92523 96105 97761 99231 99408

90836 90961 90524 96116 97802 99232 99409

90837 90963 92526 92125 97803 99233 99417

90838 90964 92601 96160 97804 99242 99418

90839 90965 92602 96161 98960 99243 99495

90840 90966 92603 97110 98961 99244 99496

90845 90967 92604 97116 98962 99245 99497

90846 90968 93228 97161 99202 99252 99498

90847 90969 93229 97162 99203 99253

90863 90970 93268 97165 99204 99255

90951 92227 93270 97166 99205 99307

1AAPC Appendix P

Definitions

AMA: American Medical Association

Modifier: Two characters (letters or numbers) appended to a CPT® or HCPCS Level II code. The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code.

Place of Service 02: The location where Health Services and Health related services are provided or received, through a telecommunication system

Telehealth: The use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, provider training,continuing medical education or public health education, administrative meetings, and electronic information sharing

Telemedicine: The use of electronic information and telecommunications technologies to provide remote clinical services.

Resources

AAPC APPENDIX P Telemedicine Codes

Cross References

Billing & Claims Administration Manual

Disclaimer

History and Approvals

12/05/2024 Bryan Turner, MD Medical Director; Dale Lyman, VP Cost Containment

ANESTHESIA AND SURGICAL SERVICES p. 67

ANESTHESIA p. 67

Application

This policy applies for all products and to all network and non-network facilities, physicians and other qualified health care professionals.

Policy

WHO IS ELIGIBLE FOR REIMBURSEMENT?

Reimbursement may be allowed for anesthesia services performed by an anesthesiologist or Certified Registered Nurse Anesthetist (CRNA).

HOW SHOULD ANESTHESIA SERVICES BE BILLED?

Electronic claims

Submit via the 837 Professional transaction set, should have the anesthesia minutes reported in loop 2400 SV 104 with an MJ qualifier in loop 2400 SV 103 per the 867 Implementation Guide

Paper claims

(CMS Paper Format 01-12): Anesthesia time (duration in minutes with start and end times) should be entered in shaded area of field 24 A-K and the total minutes in field 24G for each applicable service line. On line 24A, enter Qualifier 7 (anesthesia information). Qualifier 7 is to be used when reporting anesthesia time services.

Example: Begin 1415 End 1615 Time 120 minutes

HOW IS REIMBURSEMENT CALCULATED?

Anesthesia time begins when the member is in the operating room and anesthesiologist, or CRNA begins to prepare the patient for anesthesia care. Anesthesia time ends when the member is placed under the supervision of a post-anesthesia health care practitioner.

Pre-anesthesia set up prior to the patient’s arrival in the operating room is not separately reimbursable.

PROFESSIONAL CLAIMS Our health plan uses the Standard Anesthesia Formula for calculating professional claims: ([Base Unit Value + Time Units + Modifying Units] x Conversion Factor) x Modifier percentage. MotivHealth aligns with the Base Unit Value as defined by CMS. This may be changed annually.

Our health plan will divide the minutes you report on your claim into 15-minute increments, unless otherwise stipulated in your contract with us, to calculate anesthesia reimbursement. If we require you to send us an itemized bill for anesthesia services rendered to our member, the minutes should be divided into 15-minute increments. Submit 1 unit or fractional tenth unit for every 15 minutes that anesthesia care was provided to our member.

Example: 10.567 fifteen-minute increments. This would be priced at 10.6 fifteen-minutes.

The time reported on your electronic claim and the time reported on the itemized bill must reconcile. Those claims that do not reconcile will not be processed.

Unlisted anesthesia codes (i.e., CPT 01999) will require medical records prior to processing. For more information on unlisted codes, see MotivHealth’s Billing & Claims Administration Manual

FACILITY CLAIMS

WHAT SERVICES ARE INCLUDED IN ANESTHESIA CARE?

Services performed in conjunction with a surgical anesthetic are considered an integral part of that anesthesia service and therefore not eligible for separate reimbursement. These services include but are not limited to:

• Arterial blood gas analysis/monitoring.

• Blood pressure monitoring

• Carbon dioxide monitoring

• Moderate conscious sedation

• EEG/EKG monitoring

• Evaluation & management services (preoperative or postoperative visits by the anesthesiologist)

• Field avoidance

• Heparin analysis

• Intraoperative monitoring of any type

• Esophageal doppler hemodynamic management

• Intubation

• Local anesthesia (for regional or field block)

• Nerve block (except as noted in this policy)

• Oximetry/pulse oximetry

• Patient controlled analgesia

• Patient positioning

• Regional IV of local anesthetic

• Supplies and equipment (excluding drugs)

• Ventilator set-up and/or management.

• General anesthesia setup. (If the first one to three minutes are billed separately, this is considered a component of anesthesia setup and not eligible for separate reimbursement)

SPECIAL ANESTHESIA SERVICES

ANESTHESIA BY SURGEON

Anesthesia services provided by the same physician or health care provider performing the medical or surgical service/procedure are considered a component of the surgery/procedure and are not eligible for separate reimbursement. This includes but is not limited to nerve blocks, local, topical, regional and general anesthesia services.

BURNS The total anesthesia time should be billed to the primary code CPT 01952. Unless the AMA provides a different code edit at some future date.

CMS STATUS B CODES FOR QUALIFYING CIRCUMSTANCES

Qualifying circumstances related to extreme age (CPT 99100) , hypothermia (CPT 99116), controlled hypotension (CPT 99135), emergency conditions (CPT 99140) are not eligible for anesthesia reimbursement.

CRITICAL CARE

Critical care services reported under CPT 99291 and 99292 are eligible for separate reimbursement. The medical record must support the billing of these codes.

EPIDURAL AND SUBARACHNOID NERVE BLOCKS

Surgical Anesthesia

CPT 01996 for surgical anesthesia can only be billed in the hospital inpatient setting, place of service code 21.

Nerve blocks administered by an anesthesiologist or CRNA as a component of the anesthesia are not eligible for separate reimbursement as they are considered a part of the anesthesia service.

For specifics on how reimbursement is calculated, see section above: HOW IS REIMBURSEMENT CALCUATED?

Continuous Drug Administration

Placement of the epidural catheter is eligible for reimbursement when placed pre-operatively by a provider other than the attending surgeon for the purpose of managing post operative pain. Modifier 59 or other appropriate modifier must be appended to the code identifying epidural placement as a distinct procedural service.

CPT 01996 and all related services including but not limited to catheter maintenance, drugs, injections of anesthetic substances are eligible for reimbursement once per date of service for up to three (3) consecutive postoperative days beginning the day after surgery. Supplies and services billed separately will be denied. Charges for four (4) or more days require prior authorization.

CPT 01996 for continuous drug administration is reimbursed using a per day rate.

MODERATE SEDATION

Moderate sedation is eligible for separate reimbursement to the surgeon if:

Medicare's National Correct Coding Initiative (NCCI) does not deny the moderate sedation code as

included in the primary procedure.

MotivHealth’s health plan Correct Code Editor (CCE) does not deny the moderate sedation code as

included in the primary procedure.

The primary procedure is not listed in AAPC Appendix G (Summary of CPT Codes that include Moderate

Conscious Sedation).

MONITORED ANESTHESIA CARE (MAC)

Involves the continuous physical presence of the anesthesiologist or CRNA during the entire operative session. MAC is performed when it is anticipated that general anesthesia will be required or concerns that the patient may experience an adverse physiological reaction to some component of the surgery. It includes a pre-anesthesia evaluation, administration of any medications, monitoring of the patient’s vital signs intraoperatively and any post operative anesthesia care.

Modifier QS is appended to the primary anesthesia code and is for informational purposes only.

MULTIPLE ANESTHESIA SERVICES

When a situation warrants that a single anesthetic administration covers multiple anesthesia services, report the anesthesia code with the highest base unit. Report the combined time for all procedures for which the anesthesia was related.

Exception: see Burns and Obstetric sections for special reimbursement requirements.

OBSTETRIC

Maternity anesthesia reimbursement varies slightly due to the nature of the neuraxial labor analgesia where personal attendance by the anesthesiologist or CRNA is not required throughout the procedure. Services reported under CPT 01967 – 01969 are capped at 400one-minute increments.

CPT 01968 and 01969 are add-on codes and must be billed with the primary code 01967.

Tubal ligations billed under CPT codes 58615 and 58670-58671must be billed with appropriate modifier.

STAND BY ANESTHESIA

CPT 99360 or Trauma Team stand by anesthesia do not provide direct patient care and therefore are not eligible for separate reimbursement.

TEACHING AND SUPERVISION

All services reported for anesthesia management must be submitted with the appropriate modifier. These modifiers identify monitored anesthesia and whether a procedure was personally performed, medically directed, or medically supervised. Our health plan follows CMS Modifier percentages as indicated in the table below.

Services rendered by residents or student nurse anesthetists are not reimbursed even if modifier GC is appended.

Supervision of a CRNA by the surgeon is not eligible for reimbursement even if modifier QY is appended.

ModifierDescriptionsAllowed Amount

AA Anesthesia services performed personally by an anesthesiologist. 100%

AD Medical supervision by a physician; more than four concurrent anesthesia procedures.

100%

GC Service performed by in part by a resident under direction of a teaching physician

QK Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals.

50%

QX CRNA service; with medical direction by a physician. 50% for CRNA

50% for supervising anesthesiologist

QY Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist.

50%

QZ CRNA service; without medical direction by a physician. 100%

Coding Guidelines

Anesthesia services must be billed with CPT codes 00100-01999 and are reimbursed as time-based using the Standard Anesthesia Formula or as otherwise indicated in this policy.

All services reported for anesthesia management must be submitted with the appropriate and applicable modifier.

Modifiers P1 through P6: Modifiers used with anesthesia codes that reflect the physical status of the patient receiving anesthesia. Modifier and Physical Status Units:

• P1 — A normal healthy patient: Physical Status Units — 0

• P2 — A patient with mild systemic disease: Physical Status Units — 0

• P3 — A patient with severe systemic disease: Physical Status Units — 1

• P4 — A patient with severe systemic disease that is a constant threat to life: Physical Status Units — 2

• P5 — A moribund patient who is not expected to survive without the operation: Physical Status Units — 3

• P6 — A declared brain-dead patient organs are being removed for donor purposes: Physical Status Units — 0

Definitions

CRNA: Certified Registered Nurse Anesthetist

HCPCS: Healthcare Common Procedure Coding System

Resources

Center for Medicare and Medicaid Services (CMS) CHAPTER II ANESTHESIA SERVICES CPT CODES 00000-01999

Medicare Claims Processing Manual

American Society of Anesthesiologist (ASA) Anesthesia Payment Basics Series Codes and Modifiers

Cross References

Billing & Claims Administration Manual

Disclaimer

History and Approvals

12/03/2024 Bryan Turner, MD Medical Director; Dale Lyman, VP Cost Containment

ASSISTANT SURGEON/CO-SURGEON p. 73

Application

This policy applies to all products and to all network and non-network facilities, physicians and other qualified health care professionals.

Policy This policy describes the reimbursement of Assistant-at-Surgery, Assistant Surgeon, Co-Surgeon and Team Surgeon. Appropriate modifiers must be appended to the surgical CPT code to be considered eligible for reimbursement. Charges for surgical services without the appropriate modifier appended to the CPT code will be denied. Medical documentation must support the use of a modifier, and such documentation must be provided if requested.
Multiple procedure reductions will apply if multiple procedure codes are submitted by one or more surgeons.

The use of a robotic surgical device is not reimbursable even when billed with a modifier for Assistant Surgeon or Assistant-at-Surgery. Please check the member’s benefits for exclusions to robotic assisted surgery.

This policy is based on CMS National Physician Fee Schedule Relative Value Units payment policy indicators. All codes in the NPFS with status indicators of 1 or 2 are eligible services for Co-Surgeons and Team Surgeons.

How is reimbursement calculated?

Assistant-at-Surgery

Qualified Health care professionals billing Assistant-at-Surgery services are reimbursed based on CMS guidelines of 14% of the Allowable Amount for eligible surgical procedures. Assistant-at-Surgery must append Modifier AS using the same surgical CPT code as the primary surgeon. Per CMS guidelines, the services of a surgical technician are included in the reimbursement to the facility and not separately reimbursable. Services performed by students will not be compensated. If a surgery is performed by a student, the primary surgeon will not be compensated.

Assistant Surgeon

Assistant Surgeon services are eligible for reimbursement when medically necessary. Only one Assistant Surgeon may be reimbursed for each procedure. Assistant Surgeon must append Modifier 80, 81, 82, or AS using the same surgical CPT code as the primary surgeon. Reimbursement is based on CMS guidelines of 16% of the Allowed Amount for eligible surgical procedures.

The services of an Assistant Surgeon are not eligible for reimbursement if a Co-Surgeon was present during the same encounter as the Assistant Surgeon and the Co-Surgeon billed using the same surgical CPT code as the attending surgeon.

Co-Surgeon

Co-Surgeon is reimbursed at 62.5% of the Allowed Amount. Each Co-Surgeon must append Modifier 62 to the surgical CPT code. Reimbursement is based on CMS guidelines of 62.5% of the Allowed Amount for eligible surgical procedures. Simultaneous bilateral procedures must be reported with modifiers 50 and 62.

Team Surgeon

Each team surgeon must document in the medical record their specific participation in the surgical procedure. One operative note written by one member of the surgical team is not sufficient documentation. Surgical services provided by a team surgeon that are not individually documented are not eligible for reimbursement. Pre-authorization is required for team surgeries. Reimbursement is determined on a case-by-case basis if prior authorization was not obtained. Each Team Surgeon must append Modifier 66 to the surgical CPT code. Each Team Surgeon should submit an appropriate surgical CPT code.

Coding Guidelines

Modifier Descriptor 50 Bilateral procedure 62 Co-Surgeon 66 Team Surgeon 80 Assistant Surgeon 81 Minimum Assistant Surgeon 82 Assistant Surgeon when qualified resident surgeon not available AS Physician assistant, nurse practitioner, clinical nurse specialist services for Assistant-at-Surgery

Definitions

Allowed Amount: This is the contracted rate or billed charge, depending on whether the healthcare provider is in-network or a non-network provider

Assistant-at-Surgery: Non-physician healthcare provider (physician assistant, nurse midwife, nurse practitioner or clinical nurse specialist) that is under the direct supervision of the surgeon during the surgery and actively assists the surgeon in performing the surgical procedure.

Assistant Surgeon: Physician (M.D. or D.O.) who actively assists the surgeon during the surgical procedure. Such an individual is usually trained in the same specialty as the surgeon.

Co-Surgeon: Physician who may or may not be trained in the same specialty as the surgeon. Co-surgeons work together as primary surgeons and are utilized during complex surgical procedures where each surgeon performs distinct parts of an operation. The Co-Surgeon always performs their part of the surgery during the same encounter as the attending surgeon.

Qualified Healthcare Professional: Physician assistant or clinical nurse specialist who is not a licensed M.D. or D.O.

Simultaneous Bilateral Services: Procedure in which each surgeon performs the same procedure on opposite sides of the body.

Team Surgeon: Three or more physicians who operate in a surgical team during a highly complex surgical procedure. The surgeons in such a team are often trained in different specialties.

Resources

CMS Medicare Claims Processing, Pub. 100-04, Chapter 12, Sect. 20.4.3

CMS Healthcare Common Procedure Coding System

Cross References

None

Disclaimer

History and Approvals

4/5/2023 New policy: Approved by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

BILATERAL PROCEDURES p. 76

Application

This policy applies to all products and to all network and non-network facilities, physicians and other qualified health care professionals.

Policy

The Centers for Medicare and Medicaid Services (CMS) has assigned a Bilateral Status Indicator to each CPT code and has identified codes that are eligible for bilateral reduction adjustment. MotivHealth conforms to those payment rules. Bilateral Status Indicators are found in the CMS National Physician Fee Schedule Relative Value Units file. This file updates quarterly. It is the provider’s responsibility to follow the guidelines for appending modifiers to ensure proper processing of the claim.

Bilateral procedures must be reported with Modifier 50 appended to the surgical CPT code. If the procedure code submitted is inconsistent with the modifier appended as it pertains to the Bilateral Status Indicator, the service will be denied.

How is reimbursement calculated?

Bilateral Status Indicator

Descriptor Bilateral Reduction Adjustment

Bilateral Modifier

Eligible Reimbursement

0 Procedure is unilateral. 0

N/AReimburses one unit

1 Bilateral procedure. 50%
150% of the applicable fee schedule

2 Any code description that in its intent is bilateral or includes the term bilateral or unilateral. These procedure codes are priced to include a bilateral service; therefore, Modifiers RT/LT or 50 are not payable.

0 N/AReimburses one unit

3 Services are generally radiology procedures or other diagnostic tests.

0 N/A Number of procedures performed

9 The bilateral concept does not apply.0 N/A Codes billed with modifier 50, LT or RT are denied

How should bilateral procedures be billed?

CMS-1500 Claim Form

Bilateral Procedure
Claim lines: 1
Units of service: 1
Modifier(s): 50

CMS- UB-04 Claim Form

Bilateral Procedure
Claim lines: 2
Units of service: 1
Modifier(s) RT and/or LT

Special Bilateral Procedures
MULTIPLE PROCEDURES

CMS’s payment adjustment methodology will be applied to bilateral eligible procedures with an indicator of “1” regardless of the Multiple Procedure Indicator when the procedure code is reported bilaterally with a 50 Modifier.

If an operative session includes multiple procedures as well as a bilateral procedure, the bilateral reduction adjustment will be applied before applying the multiple surgery reduction or any other applicable coding rules. Any pricing adjustments related to co-surgeon or assistant surgeon will also apply.

BILATERAL PROCEDURES PERFORMED ON ONE SIDE OF THE BODY p. 77

If a CPT code exists for a unilateral procedure, the unilateral code should be reported. If a unilateral procedure does not exist, report the bilateral code and append modifier 52 (Service or procedure is partially reduced or eliminated at the physician’s discretion). Modifier 50 may not be reported in combination with Modifier 52.

