Empire BlueCross BlueShield Professional Commercial Reimbursement Policy

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1 Subject: Frequency Editing NY Policy: 0016 Effective: 03/01/ /30/2017 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed below. 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 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. 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 a 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. NY 0016 Page 1 of [13]

2 4. The Health Plan will apply a frequency edit, when applicable, to a base code which has a related addon 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 some frequency edits across dates of service 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. For Durable Medical Equipment (DME), the Health Plan will apply frequency maximums per day and/or per date span (usually based on the Centers for Medicare & Medicaid Services (CMS s) Medically Unlikely Edits (MUEs), industry standards, and/or HCPCS description). (See also our Durable Medical Equipment reimbursement policy.) 7. The Health Plan will apply some frequency maximums per day and/or per date span when procedures are within the same service grouping (e.g., routine blood collection 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;). The Health Plan has customized ClaimsXten unit/frequency logic for some procedure codes. Please see the table in the Coding Section for these customizations. CODING The following occurrence restrictions are examples of some frequency edits added to certain codes that do not fit into one of the categories identified in the policy section above, or the description of the code includes a designated time frame. Services billed in excess of these restrictions are not eligible for reimbursement even when billed 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 days** frequency limit includes and NY 0016 Page 2 of [13]

3 1 per 60 days** Debridement of nail(s) by any method(s); 6 or more frequency limit includes and Collection of venous blood by venipuncture ** frequency limit includes 36415, 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 (e.g., 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 36416, and S9529 ** frequency limit includes 36415, 36416, and S9529 NY 0016 Page 3 of [13]

4 77338 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) Definitive drug testing: Alcohols 80321, Definitive drug testing: Alcohol biomarkers Definitive drug testing: Alkaloids, not otherwise specified 80324, 80325, Definitive drug testing: Amphetamines , Definitive drug testing: Anabolic steroids 80329, 80330, Definitive drug testing: Analgesics, non-opioid , 80333, Definitive drug testing: Antidepressents, serotonergic class 80335, 80336, Definitive drug testing: Antidepressants, tricyclic and other cyclicals , 80340, , 80343, Definitive drug testing: Antidepressants, not otherwise specified Definitive drug testing: Antiepileptics, not otherwise specified Definitive drug testing: Antipsychotics, not otherwise specified Definitive drug testing: Barbiturates 80346, Definitive drug testing: Benzodiazepines Definitive drug testing: Buprenorphine Definitive drug testing: Cannabinoids, natural NY 0016 Page 4 of [13]

5 80350, 80351, Definitive drug testing: Cannabinoids, synthetic Definitive drug testing: Cocaine Definitive drug testing: Fentanyl Definitive drug testing: Gabapentin, non-blood Definitive drug testing: Heroin metabolite Definitive drug testing: Ketamine and norketamine Definitive drug testing: Methadone Definitive drug testing: Methylenedioxyamphetamines (MDA, MDEA, MDMA) Definitive drug testing: Methylphenidate Definitive drug testing: Opiates 80362, 80363, Definitive drug testing: Opioids and opiate analogs Definitive drug testing: Oxycodone Definitive drug testing: Phencyclidine (PCP) Definitive drug testing: Pregabalin Definitive drug testing: Propoxyphene , Definitive drug testing: Sedative hypnotics (non-benzodiazepines) Definitive drug testing: Skeletal muscle relaxants NY 0016 Page 5 of [13]

6 80371 Definitive drug testing: Stimulants, synthetic Definitive drug testing: Tapentadol Definitive drug testing: Tramadol , 80376, Definitive drug testing: Stereoisomer (enantiomer) analysis, single drug class Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified Unlisted molecular pathology procedure Complement; antigen, each component 4 per date of service Level IV Surgical pathology, gross and microscopic examination needle biopsy prostate , 93270, 93271, Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, amplified probe technique Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique 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) Fundus photography with interpretation and report Wearable patient activated EKG event recording per 30 day period of time 9 units per date of service when reported for specimens related to needle biopsy of the prostrate 3 per date of service 3 per date of service 4 per date of service NY 0016 Page 6 of [13]

7 93293, 93294, Transtelephonic rhythm strip pacemaker 93295, evaluation(s) system up to 90 days 1 per 90 days 93297, 93298, Implantable cardiovascular monitor system, interrogation device evaluation(s) up to 30 days Doppler echocardiography color flow velocity mapping 2 per date of service 94014, 94015, Patient-initiated spirometric recording per day period of time 94774, 94775, Pediatric home apnea monitoring event 94776, recording per 30 day period of time 95250, Continuous glucose monitoring 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 respiratory analysis (e.g., by airflow or peripheral arterial tone) 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, 130 doses per 1 per 7 days ** frequency limit includes 95800, 95801, 95806, G0398, G0399, and G per 7 days ** frequency limit includes 95800, 95801, 95806, G0398, G0399, and G per 7 days ** frequency limit includes 95800, 95801, 95806, G0398, G0399, and G hours/units per NY 0016 Page 7 of [13]

8 memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist s or physician s time, both face-toface 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 8 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 for the administration of drugs such as omalizumab (Xolair ), per drug Initiation of prolonged IV Chemotherapy administration (more than 8 hours) requiring the use of a portable or implantable pump 97012,97014, 97016, 97018, 97022,97024, Physical medicine modalities 97026, Physician attendance and supervision of hyperbaric oxygen therapy, per session 3 per date of service 99363, Anticoagulant management 90 days of therapy 1 per 90 days 0403T 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 A4210 Needle-free injection device, each 2 per A4230 Infusion set for external insulin pump, non needle cannula type 60 per 90 days A4231 Infusion set for external insulin pump, needle type 60 per 90 days A4232 Syringe with needle for external insulin pump, sterile, 3CC 60 per 90 days and 24 per NY 0016 Page 8 of [13]

