Professional Non Covered Codes Policy

Transcription

1 Policy Number 2018R7102I Professional Non Covered Codes Policy Annual Approval Date 7/12/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. reimbursement policies uses Current Procedural Terminology (CPT *), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider contracts, the enrollee s benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by due to programming or other constraints; however, strives to minimize these variations. may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Application This reimbursement policy applies to Medicaid product. This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a ) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Payment Policies for Medicare & Retirement, Medicare and Employer & Individual please use this link. Medicare & Retirement Policies and Medicare are listed under Medicare Advantage Reimbursement Policies. Employer & Individual are listed under Reimbursement Policies-Commercial. Proprietary information of. Copyright 2018 UnitedHealthcare Services, Inc. 2018R7102I

2 Policy Overview considers any CPT and HCPCS codes that are not on a state Medicaid fee schedule as not covered for that state s Medicaid market unless there are benefit &/or contractual agreements with negotiated rates. Reimbursement Guidelines Not Covered Any CPT and HCPCS codes that are not on the CMS NPFS but are on the state fee schedule will be covered for that state s Medicaid market. All covered services are subject to all UnitedHealthcare Community Plan Reimbursement Policies and, although they will not deny as not covered services, may deny based on another policy. Any CPT and/or HCPCS codes that are not on the CMS NPFS, nor on an individual state fee schedule will deny as not covered in that particular state unless there are benefit &/or contractual agreements with negotiated rates. Any code that is not covered in any market will be on the Non Covered Codes List. Some Medicaid markets have a listing of covered codes, rather than non-covered codes. For these States, there will be a covered code list and any code not on the list will deny as not covered. Category II Codes Category II codes are used primarily for performance measurements and, per CMS, are not payable by Medicare. Upon review of the Medicaid fee schedules, has determined that the Category II codes are not payable in their Medicaid markets. Thus, Category II codes will not be payable in any markets. Electronic Medical Records and E-prescribing Reporting Codes These codes (G8443-G8449) are to be used for reporting the use of an e-prescribing or EMR system. Upon review of the Medicaid fee schedules, has determined that these codes are not payable in their Medicaid markets. Thus, G8443-G8449 will not be payable in any markets. Benefit Considerations The service requested must be reviewed against the language in the enrollee's benefit document. When the definitions of Experimental/Investigational Services and Unproven Services in the benefit document differ from the definition, it is the definition in the enrollee's benefit document that prevails. State Exceptions Arizona Delaware Louisiana Michigan Mississippi Arizona utilizes a Covered Codes List Code A0998 is not-covered for Arizona Medicare Delaware s LTC (Product ID DELTC) has a separate Non-Covered Codes List Codes 59400, 59510, and are only covered if member has COB Michigan s Non-Covered Codes are not administered by this policy Mississippi CHIP (Plan ID MSCHIP) has a separate Non-Covered Codes List. Proprietary information of. Copyright 2018 UnitedHealthcare Services, Inc. 2018R7102I

3 New Jersey Code S5151 is covered for New Jersey Medicaid Family Care (Plan ID NJFAMCAR) only. Category II code 3008F (Body Mass Index, documented) is payable for members ages 3 through 17 years, once per year, per provider when all the following criteria are met: 1. CPT Category II code 3008F-Body Mass Index Documented The diagnosis code must be primary for CPT 3008F for this incentive. 2. One of the following evaluation and management services: , Office/Op Visit , Office/Op Visit , Consult/OP Visit , Initial preventive medicine/op Visit , Comp preventive medicine/op Visit , Preventive medical counseling/risk factor reduction , Preventive medical counseling/risk factor reduction 3. One of the following ICD-10 diagnosis codes: Z68.51 BMI, pediatric <5% Z68.52 BMI, pediatric 5% - <85% Z68.53 BMI, pediatric 85% - <95% Z68.54 BMI, pediatric >= 95% New Mexico Ohio Pennsylvania Rhode Island Tennessee Texas New Mexico utilizes a Covered Codes List Ohio utilizes a Covered Codes List Ohio s MME product (Plan ID OHMMEP) has a separate Covered Codes List. Pennsylvania s Non-Covered Codes are not administered by this policy Rhode Island s Non-Covered Codes are not administered by this policy Category II codes 0500F and 0503F are covered for Tennessee Medicaid. Texas utilizes a Covered Codes List. Per Texas Medicaid Health Plan, effective for dates of service on or after January 1, 2015, certain procedure codes will no longer be reimbursed to free-standing and hospital-based Ambulatory Surgical Centers Wisconsin Category II code 3008F (Body Mass Index, documented) is payable once per member, per year, per provider when submitted with an appropriate diagnosis code. Definitions Line of Business Experimental or Investigational Services Identification number for various products within each market. Medical, surgical, diagnostic, psychiatric, substance abuse or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time we make a determination regarding coverage in a particular case, are determined to be any of the following: Not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the Proprietary information of. Copyright 2018 UnitedHealthcare Services, Inc. 2018R7102I

