At Dean Health Plan we are committed to processing claims in a consistent and accurate manner. To support this ongoing effort, we will have enhanced our claims processing logic. These updates will improve our claims processing in a number of areas.
While not all of the following concepts are new to Dean, we wanted to take the opportunity to provide a more comprehensive guide to our claims processing logic. Note that not all statements apply to all lines of business (LOB). the last column indicates whether the edit applies to a Commercial, Medicare, Medicaid plan, or to all three.
Maximum Units Policy
Each CPT/HCPCS code has been assigned a maximum number of units that may be billed per day for a member. Where available, DHP has accepted the CMS Medically Unlikely Edit (MUE) value. All other codes have been assigned a maximum-unit-of-service based on the code definition, anatomical site, clinical guidelines and industry standards.
CPT and HCPCS Codes
Current Procedural Terminology, Forth Edition (CPT-4) is updated annually and distributed by the American Medical Association (AMA), for use in reporting physician and other health related services. Health care Common Procedure Coding System (HCPCS) is updated quarterly and is distributed by CMS. Proper CPT and HCPCS coding is essential to the accurate reimbursement of a claim.
ICD-9 CM Volumes 1, 2 & 3
Included in the HIPAA code set for diagnosis reporting is the "ICD-9-CM Official Guidelines for Coding and Reporting". These guidelines are updated and published each October and are available on the CDC website. The following are a few of the key points.
Modifiers are used to add additional specificity to a procedure or service without changing the meaning of the associated CPT or HCPCS code. Special care should be used to ensure that the modifier reported is appropriate for both the code and the clinical scenario.
Evaluation & Management (E/M) Services
Place of Service (POS)
In a 2009 audit, the Office of the Inspector General (OIG) estimated that Medicare carriers overpaid physicians $20.2 million for incorrectly coded services provided during a 2-year period that ended December 31, 2006. For 129 of the 150 services sampled, an office place of service was used for services performed in an outpatient hospital or ASC setting.
A reminder that the POS code reported should reflect the entity where the service was rendered. These codes are another one of the HIPAA code sets and are maintained by CMS. For additional information please visit their website.
National Correct Coding Initiative (NCCI)
Dean Health Plan will be using the CMS’ NCCI and its associated manual in its claims processing. According to CMS, these policies are based on a number of sources including; AMA coding conventions as defined in the CPT manual, national and local CMS policies, coding guidelines developed by national societies, analysis of standard medical and surgical practices and a review of current coding practices. NCCI tables and their associated manuals are available on the CMS website.
Reimbursement by Status Indicator
The work associated with some services and procedures is inherent to other more global procedures. Certain status indicators are available in the PFS Relative Value File to assist in identifying those codes. Commonly known as the Medicare Physician Fee Schedule Database (MPFSDB), this file is available on the CMS website.
Multiple Procedure Reduction
Multiple procedures performed by the same provider during the same session are subject to multiple procedure reduction rules. Dean Health Plan assigns the primary procedure based on the relative value unit (RVU) assigned to the code for that place of service. Secondary procedures are reimbursed at a reduced rate. All procedures should be reported at full fee to ensure appropriate reimbursement.
The PFS Relative Value File assigns RVUs to most codes. Commonly known as the Medicare Physician Fee Schedule Database (MPFSDB), this file is available on the CMS website.
Global Surgical Package / Global Period
Dean Health Plan has adopted the CMS definition and processing logic for the global surgical package.
Global Surgical Package: Included in the global surgical package are: pre-and post-operative visits, intra-operative services, complication following surgery, supplies and miscellaneous services such as dressing changes, suture removal etc. Additional information on the global surgical package may be found in Chapter 12 of the Medicare Claims Processing Manual.
Global Period: Integral to the global surgical package is the global-period concept. The global period begins one-day prior to a procedure and extends to either 0-, 10- or 90-days after. Post-operative services during this time frame are considered incidental to the corresponding procedure. For major procedures, the global period is 90 days. Minor surgeries and endoscopies are assigned either 0- or 10-day global periods.
PFS Relative Value File assigns global periods to most codes. Commonly known as the Medicare Physician Fee Schedule Database (MPFSDB), this file is available on the CMS website.
Split Surgical Care
When different physicians perform the pre-, intra- and post-operative portion of a 90-day procedure, each will be reimbursed a percentage of the global fee. The percentages allocated for each vary by procedure and are posted in the CMS PFS Relative Value File.
Modifiers should be used to indicate which portion each physician provided. All procedures should be reported at full fee to ensure appropriate reimbursement.
Modifier -54: "Surgical Care Only". The physician who performs the surgery only should append modifier 54 to the appropriate surgical procedure code.
Modifier -55: "Post-operative Management Only". The physician who performs the post-operative care only should append modifier 55 to the appropriate surgical procedure code.
Modifier - 56: "Pre-operative Management Only". The physician who performs the pre-operative care only should append modifier 56 to the appropriate surgical procedure code.
Global Obstetrical Package
According to CPT, "The services normally provided in uncomplicated maternity cases include antepartum care, delivery, and postpartum care".
Antepartum Care includes: The initial and subsequent history, physical examinations, recording of weight, blood pressures, fetal heart tones, routine chemical urinalysis, visits (approximately 13).
Delivery Services includes: The admission to the hospital, the admission history and physical examination, management of uncomplicated labor, cesarean delivery or vaginal delivery (with or without episiotomy, forceps).
Postpartum Care includes: Hospital and office visits following delivery.
A bilateral procedure is defined as one that is performed on both sides of the body at the same session or on the same date of service.
