Anthem Blue Cross and Blue Shield Commercial Professional Reimbursement Policy

Transcription

1 Subject: Frequency Editing CT Policy: 0016 Effective: 03/01/ /31/2017 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed below. This reimbursement policy also applies to Employer Group Retiree Medicare Advantage programs. Description The Health Plan uses claims processing logic based on ClaimsXten rationale to determine when the use of multiple units is appropriate. The Health Plan also uses, among other factors, the nomenclature for a particular Current Procedural Terminology (CPT ) or Healthcare Common Procedure Coding System (HCPCS Level II) code, the Centers for Medicare & Medicaid Services (CMS s) Medically Unlikely Edits (MUEs) designation, industry standards, or the ability to clinically perform or report a particular service more than one time on a single date of service or within a particular date span per member per provider in making these determinations. This policy documents the Health Plan s position on frequency editing and frequency limits. Policy 1. All or any of the following factors identify when a procedure will be limited in units, or number of times a code is eligible for reimbursement on a single date of service. a. The description of a procedure code includes the word(s) bilateral or unilateral or bilateral b. A procedure code description specifies unilateral and there is another CPT code for the bilateral service or another add-on code for additional services (the unilateral CPT code cannot be submitted more than once on a single date of service) c. The description of a procedure code includes a specified time frame (e.g. per 30 day period) d. The description of a procedure code implies multiplicity (e.g., evaluation(s), muscle(s), injection(s), area(s), material(s), etc.) e. The total number of times it is clinically possible or clinically reasonable to perform a given procedure on a single date of service is limited In some circumstances an RT/LT or site-specific modifier (e.g. F5, T3; etc.) will allow a code to process when used more than once, since these modifiers will identify the specific side or digit when more than one site is being treated or evaluated. f. A procedure code is reported more than one time, but typically is not performed more than once on a single date of service. 2. When a procedure code is submitted with multiple units, and only a single unit is acceptable, reimbursement will be based on only one unit. 3. The Health Plan will apply all unit/frequency edits pre-adjudication, using both the unit field and multiple submissions of line items. CT0016 Frequency Editing Page 1 of 12

2 4. The Health Plan will apply a frequency edit, when applicable, to a base code, which has a related add-on code listed in CPT Appendix D. Since the related add-on code(s) describes a phrase such as each additional or list separately in addition to the primary procedure, the base code is eligible for reimbursement only once per date of service. (e.g., only one of the following initial vaccine administration codes or is allowed per date of service.) 5. The Health Plan will apply frequency edits across dates of service for certain codes. This edit will use claim lines processed in history that have previous, current, and subsequent dates of service to accumulate and apply this type of frequency limit. 6. The Health Plan will apply frequency maximums per day and/or per date span, which may be based on the CMS s MUEs, industry standards, and/or code description. 7. The Health Plan will apply frequency maximums per day and/or per date span when procedures are within the same service grouping (e.g. routine blood collection services on the same date of service will be allowed once per date of service; unattended sleep studies and/or home sleep studies reported on the same date of service and/or within a seven day period will only be allowed one time during the seven day period). 8. The Health Plan will apply unit maximums to drugs that may be based on manufacturer s guidelines, U. S. Food and Drug Administration (FDA) approval, and/or code description. The Health Plan has customized ClaimsXten unit/frequency logic for the procedure codes listed in the table in the Coding Section below. Coding The following occurrence restrictions are examples of some frequency edits the Health Plan has implemented. Services reported in excess of these restrictions are not eligible for reimbursement even when reported with an override modifier (e.g., modifiers 59, 76, 91). The inclusion or exclusion of a specific code does not indicate eligibility for coverage under all circumstances Debridement of nail(s) by any method(s); 1 to 5 1 per 60 ** frequency limit includes and Debridement of nail(s) by any method(s); 6 or more 1 per 60 ** frequency limit includes and Collection of venous blood by venipuncture ** CT0016 Frequency Editing Page 2 of 12

