Subject: Frequency Editing NY Policy: 0016 Effective: 01/01/2017 02/28/2017 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 [12]
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 90471 or 90473 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. 11720 Debridement of nail(s) by any method(s); 1 to 5 1 per 60 days** frequency limit includes 11720 and 11721 NY 0016 Page 2 of [12]
1 per 60 days** 11721 Debridement of nail(s) by any method(s); 6 or more frequency limit includes 11720 and 11721 36415 Collection of venous blood by venipuncture ** frequency limit includes 36415, 36416 76942 77002 77003 77012 77021 77338 77600, 77605 Collection of capillary blood specimen (eg, finger, heel, ear stick) 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 Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan 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) 36416, and S9529 ** frequency limit includes 36415, 36416, and S9529 NY 0016 Page 3 of [12]
80320 Definitive drug testing: Alcohols 80321, 80322 Definitive drug testing: Alcohol biomarkers 80323 Definitive drug testing: Alkaloids, not otherwise specified 80324, 80325, Definitive drug testing: Amphetamines 80326 80327, 80328 Definitive drug testing: Anabolic steroids 80329, 80330, Definitive drug testing: Analgesics, non-opioid 80331 80332, 80333, 80334 Definitive drug testing: Antidepressents, serotonergic class 80335, 80336, 80337 Definitive drug testing: Antidepressants, tricyclic and other cyclicals 80338 80339, 80340, 80341 80342, 80343, 80344 Definitive drug testing: Antidepressants, not otherwise specified Definitive drug testing: Antiepileptics, not otherwise specified Definitive drug testing: Antipsychotics, not otherwise specified 80345 Definitive drug testing: Barbiturates 80346, 80347 Definitive drug testing: Benzodiazepines 80348 Definitive drug testing: Buprenorphine 80349 Definitive drug testing: Cannabinoids, natural 80350, 80351, 80352 Definitive drug testing: Cannabinoids, synthetic 80353 Definitive drug testing: Cocaine 80354 Definitive drug testing: Fentanyl NY 0016 Page 4 of [12]
80355 Definitive drug testing: Gabapentin, non-blood 80356 Definitive drug testing: Heroin metabolite 80357 Definitive drug testing: Ketamine and norketamine 80358 Definitive drug testing: Methadone 80359 Definitive drug testing: Methylenedioxyamphetamines (MDA, MDEA, MDMA) 80360 Definitive drug testing: Methylphenidate 80361 Definitive drug testing: Opiates 80362, 80363, 80364 Definitive drug testing: Opioids and opiate analogs 80365 Definitive drug testing: Oxycodone 83992 Definitive drug testing: Phencyclidine (PCP) 80366 Definitive drug testing: Pregabalin 80367 Definitive drug testing: Propoxyphene 80368 80369, 80370 Definitive drug testing: Sedative hypnotics (non-benzodiazepines) Definitive drug testing: Skeletal muscle relaxants 80371 Definitive drug testing: Stimulants, synthetic 80372 Definitive drug testing: Tapentadol 80373 Definitive drug testing: Tramadol NY 0016 Page 5 of [12]
Definitive drug testing: Stereoisomer 80374 (enantiomer) analysis, single drug class 80375, 80376, 80377 Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified 81479 Unlisted molecular pathology procedure 86160 Complement; antigen, each component 4 per date of service 88305 Level IV Surgical pathology, gross and microscopic examination needle biopsy prostate 87529 90378 91065 92250 93268, 93270, 93271, 93272 93293, 93294, 93295, 93296 93297, 93298, 93299 93325 94014, 94015, 94016 94774, 94775, 94776, 94777 Infectious agent detection by nucleic acid (DNA or RNA); Herpes simplex virus, 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 Transtelephonic rhythm strip pacemaker evaluation(s) system up to 90 days Implantable cardiovascular monitor system, interrogation device evaluation(s) up to 30 days Doppler echocardiography color flow velocity mapping Patient-initiated spirometric recording per 30 day period of time Pediatric home apnea monitoring 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 4 per date of service 1 per 90 days 2 per date of service 95250, 95251 Continuous glucose monitoring NY 0016 Page 6 of [12]
95165 95800 95801 95806 96116 96150, 96151, 96152, 96153, 96154 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, 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 Health and behavior assessment/intervention; each 15 minutes 130 doses per 1 per 7 days ** frequency limit includes 95800, 95801, 95806, G0398, G0399, and G0400 1 per 7 days ** frequency limit includes 95800, 95801, 95806, G0398, G0399, and G0400 1 per 7 days ** frequency limit includes 95800, 95801, 95806, G0398, G0399, and G0400 5 hours/units per 8 per date of service 96367 Additional sequential infusion, up to 1 hour 6 per date of service NY 0016 Page 7 of [12]
96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic for the administration of drugs such as omalizumab (Xolair ), per drug 96416 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, 97028 99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session 3 per date of service 99363, 99364 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 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 100 5 per 90 days and 24 per NY 0016 Page 8 of [12]
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, 18-30 mm Hg, each 8 per A6531 Gradient compression stocking, below knee, 30-40 mm Hg, each 8 per A6532 Gradient compression stocking, below knee, 40-50 mm Hg, each 8 per A6533 Gradient compression stocking, thigh length, 18-30 mm Hg, each 8 per A6534 Gradient compression stocking, thigh length, 30-40 mm Hg, each 8 per A6535 Gradient compression stocking, thigh length, 40-50 mm Hg, each 8 per A6536 Gradient compression stocking, full-length/chap style, 18-30 mm Hg, each 8 per A6537 Gradient compression stocking, full-length/chap style, 30-40 mm Hg, each 8 per A6538 Gradient compression stocking, full-length/chap style, 40-50 mm Hg, each 8 per A6539 Gradient compression stocking, waist length, 18-30 mm Hg, each 8 per A6540 Gradient compression stocking, waist length, 30-40 mm Hg, each 8 per A6541 Gradient compression stocking, waist length, 40-50 mm Hg, each 8 per A6545 Gradient compression wrap, nonelastic, below knee, 30-50 mm Hg, each 8 per A6549 Gradient compression stocking/sleeve, not otherwise specified 8 per NY 0016 Page 9 of [12]
E0441, E0442, E0443, E0444 Oxygen one month s supply E1812 Dynamic knee, extension/flexion device, include soft 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 days Home sleep study test (HST) with type II 1 per 7 days ** G0398 portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, frequency limit includes 95800, airflow, respiratory effort and oxygen saturation 95801, 95806, G0398, G0399, and G0400 G0399 G0400 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 days ** frequency limit includes 95800, 95801, 95806, G0398, G0399, and G0400 1 per 7 days ** frequency limit includes 95800, 95801, 95806, G0398, G0399, and G0400 G0431 Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter G0434 Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter J0129 Orencia, 10 mg 100 per date of service NY 0016 [12] Page 10 of
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 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 J7321, J7323, J7324, J7326 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 Hyaluronan or derivative for intra-articular injection, per dose 14 per 90 days 50 per date of service 48 per date of service 2 per date of service NY 0016 [12] Page 11 of
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 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 S9529 1 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. 2017 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 [12] Page 12 of