AMBULATORY SURGERY CENTER (ASC) p. 77

CMS has exempted ASCs from the bilateral modifier requirement and should not report Modifier 50. These facilities should bill the surgical CPT on two lines and append the anatomical modifiers RT and LT.

Coding Guidelines

Modifier 50: Bilateral procedure performed on both sides of the body.

Modifiers RT and LT may apply when bilateral surgery rules do not apply and would apply for ASCs. While they do provide additional detail on the surgical procedure, these modifiers do not affect payment as Modifier 50 does for bilateral procedures. Modifiers RT and LT modifiers may not be used in addition to Modifier 50.

Definitions

Bilateral Procedure: The same procedure performed on both sides of the body during the same operative session.

HCPCS: Healthcare Common Procedure Coding System

Modifier 50: Bilateral procedure. This modifier should not be used with procedure codes identified in their terminology as bilateral or procedures identified as unilateral.

Modifier 52: Reduced Services

Resources

CMS Website

CMS National Physician Fee Schedule Relative Value Units

CPT® (Current Procedural Terminology) | CPT® Codes | AMA (ama-assn.org)

HCPCS - General Information | CMS

CMS Bilateral Indicator 3: Incorrect Coding

Cross References

None

Disclaimer

History and Approvals

11/27/2023 New policy: Approved by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

CONCURRENT SURGERIES p. 79

Application

This policy applies to all network and non-network facilities, physicians, and other qualified health care professionals.

Policy

CONCURRENT SURGERY

Concurrent Surgeries (also called Simultaneous Operations, Running Two Rooms, or Double-Booked Surgery) occur when critical portions of the operation for which a single surgeon is responsible are being performed on different patients during the same period of time.

In an acute situation where life or limb are threatened, it may be essential for a surgeon to perform critical portions of a surgical procedure on two patients simultaneously. However, there exists potential safety hazards to the practice of concurrent surgeries. These are related to the possibility of missteps and complications resulting from the surgeon’s inability to provide the necessary attention to two patients simultaneously. Even small errors in a surgical procedure can result in measurable harm to a patient. The American College of Surgeons (ACS) April 2016 Statement of Principles deems the practice of concurrent surgery to be inappropriate.

Reimbursement of Concurrent Surgeries

In a scheduled elective procedure, concurrent surgeries where critical portions of the operative procedure for which a single surgeon is responsible are being performed on different patients, during the same period of time, whether or not in different rooms, will not be reimbursed. This position is consistent with Centers for Medicare and Medicaid (CMS) guidelines for reimbursement of concurrent surgeries in teaching hospitals.
Disclosure to Patients

If an urgent or emergent situation arises that requires the primary attending surgeon to leave the operating room unexpectedly during a critical portion of the procedure, the patient must be subsequently informed in writing.

OVERLAPPING SURGERY

American College of Surgeons identifies two types of surgical scenarios for overlapping surgeries.

SCENARIO 1 Key or critical portions of the first procedure have been completed, and there is no reasonable expectation that the primary attending surgeon will need to return to that operation. The surgeon leaves a qualified practitioner to continue the procedure who performs noncritical components of this first operation such as wound closure. This allows the primary attending surgeon to initiate the second operation in another operating room. This scenario is most common.
SCENARIO 2 Key or critical elements of the first operation have been completed and the primary attending surgeon is performing critical portions of a second operation in another room. The primary attending surgeon must assign immediate availability in the first operating room to another attending surgeon qualified in the procedure. This scenario should not be common.

Reimbursement of Overlapping Surgeries

Overlapping surgeries are generally reimbursable when the performance of overlapping procedures does not negatively affect flow or outcome of either procedure. The primary surgeon must have performed the key or critical portions of the surgery. After leaving the patient for another procedure, the primary surgeon must be immediately available if a matter arises that requires the attention of the surgeon, or have a practitioner qualified in the procedure(s) to effectively handle the situation. The medical record must document the primary surgeon’s availability during the timeout process and key/critical portions of the procedure as well as the qualified healthcare practitioner(s) assigned as backup to perform the noncritical portions of the procedure.

In no instance should the patient be under anesthesia longer than medically necessary. There is no reimbursement to surgeon, anesthesiologist, or facility for any portion of a patient’s surgery or anesthesia that is prolonged beyond what is medically necessary.

There is no reimbursement to surgeons attending three or more overlapping surgeries as the physician is deemed to provide only advisory services rather than care to an individual patient. This position is consistent with Centers for Medicare and Medicaid (CMS) guidelines for reimbursement of concurrent surgeries in teaching hospitals.

Disclosure to Patients

Patients are highly vulnerable during surgery. The expectation of patients is that their surgeon will be present in the operating room attending to their procedure for the entire surgery. For this reason, the patient must be informed of the intent to overlap procedures and the qualified medical providers that will participate in the surgery (assistant attending surgeon, fellows, residents, interns, physician assistants, nurse practitioners, etc.) Informed consent must be obtained from the patient prior to the surgery.

There is no reimbursement to surgeon, anesthesiologist, or facility when proper informed consent has not been provided to the patient. The medical record should include documentation that supports adequate patient disclosure.

Coding Guidelines

None

Definitions

Back-up Surgeon/Surgical Attending: A qualified surgical attending physician who is responsible for providing appropriate and timely clinical coverage for an operation during a period when the primary surgeon may be unable to fill this role.

CMS: Centers for Medicare and Medicaid Services

Concurrent Surgery: Surgical procedures in which critical portions of the operation for which a single surgeon is responsible are performed on different patients, and in different rooms, during the same period of time. The attending surgeon is not present for “critical and key” portions of a procedure. Critical portions chronologically coincide for any reason, foreseen or unforeseen.

Critical/Key Portions of an Operation Surgical: Portions of a procedure during which essential technical expertise and surgical judgement are required to achieve optimal patient outcome. The critical/key portions of each operation should be made known to all operating room staff.

Double-Booked Surgery: See Concurrent Surgery

Immediately Available: Reachable and with the ability to provide, on demand, the appropriate level of clinical care necessary to perform an operation.

Informed Consent: A process when communication between a patient and physician results in the patient’s (or surrogate’s) authorization to undergo/proceed with a specific medical intervention. The informed consent conversation and the patient’s (or surrogate’s) decision documented in a specific written consent form is included in the medical record.

Physically Present: Being in the same operating room as the patient.

Primary Attending Surgeon: The principal surgeon involved in the specific critical portions of the operation. He/she is responsible for the orchestration and progress of the critical portions of the procedure.

Qualified Healthcare Provider: A licensed healthcare provider with sufficient training and expertise, and appropriate hospital privileges and qualifications, to conduct a portion of the surgical procedure without the need for more experienced supervision.

Overlapping Surgery: Procedures in which part or all of the procedures chronologically coincide and when the patient’s care is left with another qualified medical provider. More specifically, operations are spaced out to ensure the critical portions of each operation, for which a single surgeon is responsible, do not occur at the same time.

Running Two Rooms: See Concurrent Surgery

Simultaneous Operations: see Concurrent Surgery.

Timeout Process: An immediate pause by the entire surgical team to confirm the correct patient, procedure, and site.

Resources American College of Surgeons Statements on Principles
PubMed National Library of Medicine: Overlapping and Concurrent Surgery - A Professional and Ethical Analysis
American Society of Plastic Surgeons Statement on Concurrent Surgery

CMS Manual System Pub 100-04 Medicare Claims Transmittal 2303

Concurrent and Overlapping Surgeries United States Senate Finance Committee Staff Report

American Medical Association Informed Consent Defined

The Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals. Glossary. Oakbrook Terrace, IL. 2017 update. (Manual and corresponding updates are subscription-based.)

Cross References

Anesthesia

Assistant Surgeon, Co-Surgeon

Disclaimer

History and Approvals

7/17/2023 New policy: Approved by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

GLOBAL SURGICAL PACKAGE p. 83

Application

This policy applies to all network and non-network facilities, Ambulatory Surgical Centers, physicians, and other qualified health care professionals.

Policy

Global Surgical Periods are a time span beginning with surgical procedure’s pre-operative period and ending sometime after the procedure was performed. The time span is dependent on the complexity of the surgical procedure. CMS global surgery indicators for a procedure’s global period are found in the CMS National Physician Fee Schedule Relative Value Files

Reimbursement for surgical procedures includes payment for all related services and supplies that are necessary and/or related to that procedure. These services and supplies are not eligible for separate reimbursement when provided within the global period. Appending a modifier will not override the denial edit.

Providers within the same provider group with the same or similar specialty are subject to the same global period rules when covering for another provider. Providers are identified by both TIN and name.

Global Surgical Period

Surgical Indicators Defined

000 - Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount, evaluation and management services on the day of the procedure are generally not payable.
010- The global period applies to the day of the procedure only and 10 days following the procedure. There are no pre-operative days in the global period for this surgical indicator code. Thus, services performed sometime before the surgical period are separately payable. E/M and other related services on the day of the procedure and 10 days after are not separately payable.
090- The global period applies to the day before the procedure, the day of the procedure and 90 days following the procedure. Thus, any services related to the procedure during this time period are not separately reimbursable.

MMM - Maternity codes; usual global period does not apply.

XXX - The global concept does not apply to the code.

YYY - The carrier is to determine whether the global concept applies and establishes postoperative period, if appropriate, at time of pricing.

ZZZ - The code is an add-on code and is related to another primary service. It is always included in the global period of the primary service.

Reporting E/M Services During the Global Period

E/M service that led to the decision to perform a procedure on the same date of service if a separate service in addition to the procedure is documented.

0-day or 10-day global period: append modifier -25
90-day global period: append modifier -57

E/M service during the global period.

Example: A patient had a knee replacement (CPT 27486). The global period for this procedure is 90 days. The patient is seen for the 30-day follow-up. At the time of the visit the patient complains of shoulder pain. This is not related to the knee surgery and the E/M service is separately reimbursable. Append modifier -24.
Example: A patient had a knee replacement (CPT 27486). The global period for this procedure is 90 days. The patient is seen for the 30-day follow-up. At the time of the visit the patient complains of pain and swelling at the site of the knee replacement. This is related to the knee surgery and the E/M service is not separately reimbursable. A modifier will not override the denial edit.

E/M service for treatment of an underlying condition that prompted the procedure.

Example: A patient undergoes an open incision breast biopsy (CPT 19101). The global period for this procedure is 10 days. The biopsy reveals a malignancy. The patient returns in 5 days to discuss treatment options. This E/M service is separately reimbursable because it is for treatment of the underlying condition (malignant tumor) that prompted the biopsy and not the biopsy procedure itself. Append the appropriate modifier.
Example: A patient undergoes an open incision breast biopsy (CPT 19101). The global period for this procedure is 10 days. The biopsy reveals a malignancy. The patient returns in 5 days and complains of pain at the incision site. This E/M service is not separately reimbursable because it is related to the breast biopsy procedure and not the underlying condition (malignant tumor) . A modifier will not override the denial edit.

Components of the Global Surgical Package

Preoperative Services:

Anesthesia codes (00100-01999): Preoperative denials will apply to anesthesia services.
Global maternity package codes: Preoperative denials will apply two hundred seventy (270) days prior to delivery. Intra-Operative Services: The reimbursement for a surgical procedure includes payment for all intraoperative services that are a normal, usual and necessary part of that surgical procedure.

Postoperative Services: The reimbursement for a surgical procedure includes payment for all professional services that are related to that procedure and are provided during the postoperative period within the global period. This includes but is not limited to:
Dressing changes
Incisional care
Postoperative pain management by the surgeon
Removal of staples, tubes, drains, casts, splints and cutaneous sutures
Postoperative care or treatment (including complications) that are related to the original surgery but do not require a return trip to the operating room
Insertion, irrigation and removal of catheters
A procedure or service performed within the global period solely to confirm the success of the initial procedure
Anesthesia codes one (1) day after the anesthetic was provided
Global maternity delivery codes for services within forty-five (45) days after delivery
Reimbursable Surgical Services within the Global Period: Some professional services are not included in the reimbursement for a surgical procedure and may be eligible for separate reimbursement. It may be necessary to append an appropriate Modifier to the code for the service to identify the circumstances which make the code eligible for separate reimbursement. These services include:

An E/M service the day before or the day of a major surgical procedure only if the initial decision to perform the surgery was made during that visit. Append modifier -57.

An E/M service provided on the same day as a minor procedure only if the E/M service is unrelated to the procedure performed. Append modifier -25.
An E/M service during the surgical postoperative period only if the visit is unrelated to the surgical procedure. Append modifier -24.
A repeat surgical procedure by the same surgeon performed on the same day as the original surgery, requiring a return trip to the operating room, provided that the repeated surgical procedure was not related to a hospital acquired condition or iatrogenic event. (See policies related to these situations.) Append modifier -76.
A repeat surgical procedure by a different surgeon, on the same day as the original surgery, requiring a return trip to the operating room, provided that the repeated surgical procedure was not related to a hospital acquired condition or iatrogenic event. (See policies related to these situations.) Append modifier -77.
A procedure or treatment that is related to the original surgery that requires an unplanned return to the operating room. Append modifier -78.

A procedure or service that is unrelated to the original surgery. Append modifier -79.

A staged surgical procedure (one that was planned at the time of the original surgery) performed during the postoperative period of the original surgery. Append modifier -58.

Reimbursement for Non-Surgical Procedures during the Global Period:

Separate reimbursement for E/M services will not be allowed for non-surgical services that already include E/M as part of the planned procedure or service (i.e., Chemotherapy Administration).

Codes in CPT with descriptors that include the phrase 'one or more sessions' are eligible for reimbursement only once within their own global period, regardless of the number of sessions necessary to complete the treatment and regardless of the modifier attached.

Definitions

CMS: Centers for Medicare and Medicaid Services

Hospital Acquired Condition (HAC): A condition that is not present with the patient is admitted to or arrived at the hospital or other facility but occurs during or after the stay. HAC’s include infections and medical errors.

Iatrogenic Complications: An adverse condition that is a direct result of treatment by a physician or other health care professional.

Inpatient: Admission to a hospital or skilled nursing facility on a physician’s order.

Modifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period.
Modifier 25: Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.

Modifier 57: Decision for surgery.

Modifier 58: Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period.

Modifier 76: Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional

Modifier 77: Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional.

Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period.

Qualified Healthcare Professional: Physician assistant or clinical nurse specialist who is not a licensed M.D. or D.O.
TIN: Taxpayer Identification Number

Resources Medicare Claims Processing Manual_Chapter 12

Your Quick Guide to the Global Surgical Package - AAPC Knowledge Center

Cross References

None

Disclaimer

History and Approvals

12/03/2024 Bryan Turner, MD Medical Director; Dale Lyman, VP Cost Containment

IMPLANT AND IMPLANT COMPONENTS p. 88

Application

This policy applies to all network and non-network facilities, physicians and other qualified health care professionals.

Policy

CLAIMS WITH A CASE REIMBURSEMENT PAYMENT METHODOLOGY AT THE TIME OF SERVICE

Implants and implant components implanted or remaining in the patient will not be considered for separate reimbursement.

CLAIMS PAID TO A REIMBURSEMENT METHODOLOGY OTHER THAN CASE RATE Implants and implant components implanted or remaining in the patient will be paid according to the stipulations of the contract our health plan has with the provider at the time of service. If the contract is silent or does not address a particular condition(s), the provisions of this policy will govern payment.

IMPLANTS AND IMPLANT COMPONENTS THAT ARE NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT Notwithstanding the above, implants and implant components are not eligible for separate reimbursement when:

Implants, implant components that are opened and then found to be incorrect and not implanted.
Implants, implant components that are inadvertently dropped from the sterile field and cannot be used.
Implants or implant components that are implanted then removed during the same operative procedure (i.e., implant screw removed and replaced when the wrong length of screw is used on a plate).
Implants or implant components that malfunction and are replaced during implantation.

NON-REIMBURSABLE IMPLANT AND SURGICAL SUPPLIES Examples of non-reimbursable implant and surgical supplies include but are not limited to:

Implant tools and implant instrumentation (i.e., drill bits, saw blades, suction devices, forceps, scissors, needle holder or other instruments including computer assisted instrumentation or programs to facilitate or optimize surgeries).

Medical/surgical supplies that are a component of the surgical procedure.
Anesthesia supplies.
Monitoring supplies (i.e., temperature gauges, EKG leads, BP cuffs, O2 saturation monitors, catheters)
Casting and splinting supplies.
Gowns (surgical and patient), surgical gloves.
Heparin, saline flushes and any type of IV flush or diluent to administer substances or drugs.
Intravenous supplies including needles, syringes, tubing, catheters and insertion kits.
Leg compression system.
Dressings, gauze, tape.
OR packs, procedural trays.
Skin prep, towels, drapes.
Staplers (surgical), sutures and skin glue.
Suction/irrigation supplies and additives.
Surgical instruments, including forceps, scissors, needle holder or other instruments whether reusable or not.
Hemostats: Mechanical (i.e., vascular clips, cellulose, gelatins, collagens), thrombin enzymes, sealants (fibrin or synthetic) or adhesives.
Programming of medical device or supply.

Coding Guidelines

None

Definitions

Implant: An object, device or material that is inserted surgically, or embedded via surgical or nonsurgical means, or grafted into the body and remains in the body either indefinitely for prosthetic and/or therapeutic purposes or remains in the body for a period of time for diagnostic and/or therapeutic purposes.

Implant Components:Implant integral parts (i.e., screws, plates, rods) remaining in the body used in conjunction with the primary implant.

Implant Supplies: Elements (i.e., supplies and/or tools) of implant kits or implant systems used to place or remove implants, but do not remain in the body.

Resources

Pub 100-04 Medicare Claims Processing Manual

Frequently Asked Questions on Hospital OPPS Billing for Replacement Devices

Medicare NCCI 2022 Coding Policy Manual Chapter IV

Cross References

Non-Reimbursable Services and Supplies

Disclaimer

History and Approvals

01/15/2024 New policy – Dr. Bryan Turner & Michelle Evans

ROBOTIC ASSISTED SURGERY p. 90

Application

This policy applies to all network and non-network facilities, physicians, and other qualified health care professionals.