4 REIMBURSEMENT POLICY American Hospital Formulary Service or the United States Pharmacopoeia Dispensing Information as appropriate for the proposed use. Category II codes Subject to review and approval by any institutional review board for the proposed use. (Devices which are FDA approved under the Humanitarian Use Device exemption are not considered to be Experimental or Investigational.) CPT Category II Procedure Codes are identified by the procedure code ending with "F", xxxxf, (example 1038F). Questions and Answers Q: What codes are considered non covered codes? 1 A: Non covered codes are codes for services that are either considered non reimbursable per state guidelines, CMS or are reimbursable by a payer other than. Q: How does determine which codes are not covered? 2 A: follows state guidelines as outlined in the individual state provider manual, state website or other regulatory materials. Q: Is the policy administered based on Date of Service or Date of Process? 3 A: The policy is administered based on Date of Service. Attachments: Please right-click on the icon to open the file National Non-Covered Codes List of codes that are not covered in any markets State Specific Lists States With Lists of Non-Covered Codes California Medicaid Non-Covered Codes Delaware Non-Covered Codes Florida Medicaid Non-Covered Codes California Medicaid Delaware Medicaid and LTC Florida Medicaid Proprietary information of. Copyright 2018 UnitedHealthcare Services, Inc. 2018R7102I

5 REIMBURSEMENT POLICY State Specific Lists Hawaii Medicaid Non-Covered Codes Iowa Non-Covered Codes Iowa WAIVER Non-Covered Codes Kansas Medicaid Non-Covered Codes Louisiana Medicaid Non-Covered Codes Maryland Medicaid Non-Covered Codes Massachusetts Medicaid Non-Covered Codes Missouri Medicaid Non-Covered Codes Mississippi Non-Covered Codes Nebraska Medicaid Non-Covered Codes New Jersey Medicaid Non-Covered Codes Hawaii Medicaid Iowa (Hawk-I, Medicaid and Wellness) Iowa Waiver Kansas Medicaid Louisiana Medicaid Maryland Medicaid Massachusetts Medicaid Missouri Medicaid Mississippi Medicaid and CHIP Nebraska Medicaid New Jersey Medicaid Proprietary information of. Copyright 2018 UnitedHealthcare Services, Inc. 2018R7102I

6 REIMBURSEMENT POLICY State Specific Lists New York Medicaid Non-Covered Codes Tennessee Medicaid Non-Covered Codes Virginia Medicaid Non-Covered Codes Washington Medicaid Non-Covered Codes Wisconsin Medicaid Non-Covered Codes New York Medicaid Tennessee Medicaid Virginia Medicaid Washington Medicaid Wisconsin Medicaid States With Lists of Covered Codes Arizona Medicaid Covered Codes New Mexico Medicaid Covered Codes Ohio Medicaid Covered Codes Texas Covered Codes List of CPT/HCPCS codes that are covered for Arizona Medicaid List of CPT/HCPCS codes that are covered for New Mexico Medicaid List of CPT/HCPCS codes that are covered for Ohio Medicaid and MME List of CPT/HCPCS codes that are covered for Texas CHIP, STAR Medicaid, STAR KIDS, MMP and STAR PLUS Resources Individual state Medicaid contracts, regulations, manuals & fee schedules American Medical Association, Current Procedural Terminology ( CPT ) Professional Edition and associated publications and services Proprietary information of. Copyright 2018 UnitedHealthcare Services, Inc. 2018R7102I

