Here are the latest updates to our payment policies. You’ll need to log in to see the policy updates.
January 3, 2019
Medicare Indicator “Status B” Services Reimbursement (effective 01/04/2019 with dates of service on and after)
The existing policy has been modified to allow code 96040-Medical genetics and genetic counseling services, each 30-minute face to face with patient/family to now be reimbursed for genetic counseling rendered by a trained genetic counselor only (per CPT coding guidelines) effective with dates of service 01/04/2019 and after. As stated in the coding guidelines in the AMA’s CPT Codebook, this code will be payable for trained genetic counselors only. Physicians should continue to bill E&M codes as per CPT coding guidelines for any genetic counseling. All other submissions of this code by providers other than “trained genetic counselors” will continue to be denied as a Medicare Status B code.
Modifier 51 – Multiple Procedures (NEW POLICY – effective 01/01/2019)
This policy was created in response to provider inquiries. The policy identifies the criteria used to determine which procedure codes are subject to “multiple procedure reductions” based on the Center for Medicare and Medicaid Services (CMS) National Physician Fee Schedule. The policy also identifies which codes are “not” subject to multiple procedure reductions in reimbursement.
Drugs Administered in a Physician Office (NEW POLICY – effective 04/14/2019 with process dates on and after)
Effective with process dates of 04/14/2019 and after, a number of claim edits will be applied to drugs that are administered in the Physician office and submitted under a member’s medical benefits. This policy identifies the sourcing that will be used for the edits and supplies a link to the FDA site where providers can search for their drugs and view the approved criteria as published in the drug package insert and approved by the FDA. The specific drugs and criteria that will be implemented by a claim edit will be incorporated into either a Medical or Pharmacy policy.
Consultation Code Services
Effective with dates of service 01/01/2019 and after, Interprofessional Telephone/Internet Consultation codes (99446-99449) are no longer Medicare Status B codes but reimbursable codes. For dates of service prior to 01/01/2019, these codes will continue to be denied as Medicare Status B codes.
Multiple Diagnostic Ophthalmology Services Reduction
Corrected the percentage of the reduction taken on multiple Ophthalmology codes billed on same date of service to reflect the actual percentage being applied in the claims processing pricing application.
Drug Assay Services
Code 0020U was terminated by CPT effective 10/01/2018 and the policy was updated to reflect the code termination.
January 17, 2019
The following policy is effective with dates of service on or after 01/01/2019:
Allergen Immunotherapy (95165) Unit Limits (NEW POLICY)
Code 95165 – Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses) is used to report the preparation of antigen(s) for allergen immunotherapy but doesn’t include the actual administration of the allergen therapy. To be more in line with commercial billing practices, changes have been made to the unit values associated with this code in the Premera Claims Editor.
Effective with dates of service on or after 01/01/2019, the following changes have been made to the unit claims edit on code 95165:
- Maximum daily frequency of 150 units per day/per patient
- Maximum yearly frequency of 250 units per patient
The units reflect the actual number of doses prospectively planned to be administered for a patient’s full course of treatment when the antigen is initially prepared.
Review the details of the Payment Policy by accessing it through your account on One Health Port.