Policy

Robotic surgery is a type of surgical technique that is not medically necessary to ensure the successful outcome of the procedure. MotivHealth recognizes that training programs often only teach robotic methods of surgery although the outcomes data has not proven to be clinically better. Therefore, robotic charges that are submitted on the claim will not be separately reimbursable. Reimbursement for procedures in which a robotic surgical system is used will be based on the contracted rate for the base procedure.

Reimbursement will not be made to hospitals, surgical centers, or other facilities for the use of a robotic surgical device or other specialized operating room equipment. These items are included in the operating room charge or facility fee for the base surgical procedure. Up-charging operating room fees and supplies related to the use of the robotics are also not eligible for separate reimbursement.

CHARGES NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

Separate reimbursement is not allowed for the robotic surgical technique regardless of the coding applied.

If the surgical procedure itself is reported with an unlisted code due to the use of a robotic surgical system, the unlisted code will be manually priced based on the contracted fee for the listed procedure code for the base surgical procedure. MotivHealth allows reimbursement for unlisted codes when supported by the appropriate

documentation and a concise description of the service is provided on the claim form and itemized bill.

Appending modifier 22 claiming increased procedural services when robotic techniques are used will not override the denial or provide additional reimbursement for the use of robotics.

Appending modifiers 80, 81, 82, or AS claiming robotics as assistant surgeon services will not override the denial or provide additional reimbursement.

Coding Guidelines

Identify the CPT for the primary surgical procedure. On a separate line add CPT S2900 (Surgical techniques requiring the use of a robotic surgical system for surgeries utilizing robotic assisted devices). CPT S2900 is not eligible for separate reimbursement.

Definitions

Modifier:Two characters (letters or numbers) appended to a CPT® or HCPCS Level II code. The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code.

Modifier 22:Increased Procedural Services.

Modifier 80: Assistant Surgeon

Modifier 81: Minimum Assistant Surgeon

Modifier 82: Assistant Surgeon (when qualified resident surgeon not available)

Modifier AS: Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery.

Qualified Healthcare Professional: Physician assistant or clinical nurse specialist who is not a licensed M.D. or D.O.

Robotic Surgery: A method to perform surgery using very small tools attached to a robotic arm. The surgeon controls the robotic arm with a computer.1

Resources

1Robotic surgery: MedlinePlus Medical Encyclopedia

MotivHealth Payor Policy_v5

Cross References

Assistant Surgeon/Co-Surgeon

Non-Reimbursable Services and Supplies

Disclaimer

History and Approvals

2018 New policy

7/24/2023 Policy review: Content added for clarification to all sections of this policy. Approved by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

RADIOLOGY SERVICES p. 92

Application

This policy applies to all network and non-network facilities, physicians and other qualified health care professionals.

Policy

This policy outlines the radiologic services and procedures that are eligible for reimbursement. Providers should not claim separate reimbursement for radiologic services not consistent with this policy or simply because codes exist for them.

INTERVENTIONAL RADIOLOGY

Radiologic guidance using CT, fluoroscopy, MRI, or ultrasound for needle placement or to guide small instruments, such as, but not limited to, catheters or wires, through blood vessels or other pathways, to treat, diagnose, interpret or supervise procedures are considered part of the procedure and not separately reimbursable.

Radiology for procedures requiring needle placement including but are not limited to aspiration, injection, biopsy, or device placement are an integral part of the procedure and not eligible for separate reimbursement.

RADIOLOGIC SUPERVISION AND INTERPRETATION

Radiologic supervision and interpretation of any procedure requiring radiologic intervention including but not limited to needle placement or guidance procedures using CT, fluoroscopy, MRI, and ultrasound are considered part of the procedure and not separately reimbursable. CPT codes for fluoroscopy/fluoroscopic guidance (e.g., 76000, 77002, 77003) or ultrasound/ultrasound guidance (e.g., 76942, 76998) are not separately reimbursable.

RADIOLOGIC SUPPLIES

Medical supplies, surgical items including but not limited to guide wires, catheters, tubing, needles, sheaths, introducers, stents, vascular closure devices and drugs used during interventional radiologic guidance, treatment and diagnostic procedures are considered part of the procedure and not separately reimbursable.

RADIOLOGY PERFORMED DURING THE GLOBAL PERIOD

Radiologic procedures related to a surgical procedure regardless of purpose or reason for the radiology and performed during the global period are considered a component of the surgical procedure and not separately reimbursable.

CHEST X-RAYS

An emergency endotracheal intubation procedure (CPT code 31500) is normally followed by a chest radiologic examination to confirm proper positioning of the endotracheal tube. A chest radiologic examination is a component of the intubation and is not separately payable. CPT codes (71045, 71046)

After a chest tube insertion (CPT codes 32550, 32551, 32554, 32555) a chest radiologic examination is usually performed to confirm the location and proper positioning of the chest tube and/or to determine the presence of a pneumothorax. The chest radiologic examination is integral to the procedure and is not separately payable. CPT codes (71045, 71046)
When a central venous catheter or a central flow directed catheter (i.e., Swan-Ganz, CPT 93503) is inserted a chest radiologic examination is usually performed to confirm the proper positioning of the catheter. The chest radiologic examination is integral to the procedure and is not separately payable. CPT codes (71045, 71046)
Chest X-Ray to confirm proper positioning and/or location of tubes or catheters, both immediately after the insertion procedure or anytime during the hospitalization, is a component of the procedure and not separately reimbursable.

FLUOROSCOPY

Fluoroscopic guidance is integral to diagnostic and therapeutic cardiovascular (CPT codes 92950-92998, 93451-93533, 93600-93624, 93640-93657) and intravascular procedures and is not separately reportable. Also, for these procedures ECG monitoring and injection/infusion services are a component of the procedure and not separately reimbursable.
If fluoroscopy is performed during an endoscopic procedure, it is integral to the procedure. This applies to all endoscopic procedures including, but not limited to, laparoscopy, hysteroscopy, thoracoscopy, arthroscopy, esophagoscopy, colonoscopy, other GI endoscopy, laryngoscopy, bronchoscopy, and cystourethroscopy.

ULTRASOUND

Providers/suppliers shall not report CPT codes 76937, 76942, 76998, 93318, or other ultrasound procedural codes if the ultrasound procedure is performed for the guidance of any procedure.
Ultrasound procedures for the purpose of measuring post voiding residuals (CPT 51798) when performed by the nurse in an inpatient facility setting is a point of care test. Such tests are within the scope of normal nursing practice, a component of room and board and not separately reimbursable. If this test is performed in a facility setting or a physician’s office by a physician or other Qualified Healthcare Practitioner and a print-out from the scanner of the post void residual urine volume or clear documentation exists in the medical record of the urine volume such tests are separately payable.

Coding Guidelines

See above.

Definitions

Chest X-Ray: An imaging test that uses X-rays to view structures and organs in the chest. It can be used to diagnose or determine the status of conditions in the chest.

Fluoroscopy: A type of medical imaging that shows a continuous X-ray image on a monitor. During a fluoroscopy procedure, an X-ray beam is passed through the body. The image is transmitted to a monitor so the movement of a body part or of an instrument or contrast agent through the body can be seen in detail.

Global Period: The period of time before a surgical procedure and after the procedure has been performed. The global period varies and is based on the nature of the procedure.

Interventional Radiology (IR): A specialized field within radiology that utilizes advanced imaging techniques to precisely target therapy or guide the surgeon when performing minimally invasive surgical procedures.

Modifier 52: Reduced Services

Qualified Healthcare Practitioner: A ‘physician or other qualified health care professional’ is an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.

Radiologic Supervision and Interpretation: The personal management and oversight of the performance of the radiologic portion of a procedure by one or more physicians and the explanation of the findings by the same or different physicians.

Ultrasound: A diagnostic tool that uses high frequency sound waves to create images of the inside of the body. Ultrasound is also known as sonography.

Resources

CMS Medicare Claims Processing Manual - Chapter 13 - Radiology Services and Other Diagnostic Procedures

NCCI 2022 Coding Policy Chapter 11.§A.¶2.

NCCI Coding Manual Chapter 11.I.4

NCCI 2022 Coding Policy Manual Chapter 9. §C.9

NCCI 2022 Coding Policy Manual Chapter 9 §D.12

NCCI Coding Policy Manual Chapter 13 §E.12

NCCI Coding Policy Manual Chapter 11 §I.15 &20

NCCI Coding Policy Manual Chapter 9 §C.9

Cross References

Non-Reimbursable Services and Supplies

Disclaimer

History and Approvals

2020 New policy: Interventional Radiology

Policy review: Expanded the Interventional Radiology Policy implemented in 2020 to include all aspects of radiology services. Policy name changed to reflect increased scope of services introduced in this policy. Approved by Bryan Turner, M.D., Michelle P. Evans, Director of Quality

9/18/2023

UTILIZATION MANAGEMENT p. 96

AFTER HOURS AND WEEKEND CARE p. 96

Application

This policy applies to all network and non-network physicians and other qualified health care professionals.

Policy

This policy is not intended to address instances when a member is in crisis outside of business hours or has threatened to take their own life. In those instances, the member should be directed to call 911 or go to the nearest facility with emergency services.

After hours or weekend care applies to urgent services rendered in a provider’s office outside regular office hours or on days when the office is normally closed (weekends and holidays). These services may be eligible for separate reimbursement as outlined in this policy. Unless otherwise stated in this policy, MotivHealth generally conforms to CMS guidelines for both allowable services and billing requirements.

Coding Guidelines

The following CPT are eligible for separate reimbursement when no other services have been provided. When services other than as described by the code are provided, these after care and weekend care services are bundled in the services when they are provided on the same day. Separate reimbursement only applies to urgent care. Preventive care is not eligible for separate reimbursement.

99050: Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to basic service
99051: Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service

Without exception, the following CPT codes are not eligible for separate reimbursement:

99053: Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service
99056: Service(s) typically provided in the office, provided out of the office at request of patient, in addition to basic service
99058: Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service
99060: Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service

Definitions

CMS:Centers for Medicare and Medicaid Services

health insurance companies and accreditation organizations. CPT is included in Level I Healthcare Common Procedure Coding System (HCPCS).

Qualified Healthcare Practitioner: A ‘physician or other qualified health care professional’ is an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.

Resources

Medicare NCCI 2023 Coding Policy Manual Chapter 11

Cross References

None

Disclaimer

History and Approvals

12/10/2024 Brian Turner, MD Medical Director; Dale Lyman, VP Cost Containment

LABORATORY SERVICES p. 98

Application

This policy applies to all network and non-network facilities, physicians, and other qualified health care professionals.

Policy

MotivHealth conforms to the Centers for Medicare and Medicaid Services (CMS) policies for laboratory services unless otherwise stated within this policy. Not all laboratory codes will be addressed. Services and coding, whether or not addressed in this policy, may be subject to additional reimbursement policies, including but not limited to Medicare National Correct Coding Initiative, the Clinical Laboratory Improvement Amendment Policy, and American Medical Association coding guidelines.

To be eligible for reimbursement the minimum requirements are as follows. The assay must be:

Reported with the industry standard CPT code. This includes the applicable code for COVID-19 testing at the time the test was performed.
Ordered by a Qualified Healthcare Practitioner.
Collected in the mode, method and timing specified in the order.
Resulted in the records you send to us.
Performed by a laboratory with a valid CLIA Certificate Identification Number.

The sections below provide information for additional requirements that must be met in order for specific services to be eligible for reimbursement and the laboratory services that are not eligible for reimbursement.

BLOOD SAFETY TESTING p. 98

Blood safety testing, including but not limited to, specimen collection, blood typing and retyping, cross matching, adverse reaction tests, viral or bacterial tests is a component of the blood or blood product being administered and not separately reimbursable regardless of revenue code charged. For additional information on reimbursement for blood, blood products and blood processing, see Blood and Blood Products policy.

DRUG TESTING p. 98

WHAT WE WILL PAY

MotivHealth covers medically necessary presumptive drug tests for the following clinical indications:

Suspected drug overdose, unreliable medical history, and an acute medically necessary situation. Medically necessary situations include, but are not limited to, unexplained coma, unexplained altered mental status, severe or unexplained cardiovascular instability, undefined toxic syndrome, and seizures with an undetermined history.

Monitoring of a member receiving chronic opioid therapy by a physician or other qualified health care practitioner not affiliated with a substance abuse treatment center. Decisions regarding which substances to screen should be well documented and based on the member’s:

History of past drug use or abuse
Results of any physical examinations
Previous laboratory findings
Current treatment plan
Current prescribed medication(s)
Risk assessment plan
Routine drug screening, when ordered by a treating physician, in association with a clinical visit. Routine drug screening while in a substance abuse program is excluded regardless of whether ordered by a treating physician.

Therapeutic drug monitoring (up to 12 units per calendar/plan year) used to evaluate compliance with long-term therapy for chronic conditions requiring medications with therapeutic levels (i.e., Lamictal for seizure control) or abuse of a prescribed medication or to adjust the prescribed medication dosage to achieve desired therapeutic results.

WHAT WE WILL NOT PAY

Testing as required for, or in conjunction with, participation in substance abuse facilities, at higher levels of treatment, (e.g., residential, inpatient, partial hospitalization). Urine drug presumptive or definitive testing is considered included in the facility reimbursement.

Unbundled tests when using a multi-test kit screening (i.e., strip, dip card, or cassette).

Definitive testing as a routine supplement to drug screens, or in lieu of drug screens except when immunoassay testing is not commercially available.

Presumptive testing performed in conjunction with definitive immunoassay testing.

Standing orders for definitive testing, also known as "custom profile".

Testing ordered by or for third parties (such as courts, schools, military or employers) or ordered for the sole purpose of meeting the requirements of a third party.

Specimen collection and preparation is included in reimbursement for the testing and not separately reimbursable.

Routine billing of specimen validation. This includes but is not limited to the following CPT codes: 81000, 81001, 81002, 81003, 81005, 81099, 82570, 83986.
Presumptive and definitive testing performed in a substance abuse program.

Routine drug screening while in a substance abuse program is excluded regardless of whether ordered by a treating physician.

BILLING PRESUMPTIVE TESTS

Presumptive tests are eligible for reimbursement when testing is performed in an office, laboratory or facility setting.

Report with CPT 80305, 80306, or 80307.

Only one of these codes may be billed per day.

Reimbursement is limited to one (1) unit per day.

BILLING DEFINITIVE TESTS

Presumptive tests are eligible for reimbursement when testing is performed in an office, laboratory or facility setting.

Report with CPT using procedure codes G0480, G0481, or G0659.

Only one of the three codes may be billed per day.

Reimbursement is limited to one (1) unit per day. The units used to determine the appropriate code to bill is "drug class." The number of drug classes tested determines the appropriate code to use. Each drug class may only be used once per day.

DUPLICATE TESTING p. 100

MotivHealth will not reimburse for duplicate testing to verify a result or testing for the same analyte or culture by more than one methodology. If testing by multiple methods for a single analyte is performed, one unit of service should be reported.

GENETIC TESTING p. 100

Preauthorization is required for counseling services billed under CPT 96040, 99401, 99402, 99403, 99404, S0265 and for the following genetic testing: CPT 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81162, 81163, 81164, 81165,81166, 81167, 81432, 81433.

Genomic testing for purposes of defining treatment options are reimbursable when ordered by the treating specialist. Working Group evaluation of specific genetic tests or genetic panels are used as guidelines for the clinical utility of genetic and/or genomic testing. Tests that are assessed to have low clinical utility are not reimbursable.

GENETIC COUNSELING p. 100

Genetic counseling and BRCA 1 and BRCA2 mutation testing are covered preventive service for women who have not already been diagnosed with a cancer related to a mutation in BRCA1 or BRAC2 and who meet the U.S. Preventive Services Task Force (USPSTF) recommendations for testing. Also see Preventive Services for more information on BRCA1/BRCA2 testing.

All other genetic testing is not reimbursable by MotivHealth.

LABORATORY SERVICE PROVIDERS p. 100

This section describes the information that is required on claims reported for laboratory services under the Clinical Laboratory Improvement Amendment (CLIA) 1988 statue and regulations. A valid CLIA Certificate Identification

number will be required for reimbursement of clinical laboratory services reported on a CMS-1500 claim form or its electronic equivalent.

Laboratory service providers must ensure the required CLIA information is submitted using the correct loops, segments, and associated line level qualifiers (X4 and F4). Refer to the ANSI X 12N 837 Professional Claim guidelines and the Medicare Claims Processing Manual Chapters 1, 16, 26, and 35 for further information.

All services in this policy may be subject to additional reimbursement policies, including but not limited to, CCI Editing Policy, the Laboratory Services Policy, and the Professional/Technical Component Policy.

Modifier QW – States the test performed are simple laboratory examinations and procedures that have an insignificant risk of error. They are considered CLIA waived tests/procedures.

Modifier QW should be reported when applicable laboratory service(s) is reported on a CMS 1500 claim form to evaluate the claim to determine eligibility for benefit coverage of the laboratory services based upon the CLIA certification.

POINT OF CARE TESTING p. 101

Point of care testing performed manually or by a mobile computer device regardless of assay, setting or practitioner are a component of room and board or the procedure and not separately reimbursable.

PRE-ADMISSION LABORATORY SERVICES p. 101

Diagnostic, pre-procedure or other clinical laboratory tests provided to a member by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by another entity under arrangements with the admitting hospital), within three days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment for claims with a DRG reimbursement methodology.

REFLEX TESTING/REFLECTIVE TESTING p. 101

REFLEX TESTS are clinical laboratory tests that require additional testing or follow-up to have clinical value. These tests are payable even if a specific order by a Qualified Healthcare Practitioner was not made for follow up testing. This is because additional testing is implicit in the original order.

Example: If a urine culture is positive, the laboratory would then proceed to identify the organism which is necessary to determine the treatment options. This reflex test is reimbursable.