7 Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets History 4/8/2018 Attachment Section: Covered Codes Lists updated for OH 3/25/2018 Attachment Section: Non Covered Codes List updated for IA (Hawk-I) & MD Covered Codes List updated for AZ (all lists) & TX (CHIP) 3/18/2018 Attachment Section: Non Covered Codes List updated for IA (all lists), LA & MD Covered Codes List updated for OH (Medicaid) 3/11/2018 Attachment Section: Non Covered Codes List updated for VA and WA Covered Codes List updated for AZ (Children Rehab Services) 3/4/2018 Attachment Section: Non Covered Codes List updated for KS, MO, NE and WI Covered Codes List updated for OH (MME), NM and TX (all lists) 2/25/2018 Attachment Section: Non Covered Codes List updated for IA (Brain Injury, Intellectual Disability, Hawk-I, and Medicaid) and WA Covered Codes List updated for AZ, NM and TX (all lists) 2/18/2018 Attachment Section: Non Covered Codes List updated for IA (all lists) Covered Codes List updated for TX (all lists) 2/11/2018 Attachment Section: Non Covered Codes Lists updated for HI, IA (all lists) KS, LA, NE, TN, and WA Covered Codes List updated for AZ, NM, OH (all lists) and TX (all lists) 1/14/2018 Attachment Section: Non Covered Codes Lists updated for IA, MS (Medicaid), NE & WA Covered Codes List updated for AZ & OH 1/1/2018 Annual Version Change Attachment Section: Non Covered Codes Lists updated for, CA, DE, FL, HI, KS (all lists), LA, MD, MO, MS (all lists) NE, NJ, TN, VA, WA and WI Covered Codes List updated for, AZ (all lists) NM, OH (all lists) Texas (all lists) History Section: Entries prior to 1/1/2015 were archived 12/10/2017 Attachment Section: Non Covered Codes Lists updated for VA Covered Codes List updated for Texas (CHIP, Star Medicaid, Star Kids & Star Plus 12/3/2017 Attachment Section: Covered Codes List updated Arizona (All LOB s) for Texas (Star Kids) 11/26/2017 Attachment Section: Non Covered Codes Lists updated for IA (Hawk-I), LA & WA Covered Codes List updated for Texas (Chip & Star) 11/19/2017 Attachment Section: Non Covered Codes Lists updated for MD & WA Covered Codes List updated for Texas (CHIP, Star, Star and Star Plus) Proprietary information of. Copyright 2018 UnitedHealthcare Services, Inc. 2018R7102I

8 11/12/2017 Attachment Section: Non Covered Codes Lists updated for DE, IA, MO, MS, NE & WA Covered Codes List updated for AZ & OH Medicaid & Texas 10/8/2017 Attachment Section: Florida, Iowa & WA 10/1/2017 Attachment Section: Non Covered Codes Lists updated for WA Covered Codes List updated for AZ & OH Medicaid 9/24/2017 Attachment Section: Non Covered Codes Lists updated for IA (Brain Injury, Intellectual Disability, Hawk-I, Medicaid & Wellness) 9/17/2017 Attachment Section: Non Covered Codes Lists updated for CA, KS, and MD 9/10/2017 Attachment Section: Non Covered Codes Lists updated for FL, NE, NY, VA and WI 9/3/2017 Attachment Section: Non Covered Codes Lists updated for HI & MD 8/27/2017 Attachment Section: Non Covered Codes Lists updated for KS, NJ, WA & WI Covered Codes List updated for OH Medicaid & TX 8/20/2017 State Exceptions Section: Added exception for Louisiana Attachment Section: Non Covered Codes Lists updated for DE, FL, KS, LA, NE, NY,WA and WI Covered Codes List updated for AZ, NM and TX 7/31/2017 Attachment Section: Non Covered Codes lists updated for IA (all lists) and NY 7/16/2017 Application Section: Added Medicare products as applying to this policy. Removed location for Medicare reimbursement policies Attachment Section: Non Covered Codes Lists updated for IA (all lists except Hawk-I) & VA Covered Codes List updated for AZ and NM 7/9/2017 Attachment Section: Non Covered Codes lists updated for IA (all Lists) and WA Covered Codes lists updated for TX (Star and Star Plus) 7/2/2017 Attachment Section: Non Covered Codes lists updated for FL, IA, KS, MD, VA, WA & WI Covered Codes lists updated for OH 6/25/2017 Attachment Section: Non Covered Codes lists updated for CA, FL, KS and VA Covered Codes lists updated for OH and TX (Star & Star Plus) 6/18/2017 Attachment Section: Non Covered Codes Lists updated for CA and IA Medicaid. Covered Codes Lists updated for AZ and TX (all lists) 6/4/2017 Attachment Section: Non Covered Codes Lists updated for FL, KS, VA and WI 5/28/2017 Application Section: Added Medicare products as applying to this policy. Removed location for Medicare reimbursement policies Attachment Section: Non Covered Codes Lists updated for IA, MO and WA Covered Codes List updated for Texas (CHIP, Star and Star Plus) 5/20/2017 Application Section: Removed Medicare products as applying to this policy. Added location for Medicare reimbursement policies Attachment Section: Updated language for Michigan. Removed exception regarding FL Proprietary information of. Copyright 2018 UnitedHealthcare Services, Inc. 2018R7102I