Dean Health Plan requires that bilateral procedures be reported on a single line. When a procedure is performed bilaterally and the bilateral indicator is "1" or "3", modifier 50 should be appended to the procedure code and submitted on a single line. One (1) unit of service should be reported.
Bilateral indicators assigned to each code determine reimbursement and are available in the PFS Relative Value File. Commonly known as the Medicare Physician Fee Schedule Database (MPFSDB), this file is available on the CMS website.
An assistant-at-surgery provides an additional pair of hands for the operating surgeon. They differ from co-surgeons in that they do not have primary responsibility for, nor do they perform, distinct parts of the surgical procedure.
Modifiers should be used to indicate the type of assistant at surgery. All procedures should be reported at full fee to ensure appropriate reimbursement.
Modifier -80: "Assistant Surgeon". One physician assists another in performing the entire procedure.
Modifier -81: "Minimum Assistant Surgeon". One physician assists another in performing a portion of the procedure.
Modifier -82: "Assistant Surgeon (when qualified resident surgeon not available)". Typically used by teaching hospitals.
Modifier -AS: "Physician assistant, nurse practitioner; or clinical nurse specialist services for assistant at surgery." Surgeon is assisted by a non-physician provider, PA, NP or CNS.
Assistant Surgeon indicators assigned to each code determine reimbursement and are available in the PFS Relative Value File. Commonly known as the Medicare Physician Fee Schedule Database (MPFSDB), this file is available on the CMS website.
Under some circumstances, the individual skills of two surgeons are required to perform surgery on the same patient during the same operative sessions. This may be required due to the complex nature of the procedure(s) and/or the patient's condition. In these cases, the additional physicians are not acting as assistants-at-surgery.
Each surgeon should dictate separate operative reports and bill under the same code with modifier -62, “Two Surgeons”. Additional procedures (including add-on procedures) may be reported with modifier -62 as long as the surgeons continue to work together. Bilateral and multiple procedure reduction rules apply along with any appropriate bundling edits. All procedures should be reported at full fee to ensure appropriate reimbursement.
Co-Surgeon indicators assigned to each code determine eligibility and are available in the PFS Relative Value File. Commonly known as the Medicare Physician Fee Schedule Database (MPFSDB), this file is available on the CMS website.
Highly complex surgeries are carried out under the "surgical team" concept. These procedures require the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel and various types of complex equipment.
Each surgeon reports their participation in a team surgery once using the same code and modifier -66, "Surgical Team". Bilateral and multiple procedure reduction rules apply along with any appropriate bundling edits. Team surgeons are rare. When one surgeon assists another, modifiers -80, -81 or -82 may be more appropriate. All procedures should be reported at full fee to ensure appropriate reimbursement.
Team-Surgeon Indicators assigned to each code determine eligibility and are available in the PFS Relative Value File (MPFSDB). This file is available on the CMS website.
Multiple Endoscopy Policy
CMS has established special rules for the payment of multiple endoscopic procedures performed on the same date of service based on related or unrelated families. A related endoscopic procedure, for example would be two different upper gastrointestinal endoscopies performed on the same date. An unrelated would be an upper and lower gastrointestinal endoscopy. For each family there is a base endoscopy procedure which is considered to be a component of all other endoscopies within that family. Reimbursement for multiple endoscopic procedures is calculated by deducting the cost of the base endoscopy from the related endoscopy.
Multiple Endoscopy indicators assigned to codes determine reimbursement and are available int he PFS Relative Value File (MPFSDB). This file is available on the CMS website.
Professional, Technical and Global Services Policy
Certain procedures are comprised of a professional (physician) component and a technical (facility) component. The combination of the professional and technical component is considered the global service.
Modifier -26: "Professional Component". Modifier -26 is appended to the procedure when only the professional component is performed.
Modifier -TC: "Technical Component". Modifier -TC is appended to the procedure when only the facility component is performed.
To report the global service, the procedure code should be billed without a modifier. It would not be appropriate to report:
1. The procedure code with both -26 and -TC on the same line (xxxx-26, TC); or
2. The procedure code on two lines with either the -26 or -TC (xxxxx-26 & xxxxx-TC).
PC/TC indicators assigned to each code determine reimbursement and are available int he PFS Relative Value File (MPFSDB). This file is available on the CMS website.
Services involving the administration of anesthesia should be reported using the five-digit anesthesia code (00100-01999).
Anesthesiologist - Anesthesia modifiers are required to denote whether the anesthesiologist's service was personally performed, medically directed, medically supervised ore represented monitored anesthesia care.
• -AA: "Anesthesia services performed personally by an anesthesiologist."
• -AD: "Medical supervision by a physician: more than 4 concurrent anesthesia procedures."
• -QK: "Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals."
• -QY: "Medical direction of one CRNA by an anesthesiologist."
CRNA - CRNA's must report the appropriate anesthesia modifier to indicate whether the service was performed with or without physician supervision.
• -QX: "CRNA Service: with medical direction by a physician."
• -QZ: "CRNA Service: without medical direction by a physician."
Monitored Anesthesia Modifiers
• -G8 (Monitored anesthesia care for deep, complex, complicated, or markedly invasive surgical procedure)
• -G9 (Monitored anesthesia care for patient who has history of severe cardio-pulmonary condition)
• -QS (Monitored anesthesia care service)
All procedures should be reported at full fee to ensure appropriate reimbursement.
CMS National Coverage Determination (NCD) Policies for Laboratory Testing
Dean Health Plan has adopted NCD policies for a number of laboratory tests. For the most up-to-date listing of diagnosis-to-procedure requirements, please see the CMS website.
Drugs and Biologicals