REFLECTIVE TESTING is discretionary and based on the clinical judgement of the practitioner. The original order does not imply additional testing is required in order for the test to have clinical value. Reflective testing is not eligible for reimbursement unless the assay is specifically ordered by a Qualified Healthcare Practitioner.

Example: The additional test of prostate specific antigen (PSA - CPT 84154) when total PSA (CPT 84153) is increased is not implied in the original order and must be specifically requested by a Qualified Healthcare Practitioner to be reimbursable.

SPECIMEN COLLECTION AND TRANSFER p. 101

Collection of venous or arterial blood directly or from a central or peripheral venous or arterial access device are a component of the laboratory service and not eligible for reimbursement.

Collection of secretions, fluids or tissue samples regardless of mode of acquisition are a component of the laboratory service and not eligible for reimbursement.

Collection of specimens by staff such as nurses, respiratory therapists, surgeons, and other qualified health professionals are a component of the laboratory service and not eligible for separate reimbursement.

Coding Guidelines

CPT CODING

Uncoded charges or charges using the provider’s own proprietary coding are not eligible for reimbursement. See relevant sections above for other coding requirements.

Providers should report the CPT code that describes the procedure performed to the greatest specificity possible. Providers should not report multiple CPT codes if a single CPT code exists that describes the services. This is unbundling and not reimbursable.

MEDICALLY UNLIKELY EDITS (MUE)

Providers should not report laboratory services with modifiers on multiple lines of a claim in an effort to bypass MUEs.

The MUE values and National Correct Coding Initiative(NCCI) Procedure to Procedure (PTP) edits are based on services provided by the same provider to the same beneficiary on the same date of service. Providers should not inconvenience nor increase risks to members by performing services on different dates of service to avoid MUE or NCCI PTP edits.

LABORATORY MODIFIERS

Modifier 90 Reference or Outside Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician or other qualified health care professional, the procedure may be identified by adding Modifier 90 to the usual procedure code.

Modifier 91 Repeat Clinical Diagnostic Laboratory Test: Used to report the same lab test when performed on the same patient, on the same day, to obtain subsequent test results, i.e., serial blood glucose tests . Not to be confused with Modifier 59 -distinct procedural service- which indicates a service was performed at a different anatomic site or at a different session but on the same date.

Modifier QW: Reported when applicable laboratory service(s) is reported on a CMS 1500 claim form to evaluate the claim to determine eligibility for benefit coverage of the laboratory services based upon the CLIA certification.

Do not use modifiers 59,XE, XP, XU, or 91 for reimbursement requests for any presumptive or definitive testing. These modifiers will not bypass our system edits.

Definitions

American Medical Association Coding Guidelines: The AMA has the responsibility to update or modify code descriptors, coding rules, and guidelines for the CPT code set lies with the AMA CPT Editorial Panel, authorized by the AMA Board of Trustees.

CLIA: Clinical Laboratory Improvement Amendments of 1988

Clinical Laboratory Improvement Amendments of 1988 (CLIA): Regulations include federal standards applicable to all U.S. facilities or sites that test human specimens for health assessment or to diagnose, prevent, or treat disease.

CMS: Centers for Medicare and Medicaid Services

Definitive Testing: Test that usually follows a presumptive test and is a qualitative or quantitative test used to identify specific drugs, specific drug concentrates, and associated metabolites. The test is performed in a CLIA certified laboratory or by a Qualified Healthcare Practitioner.

Medically Unlikely Edits (MUE): An MUE for a HCPCS/CPT code is the maximum Units of Service (UOS) that a provider would report under most circumstances for the same beneficiary on the same date of service.

Medicare National Correct Coding Initiative (NCCI): Promotes national correct coding methodologies and reduces improper coding, with the overall goal of reducing improper payments of Medicare Part B and Medicaid claims.

National Correct Coding Initiative (NCCI or CCI): The Centers for Medicare & Medicaid Services (CMS) developed these edits to promote consistent, correct coding and appropriate payment. These coding edits are developed based on the AMA CPT code set and the HCPCS code set, as well as analysis of standard medical and surgical practice and input from various groups, including specialty societies, other national health care organizations, Medicare contractors, providers, and consultants.

Point-of-Care Testing: Laboratory testing conducted close to the site of patient care that is done rapidly and performed by clinical personnel who are not trained in clinical laboratory sciences. Rapid test results can provide clinical personnel with answers that can quickly help determine a course of action or treatment for a patient.

Presumptive Testing: Test used to detect the presence of a drug or drug class. Presumptive tests generally do not indicate a specific level of drug but rather give a positive or negative result.

Procedure to Procedure Code Pair Edits (PTP): Automated prepayment edits that prevent improper payment when certain CPT/HCPCS codes are submitted together on a claim form.

Reflective Testing: Discretionary tests based on clinical judgment.

Reflex Testing: Follow-up or additional testing that is required for the initial testing to have clinical value.

USPSTF: The U.S. Preventive Services Task Force works to improve the health of people nationwide by making evidence-based recommendations on effective ways to prevent disease & prolong life.

Resources

CMS Chapter 10 Pathology and Laboratory Services

Pub 100-04 Medicare Claims Processing Manual Chapter 15 Section 40.3

Cross References

Blood and Blood Products

Billing & Claims Administration Manual

Disclaimer

History and Approvals

02/05/2024 Reviewed by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

RESPIRATORY THERAPY p. 105

Application

This policy applies to all network and non-network facilities inpatient and outpatient facilities.

Policy

MotivHealth will reimburse eligible respiratory therapy services at one unit per date of service for any portion of the day. Additional charges will not be reimbursed for a date of service regardless of the frequency that a service was provided, or equipment settings were adjusted, and no matter the variations in description or coding that are referred to in the claim. This applies to CPT, HCPCS or revenue codes.

All submissions for reimbursement must be supported by the medical record. Charges that would generally be eligible for reimbursement but are not supported by a medical order signed by a Qualified Healthcare Practitioner and/or documented that the service was rendered as ordered will not be reimbursed nor allowed to be retained if previously paid.

WHAT WE WILL PAY

Mechanical ventilation (invasive or non-invasive)
CPAP
BiPAP
Medicinal gases and pharmacologically active aerosols and the equipment to administer
Respiratory medications including inhaled medications when documented in the Medication Administration Record (MAR)
Wasted respiratory medications when the requirements for wasted medications are met. See policy entitled Wasted and Discarded Drugs and Biologics for those requirements.

WHAT WE WILL NOT PAY

Respiratory services that are within the scope of respiratory therapy practice or a component of room and board whether provided by RT, RN or a Qualified Health Care Practitioner.

Ventilator system checks
Oxygen, CPAP and PEEP changes when member is on ventilator support
Ventilator weaning and extubation
Spontaneous breathing trials
External chest wall oscillations or bedside pulmonary mechanics
Any type of monitoring including oximetry checks
Respiratory assessment with or without treatments
Endotracheal suctioning on or off a ventilator
Sputum inductions
Administration of mucolytics
Administration of nebulized medications
Incentive spirometry, training or device

Nebulizer treatments
Use of member’s own CPAP or BiPAP machines
The use of any respiratory equipment during a surgical procedure including that used during anesthesia and recovery, whether or not used in a PACU environment. These services are a component of the surgical procedure and not separately reimbursable. See policy entitled Global Surgical Package.
Equipment changes from one type of device to another
More than one type of device during the same date of service including supplemental oxygen. Provider may charge the more expensive device
Transport services to another area of the facility or to another facility.
Oral care
Cleaning of respiratory device components
Respiratory therapy consultations including instruction on equipment use
Patient screening for sleep apnea
Sample collection
Initial set up of equipment
Equipment or equipment component changes

Coding Guidelines

None

Definitions

BiPAP: Bilevel positive airway pressure is a noninvasive form of ventilation that is used when a person is able to breathe on their own but are not able to get enough oxygen or can’t get rid of carbon dioxide.

CPAP: Continuous positive airway pressure is a machine that uses mild air pressure to keep breathing airways open

HCPCS: Healthcare Common Procedure Coding System

Medication Administration Record (MAR):The legal record of the drugs administered to a patient at a healthcare facility by a healthcare professional. The Medication Administration Record is a permanent part of the patient’s medical records. The eMAR is an electronic version of the MAR. The MAR must contain the NDC identifier for the prescription drug administered to the patient.

PACU: Post-anesthesia care unit

PEEP:Positive end-expiratory pressure is a value that can be set up in patients receiving invasive or non-invasive mechanical ventilation.

Qualified Healthcare Practitioner:A ‘physician or other qualified healthcare professional’ is an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.

Resources Medicare Claims Processing Manual Chapter 23 NCCI Coding Policy Manual Chapter 11 §J.10 MEDICARE NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL, Chapter 5

Cross References Non-Reimbursable Services and Supplies Wasted and Discarded Drugs and Biologics
Disclaimer

History and Approvals

9/18/2023New policy: Approved by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS AND SUPPLIES (DMEPOS) p. 108

DURABLE MEDICAL EQUIPMENT RENTAL VS PURCHASE p. 108

Application

This policy applies to all network and non-network physicians and other qualified health care professionals including providers of Durable Medical Equipment (DME).

Policy

Claims must indicate whether the DME item(s) is rented or purchased. Purchased equipment must specify whether it is new or used. If the claim does not indicate whether the item is new or used, the item will be denied for the appropriate modifier.

A DME item that has been categorized by Centers for Medicare & Medicaid Services (CMS) on the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule as a capped rental (CR) item will be considered purchased and owned by the member after ten (10) continuous rental months have been paid on the item. Rental charges received for the item after the beginning on the eleventh (11) and thereafter will be denied.

Claims payment for DME are subject to other plan requirements, including but not limited to, requirements of medical necessity and benefits coverage.

Coding Guidelines

The following table indicates the Healthcare Common Procedure Coding System (HCPCS) Modifiers used to indicate rental or purchase status. Other Modifiers may be used in addition to those listed below to increase specificity.

MODIFIER DESCRIPTION

LL Lease/rental. Append when DME equipment rental is to be applied against the purchase price

NR New when rented. Append when item that was new at the time of rental is subsequently purchased

NU New equipment

RR Rental. Append when DME is rented

UE Append for used durable medical equipment

Definitions

CMS: Centers for Medicare and Medicaid Services

Durable Medical Equipment (DME): Reusable medical equipment

DMEPOS: Reusable medical equipment Prosthetics, Orthotics and Supplies

HCPCS: Healthcare Common Procedure Coding System.

Cross References

None

Disclaimer

History and Approvals

12/04/2024 Bryan Turner, MD Medical Director; Dale Lyman, VP Cost Containment

INFUSION SERVICES p. 110

HOME INFUSION THERAPY p. 110

Application

This policy applies to all network and non-network physicians and other qualified health care professionals and entities providing home infusion therapy services. Infusion services should not be reported by physicians or other qualified health care professionals when services are rendered in a facility setting.

Coverage of home infusion services is subject to the member’s contract benefits and limitations. Coverage does not guarantee reimbursement. Payment for services is subject to the provider’s adherence to the requirements set forth in this policy.

Policy

HOME INFUSION

MotivHealth conforms to guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) and American Medical Association (AMA) coding guidelines for home infusion therapy and administration of home infusion drugs unless otherwise indicated in this policy.

Any home infusion services must be ordered by a physician or other qualified healthcare practitioner and documented in the medical record.

Prior authorization must be obtained as required for the date of service home infusion therapy is rendered. All infusion therapy services must be provided in accordance with the stipulations of the authorization. Prior authorization does not guarantee payment.

MEDICAL RECORDS REQUIRED TO SUPPORT SERVICES Medical records pertaining to the infusion therapy including an itemized bill may be requested to support the care, procedures and medications you billed. The itemized bill must be consistent with the electronic bill in both units and dollar amounts for the infusion services rendered.

If we do not receive all the medical records requested in a legible format and by the date requested, the infusion services will not be paid even if records are provided for other services on the same claim form.

If our review finds that the reimbursement request is not consistent with coding and billing guidelines, or the documentation provided does not support the claim, charges for infusion services, either in whole or in part, will be denied.

PROVIDER STANDARDS AND PROTOCOLS Providers that comply with the following standards are eligible for reimbursement for home infusion therapy services. These standards may change. MotivHealth will communicate any changes thirty (30) days prior to the effective date of the change or unless otherwise required by contract. Eligibility for reimbursement of services does not guarantee payment.

Registered nurses must have the level of licensure, certification and experience to provide the infusion therapy services required. MotivHealth may require documentation that would attest to the competency of the staff rendering the infusion treatments.

Reasonable efforts must be made to provide service within MotivHealth’s service area within the following timeframes unless otherwise stipulated in our contract with you:

Routine service: 48 hours
Emergent/Urgent service: 24 hours
On call service must be available 24 hours per day, 365 days per year.
Member phone calls must be returned within thirty (30 min) of receipt.

What We Will Pay

The following services are separately reimbursable.

DRUGS Drugs used in the infusion therapy are separately payable. (See What We Will Not Pay section below for drugs that are not separately payable.) All drugs must be billed on the electronic bill. If requested, the itemized bill must include the appropriate HCPCS or CPT code, NDC number, dosage and units administered and must be consistent with AMA coding guidelines. It is the provider’s responsibility to apply the correct coding. Charges without NDC and/or HCPCS or incorrect NDC and/or HCPCS coding on requisite bill forms will be denied.

Drugs without an FDA approved NDC, such as those under the Orphan Drug Act or “Right to Try” legislation, are eligible for reimbursement when the provider submits an invoice for the drug infused. Purchase orders are not acceptable.

Facility compounded medications and admixtures including TPN may not be unbundled into its component ingredients when administered in a single bag or syringe. Component ingredients that are separately billed will be denied. Physician orders which stipulate separate administration of one or more components of TPN or admixtures will be eligible for separate reimbursement when appropriately documented. Charges with incorrect or incomplete coding will not be reimbursed.

Each infusion drug administered for each calendar day in the member’s home is eligible for reimbursement at one unit regardless of dosage. The single unit price cannot exceed the fee stipulated in our contract with you.

NURSING SERVICES Code nursing visits provided as follows:

See the section below for the specific requirements for services, drugs and supplies. Bill CPT codes S5497- S5523, S9325-S9379 as appropriate
99601: Home infusions/specialty drug administration, per visit (up to 2 hours).
99602: Each additional hour. List this code separately in addition to code for primary procedure. (Home infusions/specialty drug administration, per visit up to 2 hours; CPT 99601)

CONCURRENT THERAPY

Multiple infusion therapies performed at the same time and through the same access site for diagnostic, therapeutic or chemotherapeutic purposes is a concurrent infusion. When multiple therapies performed on the same date of service as the primary therapy, append the following modifiers to the per diem code billed:

SH: Second concurrently administered infusion therapy
SJ: Third or more concurrently administered therapies

Unless otherwise stipulated in our contract with you, payment will be at the highest fee specified for the first infusion and fifty (50) percent for each additional concurrent infusion. See What We Will Not Pay section below for drugs that are not payable.

CATHETER CARE AND PLACEMENT

Catheter care when provided as a stand-alone therapy is eligible for reimbursement. Bill CPT S5498, S5501, S5502 as appropriate.

When the catheter is inserted by a registered nurse, code this service separately from the visit. Code CPT S5522 for PICC line insertion and S5523 for a midline insertion. All insertion supplies and repair kits are included in the procedure and not separately reimbursable.

When catheter repair is performed by a registered nurse, code this service separately from the visit. Bill CPT S5518. All supplies necessary for catheter repair are included in the service and not separately reimbursable.

What We Will Not Pay

The services identified above are paid at an all-inclusive rate. Separate reimbursement will not be made for the following even if a modifier is appended to the charge:

Pharmaceutical services including but not limited to preparation or administrative services
Ancillary supplies including but not limited to IV poles, tubing, syringes, dressings
Fluids and diluents used to mix and/or deliver a drug
Concurrent administration of fluids for the purpose of hydration
Infusion of fluids and/or drugs to maintain patency of line, access site or implanted vascular device
Drugs to unblock a line, access site or implanted vascular device
Administration of local anesthesia or injectables of any type
IV insertions
Care coordination
Personal care
Respite care
Private duty nursing
Administrative services
Delivery charges, shipping charges
Member training
Education materials provided to our member
Transportation or mileage for staff
Total Parenteral Nutrition through hospice care

Claim Submission

All requests for reimbursement must be submitted on a claim using the ASC ANSI X 12N 837P format. The appropriate CPT and HCPCS codes that describe the service rendered to the greatest specificity must be appended to each charge in the claim. Only codes that are valid for the date of service should be submitted. Claims submitted without coding, incorrect coding or coding using a provider’s own proprietary codes will be denied.

Coding Guidelines

As indicated above and below.

• G0068: Professional services for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar day in the individual’s home, each 15 minutes Short Descriptor: Adm IV infusion drug in home

• G0069: Professional services for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes Short Descriptor: Adm SQ infusion drug in home

• G0070: Professional services for the administration of intravenous chemotherapy or other intravenous highly complex drug or biological infusion for each infusion drug administration calendar day in the individual's home, each 15 minutes. Short Descriptor: Adm of IV chemo drug in home

• G0088: Professional services, initial visit, for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar day in the individual’s home, each 15 minutes. Short Descriptor: Adm IV drug 1st home visit

• G0089: Professional services, initial visit, for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes. Short Descriptor: Adm Subcutaneous drug 1st home visit

• G0090: Professional services, initial visit, for the administration of intravenous chemotherapy or other highly complex infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes. Short Descriptor: Adm IV chemo 1st home visit

Definitions All-inclusive Rate: A rate that includes all of the allowable costs of providing care.

Concurrent Infusion: Multiple infusion therapies performed at the same time and through the same access site for diagnostic, therapeutic or chemotherapeutic purposes.

Discontinuation of Services: Infusion therapy has been discontinued and is not anticipated in the future at the time of cessation of the services.

FDA: Federal Drug Administration.