9 covered codes list. Non Covered Codes Lists updated for CA, FL (added), IA (Waiver and Wellness) LA, MS (Medicaid), NY, VA (added), WA and WI Covered Codes Lists updated for AZ, OH (all lists), NM, TX (all lists) 4/9/2017 Attachment Section: Non Covered Codes Lists updated for DE, KS, NE, and MO Covered Codes Lists updated for AZ, OH (all lists) and TX (all lists) 4/2/2017 Attachment Section: Non Covered Codes Lists updated for KS, LA, and WA Covered Codes Lists updated for OH (all lists) 3/27/2017 Attachment Section: Covered Codes Lists updated for FL 3/26/2017 Attachment Section: Non Covered Codes Lists updated for IA, MS, NE, NY and WA Covered Codes Lists updated for AZ, FL and OH 3/19/2017 Attachment Section: Non Covered Codes Lists updated for KS, MS (Medicaid) and NE 3/12/2017 Attachment Section: Non Covered Codes Lists updated for MO, NJ and TN Covered Codes Lists updated for AZ, OH (Medicaid) and TX (all lists) 3/5/2017 Attachment Section: Non Covered Codes Lists updated for IA Covered Codes Lists updated for FL, OH and TX (all lists) 2/26/2017 Attachment Section: Non Covered Codes Lists updated for DE, HI, IA, KS and LA Covered Codes Lists updated for AZ, NM, OH and TX (all lists) 2/12/2017 State Exceptions Section: Updated Florida Verbiage Attachment Section: Added Florida and Missouri Lists Non Covered Codes Lists updated for DE, DE LTC, HI, KS, LA, MSCAN, MSCHIP, NE, WA and WI Covered Codes Lists updated for AZ, NM and TX (all lists) 1/23/2017 State Exceptions Section: Removed Nebraska Verbiage Attachment Section: Non Covered Codes Lists updated for MS Medicaid 1/8/2017 Attachment Section: Non Covered Codes Lists updated for LA, IA Medicaid, IA Wellness, NE, WA and WI Covered Codes List updated for AZ, NM, OH (all lists) and TX (all lists) 1/1/2017 Annual Version Change Policy Name: Changed to Professional Non Covered Codes Policy Overview section: Non-Covered language updated Attachment Section: Added Non Covered Codes List for NE Non Covered Codes Lists updated for DE Medicaid, IA and HI Covered Codes List updated for NM History Section: Entries prior to 1/1/2015 archived 12/11/2016 Attachment Section: Non Covered Codes Lists updated for DE Medicaid, DE LTC, IA Hawk-I and WA Covered Codes List updated for AZ, OH Medicaid and OH MME 11/27/2016 Attachment Section: Non Covered Codes Lists updated for LA Covered Codes List updated for TX 11/20/2016 Attachment Section: Non Covered Codes Lists updated for IA (Hawk-I), KS and WI Covered Codes List updated for NM Proprietary information of. Copyright 2018 UnitedHealthcare Services, Inc. 2018R7102I