9 A4244 Alcohol or peroxide, per pint 12 per 90 days A4245 Alcohol wipes, per box 24 per 90 days A4250 Urine test or reagent strips or tablets (100 tablets or strips) 4 per 90 days A4253 Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips 13 per 90 days A4257 Replacement lens shield cartridge for use with laser skin piercing device, each A4258 Spring-powered device for lancet, each 2 per A4259 Lancets, per box of per 90 days A4556 Electrodes per pair 2 pair per 30 days (See also our Bundled Services and Supplies reimbursement policy for additional information.) A4557 Lead wires per pair 4 pair per (See also our Bundled Services and Supplies reimbursement policy for additional information.) A4595 Electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES) 2 per 30 days A6530 Gradient compression stocking, below knee, mm Hg, each 8 per A6531 Gradient compression stocking, below knee, mm Hg, each 8 per A6532 Gradient compression stocking, below knee, mm Hg, each 8 per A6533 Gradient compression stocking, thigh length, mm Hg, each 8 per A6534 Gradient compression stocking, thigh length, mm Hg, each 8 per A6535 Gradient compression stocking, thigh length, mm Hg, each 8 per A6536 Gradient compression stocking, full-length/chap style, mm Hg, each 8 per A6537 Gradient compression stocking, full-length/chap style, mm Hg, each 8 per NY 0016 Page 9 of [13]

10 A6538 Gradient compression stocking, full-length/chap style, mm Hg, each 8 per A6539 Gradient compression stocking, waist length, mm Hg, each 8 per A6540 Gradient compression stocking, waist length, mm Hg, each 8 per A6541 Gradient compression stocking, waist length, mm Hg, each 8 per A6545 Gradient compression wrap, nonelastic, below knee, mm Hg, each 8 per A6549 Gradient compression stocking/sleeve, not otherwise specified 8 per C9257 Injection, bevacizumab, 0.25 mg (for Avastin ) 10 per date of service E0441, E0442, E0443, E0444 E1812 G0249 G0398 G0399 Oxygen one month s supply Dynamic knee, extension/flexion device, include soft interface material 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 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] 3 per 90 days 1 per 7 days ** frequency limit includes 95800, 95801, 95806, G0398, G0399, and G per 7 days ** frequency limit includes 95800, 95801, 95806, G0398, G0399, and G0400 NY 0016 [13] Page 10 of

11 1 per 7 days ** G0400 Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels frequency limit includes 95800, 95801, 95806, G0398, G0399, and G0400 Definitive, per day, 1-7 drug classes G0480 G0481 G0482 G0483 Definitive, per day, 8-14 drug classes Definitive, per day, drug classes Definitive, per day, 22 or more drug classes Alcohol and/or drug services; methadone H0020 administration and/or service (provision of the drug by a licensed program) Alcohol and/or drug intervention service H0022 (planned facilitation) J0129 Orencia, 10 mg 100 per date of service J0585 Botox / Botox cosmetic, 1 unit 600 per date of service J0586 Dysport, 5 units 200 per date of service J0696 Injection, ceftriaxone sodium, per 250 mg (Rocephin) 16 per date of service 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 NY 0016 [13] Page 11 of

12 J1560 Injection, gamma globulin, intramuscular, over 10cc J1750 Iron dextran, 50 mg 40 per date of service J2353 Octreotide, depot form for intramuscular injection, (Sandostatin, depot) 1 mg 40 per date of service J2357 Injection, omalizumab, 5 mg (Xolair) 90 per 14 days 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 days J3489 Zoledronic acid, 1 mg 5 per date of service J7307 J7312 J7320 J7322 Etonogestrel (contraceptive) implant system (Implanon; Nexplanon) Dexamethasone, intravitreal implant (Ozurdex), 0.1 mg Hyaluronan or derivative, GenVisc 850, for intra-articular injection, 1 mg Hyaluronan or derivative, Hymovis, for intraarticular injection, 1 mg 14 per 90 days 50 per date of service 48 per date of service J7321, J7323, Hyaluronan or derivative for intra-articular J7324, J7326 injection, per dose 2 per date of service J7325 Hyaluronan or derivative (Synvisc or Synvisc- One), 1 mg 96 per date of service 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 (Lupron Depot, Eligard) 6 per date of service J9355 Injection, trastuzumab, 10 mg (Herceptin ) 95 units per date of service NY 0016 [13] Page 12 of

13 J9395 Fulvestrant (Faslodex), 25 mg 20 per date of service Q4101 Apligraf, per sq cm 44 per date of service S9123 Nursing care, in the home; by registered nurse, per hour 24 per date of service S9124 Nursing care, in the home; by licensed practical nurse, per hour 24 per date of service S9140 Diabetic management program, follow-up visit to non-md provider S9141 Diabetic management program, follow-up visit to MD provider S9529 Routine venipuncture for collection of specimen(s), single homebound, nursing home, or skilled nursing facility patient ** frequency limit includes 36415, 36416, and S CPT is a registered trademark of the American Medical Association Use of Reimbursement Policy: State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, take precedence over Reimbursement Policy and must be considered first in determining eligibility for coverage. The member s contract benefits in effect on the date that services are rendered must be used. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically Empire BlueCross BlueShield 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 Empire BlueCross BlueShield. NY 0016 [13] Page 13 of

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