HCPCS: Healthcare Common Procedure Coding System.

Home Infusion:The administration of medications or nutrition intravenously or through a feeding tube in the member’s home, provider’s office or at Medicare certified infusion site.

Home InfusionDrug: parenteral drug or biological administered intravenously, or subcutaneously for an administration period of 15 minutes or more, in the home of an individual through a pump that is an item of durable medical equipment. Such term does not include insulin pump systems or self-administered drugs or biologicals on a self-administered drug exclusion list.

Hydration: Infusion of fluids intravenously strictly for the purpose of replacing fluids.

Infusion: Controlled method of administering substances continuously over a pre-determined period of time.

National Drug Code (NDC): A unique 10-digit or 11-digit, 3-segment number, and a universal product identifier for human drugs in the United States. Each medication is assigned a number under Section 510 of the U.S. Federal Food, Drug and Cosmetic Act. It identifies the manufacturer, product and package size.

Modifier SH: Second concurrently administered infusion therapy

Modifier SJ: Third or more concurrently administered infusion therapy

Qualified Healthcare Practitioner: A ‘physician or other qualified health care professional’ is an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.

TPN:Total Parenteral Nutrition is a method of feeding that bypasses the gastrointestinal tract.

Unbundling: The use of multiple CPT/HCPCS codes to report a procedure or supply when a single code exists that adequately describes the service or supply, either unintentionally or in an effort to maximize reimbursement.

Resources

CMS MLN Matters: Billing for Home Infusion Therapy Services on or After January 1, 2021 Home Infusion Therapy Services | CMS Current Procedural Terminology Manual, American Medical Association, Current Version NCCI 2023 Coding and Policy Manual, Chapter XI

Cross References

Reimbursement for Pharmaceuticals Compounded Medications and Admixtures Coding Requirements for Pharmaceutical Billing Wasted and Discarded Drugs and Biologics
Disclaimer

History and Approvals

12/16/2024 Dr. Brian Turner, MD Medical Director, Michelle Evans, Director of Quality,

Dale Lyman, VP Cost Containment

INJECTIONS AND INFUSIONS, PROFESSIONAL PROVIDERS p. 115

Application

This policy applies to all network and non-network physicians and other qualified healthcare practitioners.

Policy

Unless otherwise noted in this policy, MotivHealth conforms to AMA and CMS coding guidelines for injection and infusion services performed by professional providers in a non-facility setting. Professional providers are not eligible for reimbursement of these services in an inpatient or outpatient facility setting or emergency department.

The following injection and infusion CPT codes are reimbursable when performed in a physician’s office.

96360 - 96379
96401 - 96425

The total time of the infusion is eligible for reimbursement. If the total time of the infusion exceeds the time described in the code, the appropriate add-on code may be used. All administration times must be documented in the medical record to be eligible for reimbursement.

CPT codes 96360, 96365, 96374, 96409, and 96413 are described as “initial” service codes in the AMA coding guidelines. For a patient encounter, only one “initial” service code may be reported unless it is medically necessary that the drug or substance administrations occur at separate intravenous access sites.

Intra-arterial infusion often involves selective catheterization of an arterial supply to a specific organ. Since there is no routine arterial catheterization common to all arterial infusions, arterial catheterization codes may be reported separately. See WHAT WE WILL NOT PAY section below for catheterizations that are not separately payable.

Please refer to the American Medical Association Coding Guidelines for the descriptors of each code mentioned in this policy. Each code has specific descriptions, details and guidelines that may affect eligibility for reimbursement.

EVALUATION AND MANAGEMENT (E&M) CPT CODES THAT DO QUALIFY FOR SEPARATE REIMBURSEMENT WHEN SUBMITTED WITH A DIAGNOSTIC OR THERAPEUTIC INJECTION SERVICE, WITH A MODIFIER

99202 - 99205
99212 - 99215
99381 - 99429

EVALUATION AND MANAGEMENT (E&M) CPT CODES THAT DO NOT QUALIFY FOR SEPARATE REIMBURSEMENT WHEN SUBMITTED WITH A DIAGNOSTIC OR THERAPEUTIC INJECTION SERVICE, WITH OR WITHOUT A MODIFIER

99211
99221- 99223

What We Will Not Pay

Separate reimbursement will not be made for the following even if a modifier is appended to the charge(s):

Pharmaceutical services including but not limited to preparation or administrative services
Ancillary supplies including but not limited to IV poles, tubing, syringes, dressings
Fluids and diluents used to mix and/or deliver a drug
Concurrent administration of fluids for the purpose of hydration, i.e. unbundling of fluids hydration.
Infusion of fluids and/or drugs to maintain patency of line, access site or implanted vascular device
Drugs to unblock a line, access site or implanted vascular device
Administration of local anesthesia or injectables of any type
IV insertions or placement of peripheral venous access devices
Care coordination
Administrative services
Delivery charges, shipping charges
Member training
Education materials provided to our member

Coding Guidelines

See above for coding guidelines relative to each section. Please refer to the American Medical Association Coding Guidelines for the descriptors of each code mentioned in this policy. Each code has specific descriptions, details and guidelines that may affect eligibility for reimbursement.

Definitions

AMA: American Medical Association

Charges: The regular rates published by the provider on their Charge Master for services rendered before the application of contractual allowances and/or discounts.

CMS: Centers for Medicare and Medicaid Services.

Hydration: An IV infusion that consists of pre-packaged fluid and electrolytes strictly to replace fluids.

Infusion: The slow injection of a substance into a vein or tissue.

Injection: Substance injected into the body for therapeutic or diagnostic purposes. Injections can be intramuscular (IM), intravenous (IV), subcutaneous (SC), intradermal (ID), intrathecal (IC), or intra-arterial.

Inpatient: Admission to a hospital or skilled nursing facility on a physician’s order.

Intra-arterial infusion: Delivery of drug or substance through a tube directly inserted into an artery.

Modifier 25:Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.

Outpatient: Facility care that a person receives without being admitted or for a stay of less than 24 hours even if this stay occurs overnight.

Qualified Healthcare Practitioner: A ‘physician or other qualified health care professional’ is an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.

Resources

Medicare NCCI 2023 Coding Policy Manual Chapter 11

Cross References

None

Disclaimer

History and Approvals

01/15/2024 Reviewed by Bryan Turner, MD and Michelle Evans, Director of Quality

BLOOD PROCESSING p. 118

BLOOD AND BLOOD PRODUCTS p. 118

Application

This policy applies to all network and non-network facilities inpatient and outpatient facilities.

Policy

This policy outlines MotivHealth’s payment policies for all blood products and blood processing.

WHAT WE WILL PAY MotivHealth will pay for each unit of blood or blood products administered that is in compliance with this policy. To be eligible for reimbursement, charges should be submitted in the following manner:

Bill charge with the appropriate revenue code for the product(s) administered. See Revenue Code section below
Indicate the total number of units administered for each date of service
Bill blood processing and storage costs on a separate line. See Blood Processing and Storage Costs section

WHAT WE WILL NOT PAY Reimbursement for the blood product is intended to cover the costs associated with collection, transportation, processing, and storage. The following services are not separately payable for inpatient facility claims.

Blood product collection services
Pooling
Irradiating
Leukocyte reduction
Freezing and thawing of blood products
Transportation costs
Transfusion Services
Blood splitting
Blood safety tests (including but not limited to blood typing and retyping, cross matching, adverse reaction tests, viral or bacterial tests, regardless of the revenue code billed
Blood administration supplies (e.g., tubing, bags, etc.)

See Outpatient Only section when the services above are eligible for payment when rendered by outpatient facilities.

BLOOD PROCESSING AND STORAGE COSTS

Blood processing and storage costs are eligible for reimbursement when a facility incurs costs for processing and storage using its own blood bank or a community blood bank. Charges should be submitted in the following manner:

Bill charge with one of the following revenue codes as appropriate: 0390, 0392 or 0399
Only one processing and storage fee may be billed per inpatient/outpatient encounter regardless of how often or how many fees were incurred to prepare the blood or blood product(s).

UNUSED BLOOD Blood or blood products that have not been transfused are not payable. This includes the processing and storage fees associated with the preparation of the unused blood. Member specific blood preparation costs such as blood typing and cross matching may be eligible for reimbursement. Charges should be submitted in the following manner:

Bill charge with laboratory or pathology revenue codes as appropriate: 030X or 031X
Use the date of service that the preparation services were performed

OUTPATIENT ONLY The following services are eligible for reimbursement by outpatient facilities when appropriately billed.

TRANSFUSION SERVICES

Transfusion services are eligible for reimbursement for outpatient facilities when billed as follows:

Bill the charge for the transfusion service with revenue code 0391 (Blood Administration).
Bill the appropriate CPT code for the product transfused.
One transfusion charge is allowed for each date of service regardless of the type of blood products or the number of units transfused.

AUTOLOGOUS OR DIRECTED-DONOR BLOOD

PROCESSING AND STORAGE

Bill one (1) unit of one of the following CPTs as appropriate.

▪ CPT 86890: autologous blood or component, collection, processing, and storage; pre- deposited or ▪ CPT 86891: autologous blood or component, collection, processing, and storage; intra or post-operative salvage.
UNITS TRANSFUSED
Indicate the total number of units administered for each date of service.
Do not bill the date that the autologous or directed-donor blood was collected.

UNUSED BLOOD OR BLOOD PRODUCTS

The unused blood or blood product is not eligible for reimbursement; however, the preparation, processing and storage costs/fees may be reimbursed.

Bill member specific blood preparation costs with Revenue Code 030X (Laboratory). One charge is allowed regardless of the type or number of blood products processed and/or prepared.
Bill processing and storage costs/fees with one of the following revenue codes as appropriate: 0390, 0392 or 0399. For autologous blood see Autologous and Directed-Donor Blood section above.
Identify the number of units collected but not transfused.
The decision not to administer the blood should be documented in the patient’s medical records. Lack of supporting documentation will render the charge not payable.
The date of service should be the date on which the decision was made not to administer the blood.

APHERESIS AND PHERESIS SERVICES

Apheresis and pheresis are eligible for reimbursement for outpatient facilities when billed as follows:

Bill each visit using Evaluation and Management codes CPT 99221-99223. Do not bill on a per unit basis.
Modifier -25 may be appended to the CPT code if additional and separate services were provided. Examples where apheresis would be payable:

Myasthenia gravis
Goodpasture Syndrome
Familial Hypercholesterolemia
Waldenstrom's Macroglobulinemia
Hyperviscosity Syndrome

Coding Guidelines

BILL TYPES

ALLOWED BILL TYPES

011X - Inpatient
013X - Outpatient
014X - Hospital - laboratory to non-patient
018X - Hospital Swing Bed
021X - Skilled Nursing - inpatient
028X - Skilled Nursing - swing beds
071X - Rural Health Clinic (RHC)
072X – ESRD

NON-ALLOWED BILL TYPES

012X – Special facilities

REVENUE CODES

ALLOWED REVENUE CODES

0381 – Packed red blood cells
0382 - Whole blood and blood products
0383 - Plasma
0384 - Platelets
0385 - Leucocytes
0386 - Other components
0387 - Other derivatives(Cryoprecipitates)
0389 - Other
0390 - General (Use for incurred administrative cost from a community blood bank for processing, storage and related expenses)
0392 - Processing and storage
0399 – Other processing and storage

NON-ALLOWED REVENUE CODES

0380 – General
0391 – Administration (transfusions)
Administration of blood is a component of room and board and not separately reimbursable.

Definitions

Apheresis: Process of removing a specific portion of the blood while the remainder is returned to the patient.

Autologous Blood: Blood that is pre-deposited or obtained through intra-operative or postoperative salvage.

Blood Transfusion: A procedure in which donated blood or blood components are administered to a patient through an intravenous line.

CPT: Current Procedural Terminology. A medical code set maintained by the American Medical Association (AMA) that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations. CPT is included in Level I Healthcare Common Procedure Coding System (HCPCS).
Evaluation and Management (E/M) Services: Services that require three key components; problem or comprehensive history examination; medical decision making; counseling and/or coordination of care with physician or other qualified health care provider.
Modifier: Two characters (letters or numbers) appended to a CPT® or HCPCS Level II code. The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code.

Modifier 25: Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.

Outpatient: Facility care that a person receives without being admitted or for a stay of less than 24 hours even if this stay occurs overnight.

Pheresis: Procedure in which the blood is filtered, separated and a portion retained with the remainder returned to the patient.

Revenue Code: Revenue codes are 4-digit numbers that are used on hospital bills to identify where a member was located in a facility when they received treatment or services, or what service a member received as a patient.

Split Blood: Blood that is split into its component parts where one or more parts is transfused to one member and other parts transfused into another patient or to the same member at another time(s).

Resources

Medicare Claims Processing Manual Chapter 4 Section 231

Noridian Jurisdiction F Blood and Blood Products Billing Guide

CMS Manual Request 6416 Section B.4

Cross References

Non-Reimbursable Services and Supplies

Disclaimer

History and Approvals

9/11/2023 New policy: Approved by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

PHYSICAL MEDICINE AND REHABILITATION p. 123

REHABILITATION SERVICES p. 123

Application

This policy applies to all network and non-network facilities, physicians and other qualified health care professionals.

Policy

THERAPY SERVICES p. 123

Our health plan will reimburse for rehabilitation services, assessments, therapies and treatments that are medically necessary, and the member’s condition is expected to improve within a reasonable period of time. Group therapy sessions are not eligible for reimbursement. Unless otherwise noted in this policy, MotivHealth conforms to the guidelines set forth by the Centers for Medicare and Medicaid Services (CMS) for rehabilitation services as noted below. Preauthorization for each specialty is noted below. All services rendered in the home, regardless of specialty, require preauthorization and are subject to the outpatient benefit. Check benefit plan for specific plan limits for all rehabilitation services.

OCCUPATIONAL THERAPY

Prior authorization is required.

CPT 97165-97168: evaluation and re-evaluation may be reported once on a single date of service.
Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands: bill the CPT code that best describes the service rendered.
Therapy for fine motor function: bill the CPT code that best describes the service rendered.

Check benefit plan for specific plan limits.

PHYSICAL THERAPY

Prior authorization is not required.

CPT 97161-97164: evaluation and re-evaluation may be reported once on a single date of service.
CPT 97010-97028, 97032-97036, and 97039: require a physician or therapist to be in constant attendance.
CPT 97110-97124: used for physical therapy procedures.
CPT 97140-97542 and 97597-97606: used in accordance with the CPT code description.

Any unlisted code must have a description of what procedure was performed.

Check benefit plan for specific plan limits.

SPEECH THERAPY

Prior authorization is required.

CPT 92522-92524: evaluation and re-evaluation may be reported once on a single date of service.
CPT 92507 used for speech therapy procedures.

Check benefit plan for specific plan limits.

CARDIAC AND PULMONARY REHABITATION

Prior authorization is required.
Cardiac Rehabilitation, Phase 2, following heart attack, cardiac Surgery, severe angina (chest pain), and Pulmonary Rehabilitation, Phase 2, resulting from chronic pulmonary disease or Surgery, are payable up to 5 visits combined per plan year.

Check benefit plan for specific plan limits.

WHAT WE WILL NOT PAY p. 124

The following services and supplies are not eligible for reimbursement regardless of the type of rehabilitation service is provided even if coding exists for such services and supplies:

Hot packs
Cold packs
Massage therapy
Outpatient therapy plans performed in an inpatient setting, with or without a modifier
Advance care planning
Completion of any forms regardless of type
Unlisted evaluation and management services i.e. CPT 99499 unless otherwise specifically authorized
Academic learning
Vocational or life skills learning for developmental delays
Occupational therapy evaluation/reevaluation service and physical therapy evaluation/re-evaluation service if performed by the same practitioner at the same patient encounter.
Physical or occupational therapy services performed at the same patient encounter as cardiac rehabilitation or pulmonary rehabilitation services.
Group therapy sessions that treat speech, language, voice, communication, and/or auditory processing disorders ( including but not limited to CPT 92508)

REQUIRED DOCUMENTATION p. 124

THERAPY PROVIDER

Services are eligible for reimbursement only if performed by a therapist or therapy aide who was appropriately licensed or credentialed for their discipline in the state where the service was rendered. The medical record must provide reasonable evidence of this.
If a therapy student has rendered services, as is often the case in teaching hospitals, there must be reasonable evidence that a licensed therapist was in attendance during the therapy session. An attestation of the licensed therapist’s presence documented in the Session Notes or Treatment Notes within the medical record would constitute reasonable evidence. Session Notes without an attestation, even if the notes contain a time stamped signature of the licensed therapist under the student’s own time stamped signature, would not constitute reasonable support that a licensed therapist was in attendance. These latter services would not be eligible for reimbursement.

POST SESSION/TREATMENT NOTES

The documentation in the medical record for the treatments rendered during a therapy session must include the following for a service to be eligible for reimbursement:

Date of treatment session
Start and stop times of the treatment session
Specific treatment(s) provided during the session. The description(s) of the CPT(s) billed must match the therapy documented in the treatment session notes.
Member’s response to treatment including any issues encountered.
Signoff, whether electronic or handwritten, must include name as noted in the credentialing agency’s database, credential of the individual providing the services, and date and time of signoff.

PRIOR AUTHORIZATION REQUESTS

The initial therapy request must include the following.

Diagnosis with the appropriate ICD-10 code.
Medical history including prior level of function.
Current level of function including any impacts to health, safety, or independence.
Current objective measurements from standardized assessments.
Proposed Plan of Care (POC)
Treatment duration and frequency

Requests lacking any of the required information will not be considered for prior authorization until all the necessary information has been received.

MEDICAL RECORDS REQUESTS p. 125

All requested documentation must be provided to us within 30 days of the initial records’ request or as indicated in the most recent correspondence you receive from us on a particular claim. Not responding to our request or insufficient documentation or illegible documentation may forfeit payment of some or all the claim. Additional documentation provided after our review and payment may not, at our sole discretion, be accepted for either a post payment review or for an appeal of our original decision on reimbursement. Our member may not be balanced billed for denials related to insufficient documentation. Prior authorization will not proceed until all required and any additional requested information is received.