10 11/13/2016 Attachment Section: Non Covered Codes Lists updated for CA, DE (Medicaid) IA, LA, MA, MD, MS, NJ and WA Covered Codes List updated for NM, OH, TX 10/9/2016 Attachment Section: Non Covered Code List updated for IA Waiver Covered Codes Lists updated for AZ, OH and TX 10/4/2016 Attachment Section: Covered Codes List updated for AZ 10/2/2016 State Exceptions Section: Removed exception for Hawaii Attachment Section: Non Covered Codes Lists updated for HI, IA and WA Covered Codes List updated for AZ and OH 9/25/2016 Attachment Section: Non Covered Codes Lists updated for IA and DE Covered Codes List updated for AZ and OH 9/18/2016 Attachment Section: Non Covered Codes Lists updated for IA, KS, MS and WI 9/11/2016 Attachment Section: Non Covered Codes Lists updated for LA, and MS Covered Codes List updated for OH and TX 9/4/2016 Attachment Section: Covered Code List updated for Texas 8/28/2016 Attachment Section: Non Covered Codes Lists updated for Delaware, Iowa, Kansas and Wisconsin Covered Codes List updated for Arizona 8/21/2016 Policy Section: Removed Medical Policy language Definitions Section: Removed Unproven Services language Attachment Section: Removed Non Covered Codes per Medical Policy List Added the Texas STAR KIDS Covered Codes List Non Covered Codes Lists updated for Iowa, Maryland, Massachusetts, New York, Washington and Wisconsin Covered Codes Lists updated for Arizona and Texas 7/17/2016 Annual Approval Date: Updated State Exceptions Section: Updated BMI language and codes for New Jersey Attachment Section: Non Covered Codes List updated for Washington Covered Codes List updated for Arizona 7/10/2016 Attachment Section: Non Covered Codes Lists updated for CA, DE, IA, LA, MA, MD, MS, NJ, TN, WA, and WI. Covered Codes Lists updated for AZ, NM, OH and TX. 6/26/2016 Attachment Section: Non Covered Codes Lists updated for CA, DE, IA, LA, MA, MD, MS, NJ, TN, WA, and WI. Covered Codes Lists updated for AZ, NM, OH and TX. 6/19/2016 Attachment Section: Non Covered Codes Lists updated for Iowa, Louisiana and Washington Covered Codes Lists added for Nebraska 6/12/2016 Attachment Section: Non Covered Codes Lists updated for IA, Louisiana and Washington Covered Codes Lists updated for Arizona and Ohio MME 6/5/2016 Attachment Section: Non Covered Codes List updated for Iowa (Waiver) Proprietary information of. Copyright 2018 UnitedHealthcare Services, Inc. 2018R7102I

11 5/29/2016 Attachment Section: Non Covered Codes Lists updated for Iowa, Louisiana, Mississippi, New Jersey, Washington and Wisconsin Covered Codes Lists updated for Arizona, Ohio and Texas 4/20/2016 Attachment Section: Non Covered Codes List updated for Louisiana 4/17/2016 Attachment Section: Non Covered Codes List updated for Iowa (Waiver) Covered Codes List updated for Ohio and Texas 4/10/2016 Attachment Section: Non Covered Codes List updated for Iowa (Waiver) Covered Codes List updated for Ohio 4/3/2016 State Exceptions Section: Removed language regarding coverage of code for Pennsylvania. Attachment Section: Non-Covered Codes lists updated for Iowa (Waiver) Iowa (Wellness), Louisiana and Pennsylvania Covered Codes list updated for Arizona. 03/27/2016 State Exceptions Section: Added exceptions for Arizona, Delaware, Kansas, Ohio and Texas Attachment Section: Non-Covered Codes lists updated for California, Kansas, Mississippi and New Jersey Covered Codes lists updated for all Texas plans, and Ohio. 3/21/2016 State Exceptions Section: Added exception for Arizona Medicare Attachment Section: Non Covered Codes list updated for California, Kansas, Mississippi and Texas Medicaid, Texas Star Plus, & Texas MMP Covered Codes lists updated 3/13/2016 State Exceptions Section: Added exception for Pennsylvania Pinnacle Health Providers Attachment Section: Arizona Covered Codes list updated Louisiana Non Covered Codes list updated Ohio Medicaid Covered Codes list updated Ohio MME Covered Code list updated 3/6/2016 Attachment Section: California Non Covered Codes list updated Texas STAR (Medicaid) and CHIP, Texas Star Plus, & Texas MMP Covered Codes Lists Updated 2/28/2016 Attachment Section: Kansas Non Covered Codes list updated Mississippi Medicaid Non-Covered Code list updated Wisconsin Non Covered Codes list updated Texas Medicaid, Texas Star Plus, & Texas MMP Covered Code lists updated 2/14/2016 State Exceptions Section: Remove exception for Massachusetts Attachment Section: Arizona Covered Code list updated Iowa Non Covered Codes list updated Kansas Non Covered Codes list update Louisiana Non Covered Codes list updated Mississippi Medicaid Non-Covered Codes list updated Ohio Medicaid Covered Code list updated Ohio MME Covered Code list updated Washington Non-Covered Code list added 1/10/2016 Attachment Section: Texas Medicaid, Texas MMP and Texas Star Plus Covered Code lists updated Proprietary information of. Copyright 2018 UnitedHealthcare Services, Inc. 2018R7102I

12 1/1/2016 Annual Policy Version Change State Exceptions Section: Removed ICD-9 diagnosis codes for Wisconsin Attachment Section: California Non Covered Codes list updated Louisiana Non Covered Codes list updated History Section: Entries prior to 1/1/2014 archived 5/16/2011 Policy implemented by Back To Top Proprietary information of. Copyright 2018 UnitedHealthcare Services, Inc. 2018R7102I