3 frequency limit includes 36415, 36416, and S Collection of capillary blood specimen (eg, finger, heel, ear stick) Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluoroscopy) and radiological supervision and interpretation when performed Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injections, localization device), imaging supervision and interpretation Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan 77600, Hyperthermia, externally generated; superficial (i.e., heating to a depth of 4 cm or less) or deep (i.e., heating to depths greater than 4 cm) ** frequency limit includes 36415, 36416, and S Definitive drug testing: Alcohols and 18 per , Definitive drug testing: Alcohol biomarkers and 18 per 365 CT0016 Frequency Editing Page 3 of 12

4 80323 Definitive drug testing: Alkaloids, not otherwise specified and 18 per , 80325, Definitive drug testing: Amphetamines and 18 per , Definitive drug testing: Anabolic steroids and 18 per , 80330, Definitive drug testing: Analgesics, non-opioid and 18 per , 80333, Definitive drug testing: Antidepressants, serotonergic class and 18 per , 80336, Definitive drug testing: Antidepressants, tricyclic and other cyclicals and 18 per Definitive drug testing: Antidepressants, not otherwise specified 80339, 80340, , 80343, Definitive drug testing: Antiepileptics, not otherwise specified Definitive drug testing: Antipsychotics, not otherwise specified and 18 per 365 and 18 per 365 and 18 per Definitive drug testing: Barbiturates and 18 per , Definitive drug testing: Benzodiazepines and 18 per Definitive drug testing: Buprenorphine and 18 per Definitive drug testing: Cannabinoids, natural and 18 per , 80351, Definitive drug testing: Cannabinoids, synthetic and 18 per Definitive drug testing: Cocaine and 18 per Definitive drug testing: Fentanyl and 18 per Definitive drug testing: Gabapentin, non-blood and 18 per Definitive drug testing: Heroin metabolite and 18 per Definitive drug testing: Ketamine and norketamine and 18 per Definitive drug testing: Methadone and 18 per 365 CT0016 Frequency Editing Page 4 of 12

5 80359 Definitive drug testing: Methylenedioxyamphetamines (MDA, MDEA, MDMA) and 18 per Definitive drug testing: Methylphenidate and 18 per Definitive drug testing: Opiates and 18 per , 80363, Definitive drug testing: Opioids and opiate analogs and 18 per Definitive drug testing: Oxycodone and 18 per Definitive drug testing: Phencyclidine (PCP) and 18 per Definitive drug testing: Pregabalin and 18 per Definitive drug testing: Propoxyphene and 18 per Definitive drug testing: Sedative hypnotics (nonbenzodiazepines) and 18 per , Definitive drug testing: Skeletal muscle relaxants and 18 per Definitive drug testing: Stimulants, synthetic and 18 per Definitive drug testing: Tapentadol and 18 per Definitive drug testing: Tramadol and 18 per Definitive drug testing: Stereoisomer (enantiomer) analysis, single drug class 80375, 80376, Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified and 18 per 365 and 18 per Unlisted molecular pathology procedure Complement; antigen, each component 4 per date of service Infectious agent detection by nucleic acid (DNA or 3 per date of service RNA); Chlamydia trachomatis, amplified probe technique Infectious agent detection by nucleic acid (DNA or 3 per date of service CT0016 Frequency Editing Page 5 of 12

6 RNA); Neisseria gonorrhoeae, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique Level IV Surgical pathology, gross and microscopic examination needle biopsy prostate Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each Breath hydrogen or methane test (eg, for detection of lactase deficiency, fructose intolerance, bacterial overgrowth, or oro-cecal gastrointestinal transit) 9 units per date of service when reported for specimens related to needle biopsies of the prostate 4 per date of service Fundus photography with interpretation and report 93268, 93270, 93271, Wearable patient activated EKG event recording per 30 day period of time 93293, 93294, Transtelephonic rhythm strip pacemaker 93295, evaluation(s) system up to , 93298, Implantable cardiovascular monitor system, interrogation device evaluation(s) up to Doppler echocardiography color flow velocity mapping 1 per 30 1 per 90 1 per 30 2 per date of service 94014, 94015, Patient-initiated spirometric recording per 30 day 1 per period of time 94774, 94775, Pediatric home apnea monitoring event recording per 1 per , day period of time 95250, Continuous glucose monitoring 1 per Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses) Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and 130 doses per per 7 ** frequency limit includes 95800, 95801, 95806, G0398, G0399, and 1 per 7 ** CT0016 Frequency Editing Page 6 of 12