Coding Guidelines

MODIFIERS

GPServices delivered under an outpatient physical therapy plan of care.

GO Services delivered under an outpatient occupational therapy plan of care.

GN Services delivered under an outpatient speech-language pathology plan of

care.

REVENUE CODES

Physical Therapy Occupational Therapy Speech Therapy

0420 - General

0430 - General

0440 - General

0421 - Visit charge

0431 - Visit charge

0441 - Visit charge

0422 - Hourly charge

0432 - Hourly charge

0442 - Hourly charge

0423 - Group rate

0433 - Group rate

0443 - Group rate

0424 - Evaluation or reevaluation

0434 - Evaluation or reevaluation

0444 - Evaluation or reevaluation

0429 - Other

0439 - Other

0449 - Other

Definitions

AMA: American Medical Association

CMS: Centers for Medicare and Medicaid Services

Inpatient: Admission to a hospital or skilled nursing facility on a physician’s order.

Occupational Therapy: form of therapy to develop, improve, sustain, or restore daily living activities after an illness or injury.

Outpatient: Facility care that a person receives without being admitted or for a stay of less than 24 hours even if this stay occurs overnight.

Physical Therapy: branch of rehabilitative health that uses specially designed exercises and equipment to help patients regain or improve their physical abilities due to illness or injury.

who performs a professional service within his/her scope of practice and independently reports that professional service.

Revenue Code: Revenue codes are 4-digit numbers that are used on hospital bills to identify where a member was located in a facility when they received treatment or services, or what service a member received as a patient.

Speech Therapy: the evaluation and treatment of patients with speech, language cognitive-communication and swallowing disorders.

Resources

Medicare NCCI Policy Manual 2024 Chapter 11

Cross References Billing & Claims Administration Manual
Disclaimer This policy outlines the basis for reimbursement of the service described herein. The information in this policy is intended to serve as a general resource. It is not intended to address every aspect of reimbursement. You are responsible for submitting accurate claims that are consistent with our member contracts, our contract with you and our medical policies. This policy does not guarantee payment. Services must meet our authorization requirements and the medical necessity guidelines that are appropriate for the member’s diagnosis and medical condition at the time of service. In addition to the requirements of this policy, you must follow all guidelines in our Billing & Claims Administration Manual. The codes that are billed must be fully supported by the medical record. If our billing guidelines or the requirements outlined in this policy are not followed, we may deny the claim or recover the claim payment.

History and Approvals

02/26/2024 Bryan Turner, MD Medical Director and Michelle Evans, Director of Quality

MEDICATIONS p. 128

REIMBURSEMENT FOR PHARMACEUTICALS p. 128

Application

This policy applies to all network and non-network facilities, physicians and other qualified health care professionals.

Policy

Reimbursement for any pharmaceutical must be billed with coding that completely and accurately describes the substance and is compliant with current AMA and/or CMS coding standards. For additional detail on coding requirements, see CODING REQUIREMENTS FOR PHARMACEUTICAL BILLING. . Substances reported with proprietary coding of any type will not be reimbursed.

Prescription drugs must be billed with a valid, active NDC and the substance must have current FDA approval for the indication and deemed to be effective by the FDA unless Emergency Use Authorization (EUA) has been approved. Invalid NDCs or deprecated codes will not be reimbursed.

Facilities may be eligible for reimbursement if all of the following are present in the Medication Administration Record (MAR).

Medical order signed by a qualified licensed healthcare provider prior to discharge. For additional detail on medical orders, see MEDICAL ORDERS.
NDC of the drug that was administered. This requirement applies to all medication types and routes of administration including compounded medications and admixtures such as TPN.
Date, time, dosage and route of administration. Administration of the pharmaceutical must be consistent with the order in all respects. Administrations that are not consistent in one or more respects may be denied or only partially reimbursed. If the dosage that is reported as given by the RN differs from the scanned NDC documented in the MAR, the scanned package(s) will be considered the drug and dosage administered and reimbursed accordingly.
Name and title of healthcare provider who administered the medication.

Medications that are reported in the physician’s progress notes, operative/procedure notes or nursing notes but not in the MAR will not be reimbursed. Medications administered during anesthesia are an exception. These may be reported in the anesthesia notes only.

NON-REIMBURSABLE SUPPLIES The following supplies are not reimbursable:

Diluents that may be required to prepare a drug or substance for administration
IV tubing, poles, bags, pumps and other DME
IV or TPN Administration sets/kits whether commercially or facility prepared
Fluids or drugs infused for the sole purpose of maintaining patency of the IV or line.
IV supplies including but not limited to catheters (peripheral and central), needles, insertion kits, prep kits, lines. These supplies are a component of room and board and/or the procedure required to insert the line, i.e., PICC line.
IV fluids administered in the Emergency Department (ED)
Drugs and biologics that are used during a procedure

NON-REIMBURSABLE SERVICES

The following pharmacy services are not separately reimbursable:

Pharmacy consultation for patient education and medication management
Preparation of medications/infusions regardless of complexity of preparation and care setting of administration
Administration of member’s own medications
Discharge planning including coordinating transfer to another inpatient facility, post-acute care facility, and home health services

Coding Guidelines

AMA coding guidelines stipulate that certain injection and infusion services codes are not intended to be reported by physicians or other qualified healthcare professionals in any facility setting. The procedure codes are: 96360-96379, 96401, 96402, 96409-96425, 96521-96523

Definitions

Compounded Medications: As defined by FDA: Drug compounding is the process of combining, mixing, or altering ingredients to create a medication tailored to the needs of an individual patient. Compounding includes the combining of two or more drugs.

Deprecated: For the purpose of this policy, a deprecated code is a legacy code, that is, a code that is no longer valid. Deprecation may apply to NDC and HCPCS codes.

Emergency Use Authorization (EUA): As defined by FDA: Under an EUA, FDA may allow the use of unapproved medical products, or unapproved uses of approved medical products in an emergency to diagnose, treat, or prevent serious or life-threatening diseases or conditions when certain statutory criteria have been met, including that there are no adequate, approved, and available alternatives.

FDA: Food and Drug Administration

Infusion: The slow injection of a substance into a vein or tissue.

TPN:Total Parenteral Nutrition

Resources

NCCI Policy Manual, Chapter XI

U.S. Food & Drug Administration

Current Procedural Terminology (CPT) Manual, American Medical Association. (Subscription Service Only)

Cross References

Medical Orders

Coding Requirements for Pharmaceutical Billing

Compounded Medications and Admixtures

Billing & Claims Administration Manual

Disclaimer

History and Approvals

7/17/2023 New policy: Approved by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

COMPOUNDED MEDICATIONS AND ADMIXTURES p. 131

Application

This policy applies to all network and non-network facilities.

Policy

Facility compounded medications and admixtures including TPN may not be unbundled into their component ingredients when administered in a single bag or syringe. Component ingredients that are separately billed will be denied. Providers may be reimbursed if the component ingredients are rebilled in one billing unit increment. See Coding Guidelines below.

Orders by a physician or other healthcare professionals that stipulate separate administration of one or more components of a compounded medication or admixture including TPN will be eligible for separate reimbursement. Administration of each component including its NDC must be documented in the Medication Administration Record (MAR) as a separate administration. The exception to this documentation requirement is compounded anesthesia medications. Component administrations may be reported in the anesthesia records. This exception applies only to the documentation requirements; it does not extend to the policy as it relates to unbundling of component ingredients.

NON-REIMBURSABLE SUPPLIES The following supplies are not reimbursable:

Diluents that may be required to prepare a drug or substance for administration
IV tubing, poles, pumps, and bags
IV or TPN Administration sets/kits whether commercially or facility prepared
Fluids or drugs infused to keep lines patent

Coding Guidelines

Compounded medications and admixtures should be coded as follows:

OUTPATIENT FACILITIES

C9399 (Unclassified Drugs or Biologicals)
J7999 (Compounded drug, not otherwise classified

Billing more than one unit may result in an excess charge denial for all additional units.

INPATIENT FACILITIES One of the following codes should be used in the inpatient facility setting:

J7999 (Compounded drug, not otherwise classified
J9999 (Not otherwise classified, anti-neoplastic drug)
J3490 (Unclassified drugs)
J3590 (Unclassified biologics)

One billing unit increment should be reported. Billing more than one unit may result in an “excess charge” denial for all additional units.

Definitions

TPN: Total Parenteral Nutrition

UNBUNDLING: The act of billing the component parts of a service or supply to acquire higher reimbursement.

Resources

NCCI Policy Manual

U.S. Food & Drug Administration

Cross References

Billing & Claims Administration Manual

Coding Requirements for Pharmaceutical Billing

Disclaimer

History and Approvals

7/17/2023 New policy: Approved by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

CODING REQUIREMENTS FOR PHARMACEUTICAL BILLING p. 133

Application

This policy applies to all network and non-network facilities, physicians and other qualified health care professionals.

Policy

Revenue codes, HCPCS Level II coding and National Drug Codes (NDC) must be provided, as applicable, for all drugs for which the provider requests reimbursement. Complete and proper coding is required so that the accuracy of the charge can be determined.

NATIONAL DRUG CODES The National Drug Code (NDC) must be provided for all prescription drugs. The NDC must be present in the Itemized Bill (IB) and within the Medication Administration Record (MAR). Not providing the NDC in both of these documents may result in denial of the charge. Charges identified using proprietary, invalid, or deprecated NDC or HCPCS codes will not be reimbursed.

HCPCS LEVEL II CODES The HCPCS Level II code for all drugs for which reimbursement is requested must be identified in the Itemized Bill and/or applicable billing form as appropriate. Incomplete coding or coding that is inconsistent with the description of the drug identified in the MAR may result in a denial of the charge.

Each HCPCS Level II code has a defined unit of service for reporting purposes. Providers should not report units of service for a HCPCS Level II code using a criterion that differs from the code’s defined unit of service.

REVENUE CODES Hospitals and facilities must report all services, supplies and items, including pharmaceuticals, using accurate revenue codes.

MotivHealth considers revenue codes with a description of ‘Other’ and/or ending with ‘9’ to be unlisted revenue codes and are generally not accepted for reporting services or supplies in any claim type. The revenue code ending with ‘0’ and entitled ‘General’ may be used, however more specificity as provided by National Uniform Billing Editor (NUBC) is preferred. For additional information on billing unlisted codes see MotivHealth’s policy entitled "Billing & Claims Administration”.

Coding Guidelines

OUTPATIENT FACILITIES AND PHYSICIANS’ OFFICES If the drug or biologic does not have a HCPCS Level II code, the following codes should be used in the following settings:

Outpatient Facilities: C9399 (Unclassified Drugs or Biologicals)
Physicians’ Offices: J9999 (Not otherwise classified, anti-neoplastic drug), or J3490 (Unclassified drugs), or J3590 ( Unclassified biologics).

Drugs/biologics billed with an unlisted or unclassified code should be reported in one billing unit increment. Billing more than one unit may result in an “excess charge” denial for all additional units.

Unlisted drug codes or unclassified drug codes that are used for drugs and biologicals that have a HCPCS Level II code may result in an “incorrect coding” denial. These denials may be rebilled with the corrected HCPCS Level II coding.

INPATIENT FACILITIES

If the drug or biologic does not have a HCPCS Level II code, the following codes should be used in the inpatient facility setting:

J9999 (Not otherwise classified, anti-neoplastic drug)
J3490 (Unclassified drugs)
J3590 ( Unclassified biologics)

HCPCS codes that begin with a C represent devices and supplies used in a hospital outpatient setting and in an ambulatory surgery center. This series of codes does not apply to inpatient services. Pharmaceuticals billed with a C-series code in an inpatient setting may result in a denial.

Definitions

Deprecated: For the purpose of this policy, a deprecated code is a legacy code, that is, a code that is no longer valid. Deprecation may apply to NDC and HCPCS codes.

HCPCS Level II: A standardized coding system that is used primarily to identify medical supplies, durable medical equipment, non-physician services, and services not represented in the Level I code set CPT

Itemized Bill (IB): A full listing of all the charges being billed by a provider for the services rendered.

Resources

NCCI Policy Manual

Cross References Billing & Claims Administration Manual

Disclaimer This policy outlines the basis for reimbursement of the service described herein. The information in this policy is intended to serve as a general resource. It is not intended to address every aspect of reimbursement. You are responsible for submitting accurate claims that are consistent with our member contracts, our contract with you and our medical policies. This policy does not guarantee payment. Services must meet our authorization requirements and the medical necessity guidelines that are appropriate for the member’s diagnosis and medical condition at the time of service. In addition to the requirements of this policy, you must follow all guidelines in our Billing & Claims Administration Manual. The codes that are billed must be fully supported by the medical record. If our billing guidelines or the requirements outlined in this policy are not followed, we may deny the claim or recover the claim payment.

History and Approvals

2019 New policy
07/10/2023 Policy review. Content added for clarification to all section of this policy. Approved by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

WASTED AND DISCARDED DRUGS AND BIOLOGICS p. 136

Application

This policy applies to all network and non-network facilities, Critical Access Hospitals, physicians and other qualified health care professionals.

Background

Drugs and Biologics that are labeled as single-dose should only be used for a single patient as part of a single case, procedure, or injection. This ensures that single-dose drugs require only a single entry into the vial or package (CDC1). The CDC directs that, “Even if a single-dose or single-use vial appears to contain multiple doses or contains more medication than is needed for a single patient, that vial should not be used for more than one patient nor stored for future use on the same patient.” The agency cites risk of contamination and outbreaks resulting from healthcare personnel using single-dose vials and packages for multiple patients (CDC2).

Policy

WASTED OR DISCARDED DRUGS AND BIOLOGICS THAT ARE SEPARATELY REIMBURSABLE

All of the following requirements must be met in order for a discarded drug or biologic to be eligible for reimbursement. This policy pertains to all parenteral when only a portion of the package is administered.

The drug or biologic is commercially available only in single-dose vials/packages or, in the case of oral preparations, no dose smaller than that administered.
The units billed must correspond with the smallest vial/package/dose available for purchase from the manufacturer that could provide the appropriate dose for the patient, thereby resulting in the least amount of waste.
MAR or eMAR must include all the following information:

Name of the drug/biologic
NDC number of the drug
Amount administered
Date and time administered
Route of administration
Amount of the drug/biologic wasted
Name and credential of the qualified healthcare provider who wasted or discarded the drug or biologic.

In the case of anesthesia drugs or drugs administered in the emergency department (ED), these documentation requirements may be recorded in the reports or flowsheets normally used for those areas but must be documented.

Each HCPCS Level II code has a defined unit of service for reporting purposes. A facility should not report units of service for a HCPCS Level II code using a criterion that differs from the code’s defined unit of service. (NCCI Policy Manual)

WASTED OR DISCARDED DRUGS AND BIOLOGICS THAT ARE NOT SEPARATELY REIMBURSABLE

Undocumented Drug or Biologic Waste: If only a portion of the single-use vial, single-dose vial or single- use package of a drug/biologic is administered and waste is not documented and the entire unit for the vial/package is billed, the charge will be denied or only partially reimbursed.
Overfill Wastage: Reimbursement will not be provided for wasted portions that are greater than the dose commercially available in the single-dose vial or package less the units administered to the patient.
Unadministered Drugs or Biologics: Waste for drugs that were never administered to a patient even if the discarded units are reported in the medical record as wasted. This includes drugs that were specifically prepared for the patient and could not be administered regardless of the reason.
Inconsistent documentation: If the wasted or discarded drug or biologic is reported in more than one location within the facility and it is found that the amount wasted is not consistent with the MAR or eMAR, the waste billed will be denied for lack of consistent supporting documentation. Charge capture reports are not part of the medical record and will not be considered as acceptable documentation when determining reimbursement for drug waste charges.

Example of inconsistent documentation that renders the drug waste charge not reimbursable:

▪ Physician’s order requires 15 mg of a drug. ▪ Pharmacy dispensed one single-dose vial of 20 mg in the facility’s Pyxis machine and documents in Pharmacy records: Dispensed 20 mg/Wasted 5 mg ▪ RN administered 15 mg but did not document waste of the 5 mg in the MAR.
Excess Wastage: If a larger vial size is used and wastage is documented but the drug or biologic is commercially available in a smaller single-dose vial or package, MotivHealth will not reimburse for waste even if waste is documented. The entire charge may be denied if the unit administered and wasted is less than one. Fractional units are not allowed.
Excess Wastage due to Inventory Shortages: MotivHealth considers a provider’s formulary and inventory processes to be provider’s business decisions. Consequently, any excess waste resulting from those business decisions is not reimbursable and becomes provider liability.

Excess waste due to drugs and biologics not commercially available due to documented national and/or civil emergency shortages around or near the date of administration are eligible for reimbursement, if the requirements related to drug waste, as indicated above, are met.
Multi-use Vials or Packages: Discarded portions of multi-use vials or packages are not eligible for separate reimbursement.
Insufficient Documentation: Once records are received, MotivHealth will deem them to be complete and in their entirety and appropriate for review. Inability to determine with reasonable accuracy the amount of wastage due to incomplete records, illegible records or insufficient documentation will render a denial of the charge for wasted drugs or biologics.
DRG and APC Reimbursement Methodology: Reimbursement for wasted or discarded drugs/biologics does not apply to claims paid to a DRG or APC reimbursement methodology. Drugs and biologicals are packaged into the DRG and APC rates and are not separately reimbursable.

Fractional Units: If waste is not documented on a single dose vial or package where only one billing unit is allowed, reimbursement on the wastage charge will be denied. Fractional units of wastage are not allowed.