7 respiratory analysis (e.g., by airflow or peripheral arterial tone) frequency limit includes 95800, 95801, 95806, G0398, G0399, and Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement) Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist s or physician s time, both face-to-face time with the patient and time interpreting test results and preparing the report 96150, 96151, 96152, 96153, Health and behavior assessment/intervention; each 15 minutes 1 per 7 ** frequency limit includes 95800, 95801, 95806, G0398, G0399, and 5 hours per per date of service Additional sequential infusion, up to 1 hour 6 per date of service Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic Initiation of prolonged IV Chemotherapy administration (more than 8 hours) requiring the use of a portable or implantable pump for the administration of drugs such as omalizumab (Xolair ), per drug 97012,97014, Physical medicine modalities 97016, 97018, 97022,97024, 97026, Physician attendance and supervision of hyperbaric oxygen therapy, per session 3 per date of service 99363, Anticoagulant management 90 of therapy 1 per T Preventive behavior change, intensive program\of prevention of diabetes using a standardized diabetes prevention program curriculum, provided to individuals in a group setting, minimum 60 minutes, per day and 24 per 365 CT0016 Frequency Editing Page 7 of 12

8 A4210 Needle-free injection device, each 2 per 365 A4230 Infusion set for external insulin pump, non needle 60 per 90 cannula type A4231 Infusion set for external insulin pump, needle type 60 per 90 A4232 Syringe with needle for external insulin pump, 60 per 90 sterile, 3CC A4244 Alcohol or peroxide, per pint 12 per 90 A4245 Alcohol wipes, per box 24 per 90 A4250 A4253 A4257 Urine test or reagent strips or tablets (100 tablets or strips) Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips Replacement lens shield cartridge for use with laser skin piercing device, each 4 per per 90 1 per 30 A4258 Spring-powered device for lancet, each 2 per 365 A4259 Lancets, per box of per 90 A4556 Electrodes per pair 2 pair per 30 (See also our Bundled Services and Supplies reimbursement policy for additional information.) A4557 Lead wires per pair 4 pair per 365 (See also our Bundled Services and Supplies reimbursement policy for additional information.) A4595 Electrical stimulator supplies, 2 lead, per month, 2 per 30 (e.g., TENS, NMES) A6530 Gradient compression stocking, below knee, per 365 A6531 Gradient compression stocking, below knee, per 365 A6532 Gradient compression stocking, below knee, per 365 A6533 Gradient compression stocking, thigh length, per 365 A6534 Gradient compression stocking, thigh length, per 365 A6535 Gradient compression stocking, thigh length, per 365 A6536 Gradient compression stocking, full-length/chap style, per 365 CT0016 Frequency Editing Page 8 of 12

9 A6537 Gradient compression stocking, full-length/chap 8 per 365 style, A6538 Gradient compression stocking, full-length/chap 8 per 365 style, A6539 Gradient compression stocking, waist length, per 365 A6540 Gradient compression stocking, waist length, per 365 A6541 Gradient compression stocking, waist length, per 365 A6545 Gradient compression wrap, nonelastic, below knee, 8 per A6549 Gradient compression stocking/sleeve, not otherwise 8 per 365 specified C9257 Injection, bevacizumab, 0.25 mg (for Avastin ) 10 per date of service (5 per eye for intravitreal injection) E0441, E0442, Oxygen one month s supply 1 per 30 E0443, E0444 E1812 Dynamic knee, extension/flexion device, include soft 1 per 30 interface material G0249 Provision of test materials and equipment for home INR monitoring includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests 3 per 90 G0398 G0399 Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation] Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels 1 per 7 ** frequency limit includes 95800, 95801, 95806, G0398, G0399, and 1 per 7 ** frequency limit includes 95800, 95801, 95806, G0398, G0399, and 1 per 7 ** frequency limit includes 95800, CT0016 Frequency Editing Page 9 of 12