Coding Guidelines

ASC, OUTPATIENT FACILITIES AND PHYSICIANS’ OFFICES

INFORMATION REQUIRED: All information cited under WASTED OR DISCARDED DRUGS AND BIOLOGICS THAT ARE SEPARATELY REIMBURSABLE is required for wasted or discarded substances to be eligible for reimbursement in the record appropriate for the entity.
MODIFIER JW: Modifier JW must be appended to the HCPCS Level II code in order to obtain reimbursement for the discarded units on the CMS-1500. The units administered should be billed on one line and the discarded units should be billed on another line according to the HCPCS Level II billing units. Wasted drugs or biologics that are not billed with modifier JW appended to the HCPCS Level II code will be denied as a provider liability.
The JW Modifier does not apply under the following circumstances:

If the actual dose of the drug or biologic is less than the billing unit for the drug, one unit should be billed on one line. Modifier JW should not be used to bill the discarded unit. Doing so would report two units and result in an overpayment. Example: Physician’s order requires member to receive 15 mgs of a medication. The drug is manufactured in one concentration in a single-dose vial of 20 mg/ml. The billing unit for the vial is one unit. One unit should be billed. The 5mg discarded portion should not be billed on a separate line.
If reimbursement for discarded units is not being requested.

Drugs assigned with status indicator N. These items and services are packaged into APC Rates and not separately reimbursable.

Unlisted or unclassified drug codes.
CODING FOR DRUGS NOT ASSIGNED A HCPCS LEVEL II CODE: Drugs and biologics billed with an unlisted or unclassified code should be reported in one billing unit increment with the correct unlisted code.

Outpatient facilities and ASC: C9399
Physicians’ offices: A not otherwise classified anti-neoplastic drug (J9999), unclassified drugs (J3490), unclassified biologics (J3590)
Using an unlisted or unclassified drug code for drugs that have an assigned HCPCS Level II code or appending Modifier JW to an unlisted code will result in a denial of the charge.

INPATIENT FACILITIES INCLUDING CRITICAL ACCESS HOSPITALS

INFORMATION REQUIRED: All information cited under WASTED OR DISCARDED DRUGS AND BIOLOGICS THAT ARE SEPARATELY REIMBURSABLE is required for wasted or discarded substances to be eligible for reimbursement in the MAR or eMAR.
ITEMIZED BILL: Provider must supply an itemized billing of the CMS-1450 (UB-04) claim submission if requested.
MODIFIER JW: Modifier JW may be used on the itemized bill for the discarded portion but is not required for inpatient facility billings.
CODING FOR DRUGS NOT ASSIGNED A HCPCS LEVEL II CODE: Drugs/biologics billed with an unlisted or unclassified code should be reported in one billing unit increment with the correct unlisted code.

Not otherwise classified, anti-neoplastic drug: J9999
Unclassified drug: J3490
Unclassified biologics: J3590 Unlisted drug codes or unclassified drug codes that are used for drugs and biologicals that have a HCPCS Level II code may result in an “incorrect coding” denial. These denials may be rebilled with the corrected HCPCS Level II coding.

Definitions

APC: Ambulatory Patient Classification

ASC: Ambulatory Surgery Center

CMS: Centers for Medicare and Medicaid Services

Discarded Drug or Biologic: The amount of a single-use vial, single-dose vial or single-use package that remains after administering a dose/quantity of the drug or biologic and that has been appropriately discarded.

Emergency Use Authorization: As defined by FDA: Under an EUA, FDA may allow the use of unapproved medical products, or unapproved uses of approved medical products in an emergency to diagnose, treat, or prevent serious or life-threatening diseases or conditions when certain statutory criteria have been met, including that there are no adequate, approved, and available alternatives.

HCPCS: Healthcare Common Procedure Coding System.

Itemized Bill (IB): A full listing of all the charges being billed by a provider for the services rendered.

Modifier JW: Modifier JW is a HCPCS Level II modifier with the descriptor, “Drug/Biological amount discarded/not administered to any patient”. While modifier JW was created by CMS, CMS contractors may or may not require its use. The use of modifier JW is not limited to CMS members or plans. MotivHealth requires the use of modifier JW as indicated in the policy section below when reimbursement is sought for appropriately discarded drugs or biologics from single-dose vials or single-use packages for claims submitted by physicians’ offices and outpatient hospital facilities.

Overfill: Any amount of drug greater than the amount identified on the package or label.

Single-dose or Single-use Vial: A vial of liquid medication intended for parenteral administration (injection or infusion) that is meant for use in a single patient for a single case, procedure, injection. Single-dose or single-use vials are labeled as such by the manufacturer and typically lack an antimicrobial preservative. (CDC1)

Single-use Package (Unit Dose Package): a package that contains one discrete pharmaceutical dosage form, i.e., one tablet.

Wastage: see definition for Discarded Drug or Biologic above.

Resources

CMS Publication 100-4, Claims Processing Manual, Chapter 17, § 40

(www.cms.hhs.gov/manuals/downloads/clm104c17.pdf)

Local coverage article, A53049, Approved Drugs and Biologicals; Includes Cancer Chemotherapeutic Agents

CMS. National Correct Coding Initiative Policy Manual. Chapter 1 General Correct Coding Policies, § A

CDC1: https://www.cdc.gov/injectionsafety/providers/provider_faqs_singlevials.html

CDC2: Fischer GE et al. Hepatitis C Virus Infections from Unsafe Injection Practices at an Endoscopy Clinic in Las Vegas, Nevada, 2007-2008. CID 2010;51:267-273.

CDC3 https://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html

Modifier JW Captures Drug Waste of Single-use Vials: https://www.aapc.com/blog/39864-modifier-jw-captures-drug-waste-of-single-use-vials/

Centers for Medicare and Medicaid Services. Chapter 1, General Correct Coding Policies. In: National Correct Coding Initiative Policy Manual for Medicaid Services. Revised January 1, 2019. https://www.medicaid.gov/medicaid/program-integrity/ncci/reference-documents/index.html

Cross References

Coding Requirements for Pharmaceutical Billing Compound Medications and Admixtures Reimbursement for Pharmaceutical Billing Billing & Claims Administration Manual
Disclaimer

This policy outlines the basis for reimbursement of the service described herein. The information in this policy is intended to serve as a general resource. It is not intended to address every aspect of reimbursement. You are responsible for submitting accurate claims that are consistent with our member contracts, our contract with you and our medical policies. This policy does not guarantee payment. Services must meet our authorization requirements and the medical necessity guidelines that are appropriate for the member’s diagnosis and medical condition at the time of service. In addition to the requirements of this policy, you must follow all guidelines in our Billing & Claims Administration Manual. The codes that are billed must be fully supported by the medical record. If our billing guidelines or the requirements outlined in this policy are not followed, we may deny the claim or recover the claim payment.

History and Approvals

Policy review. Content added for clarification to all section of this policy. Approved by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

7/17/2023

PREVENTABLE HEALTHCARE ACQUIRED EVENTS p. 142

Application

This policy applies to all network and non-network facilities inpatient, and outpatient facilities.

Policy

The purpose of this policy is to encourage facilities and Qualified Health Care Practitioners to implement best practices that would reduce infection rates, accidents and other adverse events associated with health care and thereby improve overall patient safety.

The payment reductions that MotivHealth will implement for claims where Hospital Acquired Conditions, Never Events, and Iatrogenic Complications occur are delineated below.

HOSPITAL ACQUIRED CONDITIONS

A Hospital Acquired Condition is a condition that is not present when the patient was admitted to or arrived at the hospital or other facility owned by the hospital but occurs during or after the stay. Examples include but are not limited to:

Surgical site infections

Post-operative hemorrhage, embolism, hematoma or deep vein thrombosis

In-hospital falls with fracture

Pressure ulcers

Pneumothorax related to chest tube insertion

Post-operative sepsis

Post-operative kidney injury requiring dialysis

Post-operative wound dehiscence

Post-operative respiratory failure

Hospital acquired infections including central line associated blood infections

Methicillin-resistant Staphylococcus Aureus (MRSA) bacteremia

Clostridium difficile infection (CDI)

Pseudomonas infections

WHAT WE WILL PAY

MotivHealth will pay for services and supplies unrelated to the hospital acquired condition.

MotivHealth will pay for services of a facility and Qualified Health Care Practitioner(s) unrelated to the circumstances that caused the hospital acquired condition and are rendered in an effort to correct, repair or restore the effects of the infection or injury caused by another facility and/or Qualified Health Care Practitioner.

WHAT WE WILL NOT PAY

MotivHealth will not pay to either rendering facility or Qualified Health Care Practitioner(s) for any services or supplies that caused the infection or injury. This includes the operative procedure where the preventable healthcare acquired event occurred.

NEVER EVENTS

A Never Event is an error in medical care that are of concern to the public, health care professionals and providers and are of a nature that the risk of occurrence is significantly influenced by the policies and procedures of the health care organization. Examples include but are not limited to:

Performance of the wrong operation/procedure on a patient.

Performance of the correct operation/procedure on the wrong side of the body.

Unintended retention of a foreign object after surgery.

Patient death or serious injury associated with unsafe administration of blood products.

Patient suicide

Location of patient was unknown for a period of time while under the care of the provider

Kidnapping

WHAT WE WILL PAY

MotivHealth will reimburse of costs of care leading up to a procedure or operation if the Never Event occurred during a procedure or operation.

WHAT WE WILL NOT PAY

MotivHealth will not pay for the costs to the facility or Qualified Health Care Practitioner(s) for a procedure or operation or any costs of care including room and board after the Never Event.

MotivHealth will pay no part of a facility claim where a patient was kidnapped while under a provider’s care even if the patient was retrieved.

MotivHealth will not pay any portion of a facility claim where the death of a patient was a result of a Never Event. The entire episode of care in these instances would be provider liability.

MotivHealth will not reimburse for any portion of room and board of a facility claim during the period of time that a patient’s whereabouts were unknown while under a provider’s care, or any costs associated with locating a patient either within the facility or outside the facility.

IATROGENIC COMPLICATIONS

An Iatrogenic Complication is an adverse condition that is a direct result of treatment by a physician or other health care professional. Examples include but are not limited to:

Air Embolism

Perioperative pulmonary embolism or deep vein thrombosis

Abdominopelvic accidental puncture or laceration

Iatrogenic pneumothorax

Fractures incurred during transport or therapeutic activities

Blood incompatibility

Misplaced instruments

Wrong drug

Improper route of drug administration

Improper drug administration

WHAT WE WILL PAY

MotivHealth will reimburse the costs of care that were not affected by or the result of the iatrogenic complication.

MotivHealth will pay an alternate facility or Qualified Health Care Practitioner that corrects, repairs or restores the effects of care caused by the Iatrogenic Complication.

WHAT WE WILL NOT PAY

MotivHealth will not pay for the costs to the facility or Qualified Health Care Practitioner(s) that caused the Iatrogenic Complication for any portion of the procedure or operation or service that is required to correct, repair or remedy the iatrogenic complication.

MotivHealth will not pay any portion of a facility claim where the death of a patient was a result of an iatrogenic complication. The entire episode of care in these instances are provider liability.

Coding Guidelines

INPATIENT FACILITY CLAIMS – PRESENT ON ADMISSION INDICATORS

Inpatient facilities are required to submit Present on Admission (POA) indicators. A payment reduction or adjustment will be made based on the POA indicators on the claim and the medical record if the POA indicator is documented in error. The requirements for POA coding are below:

Code the appropriate indicator at the time of admission. This includes conditions that develop during an outpatient encounter immediately preceding the inpatient admission for the same provider.
Assign the POA indicator to principal and secondary diagnoses.

Indicator Description

Y Diagnosis was present at time of inpatient admission.

N Diagnosis was not present at time of inpatient admission.

U Documentation insufficient to determine if the condition was present at the time of inpatient admission.

Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.

1 Unreported/Not used. Exempt from POA reporting. This code is equivalent to a blank on the UB-04, however; it was determined that blanks are undesirable when submitting this data via the 4010A.

INPATIENT FACILITY CLAIMS – BILLING A CLAIM WITH A PREVENTABLE HEALTHCARE EVENT

Never Events/No-Pay/Provider Liable Claim:

Identify claim with Type of Bill:110 (No-Pay/Provider Liable Claim) for all charges associated with services and supplies related to a Preventable Healthcare Acquired Event.
Report the appropriate ICD-10 code on the claim:

Y65.51 – Performance of wrong procedure (operation) on correct patient.

Y65.52 – Performance of procedure (operation) on patient not scheduled for surgery.

Y65.53 – Performance of correct procedure (operation) on wrong side of body parts.

Services/supplies that are unrelated to Preventable Healthcare Acquired Event:

Bill on a separate claim with the appropriate Type of Bill code.

OUTPATIENT FACILITIES, AMBULATORY SURGERY CENTERS AND PROFESSIONAL CLAIMS

Outpatient, ASC’s and physicians or other health care professionals must report the applicable HCPCS Modifier(s) with the associated charges on all lines related to the surgical error.

PA- Surgery Wrong Body Part.

PB- Surgery Wrong Patient.

PC- Wrong Surgery on Patient.

Definitions

Hospital Acquired Condition (HAC): A condition that is not present with the patient is admitted to or arrived at the hospital or other facility but occurs during or after the stay.

Iatrogenic Complications: An adverse condition that is a direct result of treatment by a physician or other health care professional.

Never Events: Errors in medical care that are of concern to both the public, health care professionals and providers and of a nature that the risk of occurrence is significantly influenced by the policies and procedure of the health care organization.

Present on Admission (POA) Indicator:A designation on the claim that identifies conditions that were present at the time the order for inpatient admission was written. Conditions that occurred in the emergency department, during outpatient surgery or observation stays that resulted in an inpatient admission are considered present on admission.

Qualified Healthcare Practitioner: A ‘physician or other qualified health care professional’ is an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.

Serious Reportable Events:Events that could have been reasonably prevented through application of evidence-based guidelines. These conditions are not present on admission, or when the patients are initially treated, but occurred during the course of treatment or stay.

Type of Bill code (TOB):A four-digit alphanumeric codes that specify different pieces of information on claim form UB-04 or form CMS-1450 and is reported in box 4 on line 1.

First Digit = Leading zero. Ignored by CMS
Second Digit = Type of facility
Third Digit = Type of care
Fourth Digit = Sequence of this bill in this episode of care. Referred to as a "frequency" code

Resources

Hospital Acquired Conditions | CMS

Hospital-Acquired Condition Reduction Program

CMS Hospital-Acquired Conditions Present on Admission Indicators

Cross References

None

Disclaimer

History and Approvals

10/24/2023 Policy review: Content added for clarification to all sections of this policy. Approved by Bryan Turner, M.D. and Michelle P. Evans, Director of Quality

APPENDIX p. 147

DEFINITIONS
ACOG: American College of Obstetricians and Gynecologists
Advanced Life Support (ALS): A set of life-saving protocols and skills including invasive techniques that extend beyond Basic Life Support (BLS). Examples of invasive techniques include advanced airway equipment, cardiac defibrillator, IV fluids, medications, and more. It is used to provide urgent treatment for cardiac emergencies such as cardiac arrest, stroke, myocardial infarction, and other conditions.
All-cause: The cause of the readmission does not need to be related to the cause of the index admission.

All-inclusive Rate: A rate that includes all of the allowable costs of providing care.

Allowed Amount: This is the contracted rate or billed charge, depending on whether the healthcare provider is in- network or a non-network provider.

AMA: Against Medical Advice

AMA: American Medical Association

Ambulance Trip Sheet: Also called the Run Sheet is a record of the patient encounter and is used as a medical record for ambulance services.

Ambulance Modifier: Identifies the place of origin and destination of the ambulance trip. These must be submitted on all ambulance claims.

Ambulatory Surgical Center: A distinct entity that operates exclusively for the purpose of furnishing outpatient surgical services to patients. An ASC is either independent (i.e., not a part of a provider of services or any other facility), or operated by a hospital (i.e., under the common ownership, licensure or control of a hospital)

American Medical Association Coding Guidelines: The AMA has the responsibility to update or modify code descriptors, coding rules, and guidelines for the CPT code set lies with the AMA CPT Editorial Panel, authorized by the AMA Board of Trustees.
Apheresis: Process of removing a specific portion of the blood while the remainder is returned to the patient.

Appeal: A request from a provider or Member for the Plan to review an adverse determination of either a preauthorization or claim denial, where the Member may have some financial responsibility.

Assistant Surgeon: Physician (M.D. or D.O.) who actively assists the surgeon during the surgical procedure. Such an individual is usually trained in the same specialty as the surgeon.

Autologous Blood: Blood that is pre-deposited or obtained through intra-operative or postoperative salvage.

Back-up Surgeon/Surgical Attending: A qualified surgical attending physician who is responsible for providing appropriate and timely clinical coverage for an operation during a period when the primary surgeon may be unable to fill this role.

Basic Life Support (BLS): A level of medical skill used to treat victims experiencing life-threatening illnesses or injuries until they can be given full medical care at a hospital. A BLS provider is not authorized to perform invasive procedures, and may only administer a few select medications.

Bilateral Procedure: The same procedure performed on both sides of the body during the same operative session.

BiPAP: Bilevel positive airway pressure is a noninvasive form of ventilation that is used when a person is able to breathe on their own but are not able to get enough oxygen or can’t get rid of carbon dioxide.

Blood Transfusion: A procedure in which donated blood or blood components are administered to a patient through an intravenous line.

Charges: The regular rates published by the provider on their Charge Master for services rendered before the application of contractual allowances and/or discounts.

Chest X-Ray: An imaging test that uses X-rays to view structures and organs in the chest. It can be used to diagnose or determine the status of conditions in the chest.

Clinical Laboratory Improvement Amendments of 1988 (CLIA): Regulations include federal standards applicable to all U.S. facilities or sites that test human specimens for health assessment or to diagnose, prevent, or treat disease.

CLIA: Clinical Laboratory Improvement Amendments of 1988

CMS: Centers for Medicare and Medicaid Services

CMS-1500 Claim Form: The CMS 1500, also known as the HCFA-1500 is the claim form for individual providers and charges under Medicare Part B.

CMT: Chiropractic Manipulative Treatment

Compounded Medications: As defined by FDA: Drug compounding is the process of combining, mixing, or altering ingredients to create a medication tailored to the needs of an individual patient. Compounding includes the combining of two or mor drugs.

Corrected Claim: These are claims that we receive from the claimant after we have reviewed and paid your claim.

CPAP: Continuous positive airway pressure is a machine that uses mild air pressure to keep breathing airways open.

Critical/Key Portions of an Operation Surgical: Portions of a procedure during which essential technical expertise and surgical judgement are required to achieve optimal patient outcome. The critical/key portions of each operation should be made known to all operating room staff.

CRNA: Certified Registered Nurse Anesthetist

Custodial Care: Non-medical care provided to assist people with daily living activities. Services may include bathing, cooking, cleaning, and other necessary functions.

Deprecated: For the purpose of this policy, a deprecated code is a legacy code, that is, a code that is no longer valid. Deprecation may apply to NDC and HCPCS codes.

Diagnostic Service: a service is “diagnostic” if it is an exam or procedure to which you subject the patient, or which you perform on materials derived from a hospital outpatient, to get information to aid in your assessment of a medical condition or to identify a disease.

Double-Booked Surgery: See Concurrent Surgery

DRG: Diagnostic Related Group
Durable Medical Equipment (DME): Reusable medical equipment
DMEPOS: Reusable medical equipment Prosthetics, Orthotics and Supplies
Emergency Department - Type A: A Type A provider-based emergency department must meet at least one of the following requirements: (1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department and be open 24 hours a day, 7 days a week; or (2) It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment and be open 24 hours a day, 7 days a week.

during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment, regardless of its hours of operation.

EMTALA: Emergency Medical Treatment and Labor Act. In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay.

FDA: Federal Drug Administration

Grouper: Computer software system that classifies the DRG

Global allowance: the period of time and the services/supplies that are within the preoperative, intraoperative and postoperative services.

Global Period: The period of time before a surgical procedure and after the procedure has been performed. The global period varies and is based on the nature of the procedure.

HCPCS: Healthcare Common Procedure Coding System.

HCPCS Level II: A standardized coding system that is used primarily to identify medical supplies, durable medical equipment, non-physician services, and services not represented in the Level I code set CPT
Home Infusion: The administration of medications or nutrition intravenously or through a feeding tube in the member’s home, provider’s office or at Medicare certified infusion site.

Hospice: Care provided to a terminally ill patient. Also known as palliative care.

Hydration: An IV infusion that consists of pre-packaged fluid and electrolytes strictly to replace fluids.

IAT: Intraoperative Autologous Transfusion
Iatrogenic Complications: An adverse condition that is a direct result of treatment by a physician or other health care professional.

ICU: Intensive Care Unit

IDE: An Investigational Device Exemption (IDE) allows the investigational device to be used in a clinical study in order to collect safety and effectiveness data. An approved IDE permits a device to be shipped lawfully for the purpose of conducting investigations of the device without complying with other requirements of the Food, Drug, and Cosmetic Act that would apply to devices in commercial distribution.

Immediately Available: Reachable and with the ability to provide, on demand, the appropriate level of clinical care necessary to perform an operation.

Implantable Cardiac Defibrillators (ICD): For the purposes of this policy ICDs include defibrillators, pacemakers, and their associated components such as electrical leads, batteries, etc.

Immunization: The process whereby a person is made resistant to a disease, typically by the administration of a vaccine.

Index admission: Initial inpatient hospitalization

Index admission measurement: Thirty days from the initial inpatient hospitalization

Infusion: The slow injection of a substance into a vein or tissue.

Incidental procedure: a procedure performed at the same time as a more complex primary procedure.

Informed Consent: A process when communication between a patient and physician results in the patient’s (or surrogate’s) authorization to undergo/proceed with a specific medical intervention. The informed consent conversation and the patient’s (or surrogate’s) decision documented in a specific written consent form is included in the medical record.

Injection: Substance injected into the body for therapeutic or diagnostic purposes. Injections can be intramuscular (IM), intravenous (IV), subcutaneous (SC), intradermal (ID), intrathecal (IC), or intra-arterial.
Inpatient: Admission to a hospital or skilled nursing facility on a physician’s order.

Integral procedure: occurs in multiple surgery situations when one or more of the procedures are included in the principal procedure. Intra-arterial infusion: delivery of drug or substance through a tube directly inserted into an artery.

Itemized Bill (IB): A full listing of all the charges being billed by a provider for the services rendered.

Intensive Care Chiropractic Treatment: Chiropractic approach where multiple daily visits (as many as four or five in a single day) are given in the office or clinic. The patient is confined to bed for the day when such an approach is used.
Interim Billing: These are claims for which services or supplies are billed BEFORE the member has discharged and are an extension of the dates of services on a previously billed or paid claim.

Interim Claim: Any billing for services prior to the final claim for a continuous course of treatment.
Interim Payment: Partial reimbursement for services while the patient is still an inpatient.

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM, ICD-10): A morbidity classification system for classifying diagnoses and reason for visits in all health care settings for the purpose of coding and reporting.

IPC: Intermittent Pneumatic Compression
IPPS: Inpatient Prospective Payment System
Leave of absence: An intentional readmission within 30 days that is a scheduled part of the patient’s plan of care, but the patient does not require a hospital level of care. If an unplanned emergent admission occurs during the leave of absence period, the admission is considered a readmission.

MCG: Formerly known asMilliman Care Guidelines

Medical Order: The prescription of a physician or other qualified healthcare professional regarding the treatment of a patient.

Medicare Severity Diagnosis Related Group (MS-DRG or DRG): A classification system statistically designed to calculate inpatient hospital claim pricing. DRG’s are defined by a specific set of patient attributes which include principal diagnosis, specific secondary diagnoses, procedures, sex, and discharge status, and the present of complications or comorbidities.

Medication Administration Record (MAR): The legal record of the drugs administered to a patient at a healthcare facility by a healthcare professional. The Medication Administration Record is a permanent part of the patient’s medical records. The eMAR is an electronic version of the MAR. The MAR must contain the NDC identifier for the prescription drug administered to the patient.
Modifier: Two characters (letters or numbers) appended to a CPT® or HCPCS Level II code. The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code.

Modifier 22: Increased Procedural Services.
Modifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period.
Modifier 25: Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.
Modifier 50: Bilateral procedure. This modifier should not be used with procedure codes identified in their terminology as bilateral or procedures identified as unilateral.
Modifier 52: Reduced Services

Modifier 57: Decision for surgery

Modifier 58: Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period.

Modifier 59: Used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.

Modifier 73: Procedure terminated before administration of anesthesia.

Modifier 74: Procedure terminated after administration of anesthesia.

Modifier 76: Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional

Modifier 77: Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional.

Modifier 80: Assistant Surgeon

Modifier 81: Minimum Assistant Surgeon

Modifier 82: Assistant Surgeon (when qualified resident surgeon not available)

Modifier 95: Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system

Modifier AS: Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery.

Modifier GO: Services delivered under an outpatient occupational therapy plan of care.

Modifier GN: Services delivered under an outpatient speech-language pathology plan of care.

Modifier GP: Services delivered under an outpatient physical therapy plan of care.

Modifier GT: Via interactive audio and video telecommunications systems
Modifier JW: Modifier JW is a HCPCS Level II modifier with the descriptor, “Drug/Biological amount discarded/not administered to any patient”. While modifier JW was created by CMS, CMS contractors may or may not require its use. The use of modifier JW is not limited to CMS members or plans. MotivHealth requires the use of modifier JW as indicated in the policy section below when reimbursement is sought for appropriately discarded drugs or biologics from single-dose vials or single-use packages for claims submitted by physicians’ offices and outpatient hospital facilities.
Modifier LL: Lease/rental. Append when DME equipment rental is to be applied against the purchase price
Modifier NR: New when rented. Append when item that was new at the time of rental is subsequently purchased
Modifier NU: New equipment
Modifier PA: Surgery wrong body part
Modifier PB: Surgery wrong patient
Modifier PC: Wrong surgery on patient
Modifier RR: Rental. Append when DME is rented.
Modifier SH: Second concurrently administered infusion therapy
Modifier SJ: Third or more concurrently administered infusion therapy
Modifier QW: States the test performed are simple laboratory examinations and procedures that have an insignificant risk of error. They are considered CLIA waived tests/procedures

Modifier UE: Append for used durable medical equipment
Medicare Severity Diagnosis Related Group (MS-DRG or DRG): Classification system statistically designed to calculate inpatient hospital claim pricing. DRG’s are defined by a specific set of patient attributes which include principal diagnosis, specific secondary diagnoses, procedures, sex, and discharge status, and the presence of complications or comorbidities.
MS-DRG: MS-DRG
MTP: Massive Transfusion Protocol
Multi-dose vial: A multi-dose vial is a vial of liquid medication intended for parenteral administration (injection or infusion) that contains more than one dose of medication. Multi-dose vials are labeled as such by the manufacturer and typically contain an antimicrobial preservative to help prevent the growth of bacteria. The preservative has no effect on viruses and does not protect against contamination when healthcare personnel fail to follow safe injection practices. (CDC3)

Mutually exclusive procedure: two or more procedures that are not usually performed on the same patient on the same date of service.

National Correct Coding Initiative (NCCI or CCI): The Centers for Medicare & Medicaid Services (CMS) developed these edits to promote consistent, correct coding and appropriate payment. These coding edits are developed based on the AMA CPT code set and the HCPCS code set, as well as analysis of standard medical and surgical practice and input from various groups, including specialty societies, other national health care organizations, Medicare contractors, providers, and consultants.
National Drug Code (NDC): A unique 10-digit or 11-digit, 3-segment number, and a universal product identifier for human drugs in the United States. Each medication is assigned a number under Section 510 of the U.S. Federal Food, Drug and Cosmetic Act. It identifies the manufacturer, product and package size.
National Uniform Billing Committee (NUBC): Committees responsible for the revenue code definitions and requirements for use.

Never Events/Serious Reportable Events (SRE): Errors in medical care that are of concern to both the public and health care professionals and providers and of a nature that the risk of occurrence is significantly influenced by the policies and procedure of the health care organization.

Occupational Therapy: form of therapy to develop, improve, sustain, or restore daily living activities after an illness or injury.

Occurrence Span Code: Displayed on Institutional claims to identify a specific event related to a claim, which occurred for a certain span of time.
Occurrence Span Code 74: Non-Covered Level of Care. Dates represent the period at a non-covered level of care in an otherwise covered stay.

OTC drugs: Medications that are safe and effective for use by the general public without seeking treatment by a health professional.

Outpatient: Facility care that a person receives without being admitted or for a stay of less than 24 hours even if this stay occurs overnight.

Overfill: Any amount of drug greater than the amount identified on the package or label.

Overlapping Surgery: Procedures in which part or all of the procedures chronologically coincide and when the patient’s care is left with another qualified medical provider. More specifically, operations are spaced out to ensure the critical portions of each operation, for which a single surgeon is responsible, do not occur at the same time.

PACU: Post-anesthesia care unit.
Palliative Care: Care that is focused on providing relief from the symptoms and stress of the illness. The goal is to improve quality of life for both the patient and the family.
PEEP: Positive end-expiratory pressure is a value that can be set up in patients receiving invasive or non-invasive mechanical ventilation.

Pheresis: Procedure in which the blood is filtered, separated and a portion retained with the remainder returned to the patient.
Physical Therapy: branch of rehabilitative health that uses specially designed exercises and equipment to help patients regain or improve their physical abilities due to illness or injury.

Physically Present: Being in the same operating room as the patient.

Planned Readmission: See Leave of Absence

Point-of-Care Testing: Laboratory testing conducted close to the site of patient care that is done rapidly and performed by clinical personnel who are not trained in clinical laboratory sciences. Rapid test results can provide clinical personnel with answers that can quickly help determine a course of action or treatment for a patient.

Present on Admission (POA) Indicator: A designation on the claim that identifies conditions that were present at the time the order for inpatient admission was written. Conditions that occurred in the emergency department, during outpatient surgery or observation stays that resulted in an inpatient admission are considered present on admission.

Presumptive Testing: Test used to detect the presence of a drug or drug class. Presumptive tests generally do not indicate a specific level of drug but rather give a positive or negative result.

Preventive Services: Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.

Principal Diagnosis: This is defined by the ICD-10-CM Official Guidelines for Coding and Reporting as the “condition, after study, which caused the admission to the hospital”. This is not necessarily what brought the patient to the emergency room.

Primary Attending Surgeon: The principal surgeon involved in the specific critical portions of the operation. He/she is responsible for the orchestration and progress of the critical portions of the procedure.

Procedure to Procedure Code Pair Edits (PTP): Automated prepayment edits that prevent improper payment when certain CPT/HCPCS codes are submitted together on a claim form.

Provider Reconsideration: A request from the provider to the Plan to review an adverse determination without a preauthorization or claim denial where the Member or patient has no financial responsibility.

Qualified Healthcare Practitioner: A ‘physician or other qualified health care professional’ is an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.
Qualified Healthcare Professional: Physician assistant or clinical nurse specialist who is not a licensed M.D. or D.O. or nurse practitioner.

Radiologic Supervision and Interpretation: The personal management and oversight of the performance of the radiologic portion of a procedure by one or more physicians and the explanation of the findings by the same or different physicians.

Readmission: An admission to the same acute care hospital or facility within its network within 30 days of discharge from the initial index admission or as described in the provider contract.

Rebilled Claim: These are claims we receive from the provider prior to our payment of a clean claim.

Respite Care: Provides short-term relief for primary caregivers

Resubmitted Claim: These are claims that you submit after we have determined your original claim was not clean.

Revenue Code: Revenue codes are 4-digit numbers that are used on hospital bills to identify where a member was located in a facility when they received treatment or services, or what service a member received as a patient.

Robotic Surgery: A method to perform surgery using very small tools attached to a robotic arm. The surgeon controls the robotic arm with a computer.

Running Two Rooms: See Concurrent Surgery

Same, similar or related condition: Based upon the same Major Diagnostic Category or same Diagnosis Related Group (DRG) or same principal diagnosis/procedure assigned to the claim

Secondary Diagnosis: This is defined by the Uniform Hospital Discharge Data Set as “conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or length of stay. These diagnoses are vital to documentation and have the potential to impact a patient’s severity of illness and risk of mortality, regardless of POA status. Diagnoses that relate to an earlier episode which have no bearing on the current inpatient admission should be excluded”. Only diagnoses that are monitored, evaluated, or treated should be documented.

Self-administered Drugs: Medications that are normally taken by the patient independently and unassisted.

Simultaneous Bilateral Services: Procedure in which each surgeon performs the same procedure on opposite sides of the body.

Simultaneous Operations: see Concurrent Surgery.

Single-use Package (Unit Dose Package): a package that contains one discrete pharmaceutical dosage form, i.e., one tablet.

SNF: Skilled Nursing Facility
Social Admit: Patient is admitted to an inpatient facility from the emergency department for the convenience of patient, family, or care provider while awaiting transfer to more appropriate arrangements.

Speech Therapy: the evaluation and treatment of patients with speech, language cognitive-communication and swallowing disorders.
Split Billing: These are claims for which services or supplies are billed AFTER the member has discharged and are an extension of the dates of services on a previously paid claim.

Split Blood: Blood that is split into its component parts where one or more parts is transfused to one member and other parts transfused into another patient or to the same member at another time(s).

Standing Order: The order of a physician or other qualified healthcare professional that can be exercised by other health care workers when predetermined conditions have been met.

Subluxation: A motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact.

Team Surgeon: Three or more physicians who operate in a surgical team during a highly complex surgical procedure. The surgeons in such a team are often trained in different specialties.

Telehealth: The use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, provider training, continuing medical education or public health education, administrative meetings, and electronic information sharing.

Telemedicine: The use of electronic information and telecommunications technologies to provide remote clinical services.

Timeout Process: An immediate pause by the entire surgical team to confirm the correct patient, procedure, and site.

TIN: Taxpayer Identification Number
Total Parenteral Nutrition: A method of feeding that bypasses the gastrointestinal tract.

TPN:Total Parenteral Nutrition is a method of feeding that bypasses the gastrointestinal tract.

Type of Bill code (TOB): A four-digit alphanumeric codes that specify different pieces of information on claim form UB-04 or form CMS-1450 and is reported in box 4 on line 1.

First Digit = Leading zero. Ignored by CMS
Second Digit = Type of facility
Third Digit = Type of care
Fourth Digit = Sequence of this bill in this episode of care. Referred to as a "frequency" code
UB-04 Claim Form: The UB-04 also known as the CMS-1450 is the claim form for institutional facilities and charges under Medicare Part A

Ultrasound: A diagnostic tool that uses high frequency sound waves to create images of the inside of the body. Ultrasound is also known as sonography.

Unbundling: The use of multiple CPT/HCPCS codes to report a procedure or supply when a single comprehensive code exists that adequately describes the service or supply, either unintentionally or in an effort to maximize reimbursement.

Unlisted Code or Not Otherwise Classified (NOC) Code: These codes do not provide clear information about the service or item being billed. Additional information is required to determine if services meet benefit

coverage/eligibility and medical necessity guidelines. Some drugs or procedures with an unlisted code may require prior authorization.

Uniform Billing Editor (UBE): A reference tool utilized by facilities to manage the constant changes to Medicare billing and reimbursement processes. The UBE provides detailed, accurate, and timely information about Medicare and UB-04 billing rules and requirements.

USPSTF: The U.S. Preventive Services Task Force works to improve the health of people nationwide by making evidence-based recommendations on effective ways to prevent disease & prolong life.
Vaccine: A preparation that is used to stimulate the body’s immune response against diseases. Vaccines are usually administered through needle injections, but some can be administered by mouth or sprayed into the nose.

Wastage: see definition for Discarded Drug or Biologic above.

Wholly Operated: Per CMS an entity is wholly operated by a hospital if the hospital has exclusive responsibility for conducting and overseeing the entity’s routine operations, regardless of whether the hospital also has policymaking authority over the entity.

Wholly Owned: Per CMS an entity is wholly owned by the hospital if the hospital is the sole owner of the entity.