10 95801, 95806, G0398, G0399, and G0480 Definitive, per day, 1-7 drug classes and 18 per 365 G0481 Definitive, per day, 8-14 drug classes and 18 per 365 G0482 Definitive, per day, drug classes and 18 per 365 G0483 Definitive, per day, 22 or more drug classes and 18 per 365 H0020 Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program) H0022 Alcohol and/or drug intervention service (planned facilitation) J0129 Orencia, 10 mg 100 per date of service J0585 Injection, onabotulinumtoxina, 1 unit (Botox) 600 per date of service J0586 Dysport, 5 units 200 per date of service J0696 Injection, ceftriaxone sodium, per 250 mg 16 per date of service (Rocephin) J0717 Cimzia, 1 mg 400 per date of service J0897 Prolia/Xgeva, 1 mg 120 per date of service J1453 Fosaprepitant (Emend), 1 mg 150 per date of service J1560 Injection, gamma globulin, intramuscular, over 10cc J1750 Iron dextran, 50 mg 40 per date of service J2353 Octreotide, depot form for intramuscular injection, 40 per date of service (Sandostatin, depot) 1 mg J2357 Injection, omalizumab, 5 mg (Xolair) 90 per 14 J2469 Injection, palonosetron HCl, 25 mcg (Aloxi) 10 per date of service J2505 Injection, pegfilgrastim, 6 mg (Neulasta) J2507 Pegloticase (Krystexxa), 1 mg 8 per date of service J2800 Injection, methocarbamol, up to 10 ml (Robaxin) 3 per date of service J3357 Injection ustekinumab 1 mg (Stelara) 90 per 28 J3489 Zoledronic acid, 1 mg 5 per date of service J7307 Etonogestrel (contraceptive) implant system (Implanon; Nexplanon) J7312 Dexamethasone, intravitreal implant (Ozurdex), per 90 mg J7320 Hyaluronan or derivative, GenVisc 850, for intraarticular injection, 1 mg 50 per date of service CT0016 Frequency Editing Page 10 of 12

11 J7321, J7323, Hyaluronan or derivative for intra-articular 2 per date of service J7324, J7326 injection, per dose J7322 Hyaluronan or derivative, Hymovis, for intraarticular injection, 1 mg 48 per date of service J7325 Hyaluronan or derivative (Synvisc or Synvisc-One), 96 per date of service 1 mg J9031 BCG (intravesical) per instillation (Theracys/Tice Bcg) J9047 Carfilzomib (Kyprolis), 1 mg 150 per date of service J9202 Goserelin acetate implant (Zoladex), per 3.6 mg 3 per date of service J9217 Leuprolide acetate (for depot suspension), 7.5 mg 6 per date of service (Lupron Depot, Eligard) J9355 Injection, trastuzumab, 10 mg (Herceptin ) 95 units per date of service J9395 Fulvestrant (Faslodex), 25 mg 20 per date of service Q4101 Apligraf, per sq cm 44 per date of service S9123 S9124 S9140 S9141 S9529 Nursing care, in the home; by registered nurse, per hour Nursing care, in the home; by licensed practical nurse, per hour Diabetic management program, follow-up visit to non-md provider Diabetic management program, follow-up visit to MD provider Routine venipuncture for collection of specimen(s), single homebound, nursing home, or skilled nursing facility patient 24 per date of service 24 per date of service ** frequency limit includes 36415, 36416, and S9529 ClaimsXten is a registered trademark of McKesson Information Solutions LLC CPT is a registered trade mark of the American Medical Association Use of Reimbursement Policy: This policy is subject to federal and state laws, to the extent applicable, as well as the terms, conditions, and limitations of a member s benefits on the date of service. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Anthem Blue Cross and Blue Shield. CT0016 Frequency Editing Page 11 of 12

12 2017 Anthem Blue Cross and Blue Shield CT0016 Frequency Editing Page 12 of 12