September 3, 2020
Premera will be implementing additional professional and outpatient facility correct coding edits. The following professional and facility edits will be implemented for claims processed on or after October 6, 2020:
Behavioral Health Integration Care Management (Code 99484)
Following coding guidelines in the Current Procedural Terminology (CPT) codebook, the care management code for behavioral health conditions (CPT code 99484) will no longer be allowed or reimbursed when billed in conjunction with psychiatric collaborative care management codes (CPT codes 99492, 99493, 99494) by the same professional in the same calendar month. Code 99484 will be denied reimbursement since the services are considered part of the services provided in code 99492, 99493, and 99494.
Facility codes reported on professional claims
Healthcare Common Procedure Coding System (HCPCS) codes for hospital observation unit hours, multiple levels of emergency room visits, and hospital outpatient clinic visits (codes G0378-G0384 and G0463) can’t be billed on professional claims as they represent a facility-based charge rather than a professional charge. If these codes are billed on a professional claim with other professional services, these codes will be denied.
Correct use of modifier 25 and modifier 57 and surgical procedures
Per National Correct Coding Initiative (NCCI) criteria, to bill for a “distinct” E&M office visit provided on the same date of service as a surgical procedure, a correct modifier (either 25 or 57) must be appended to the E&M office visit code. The selection of the correct modifier is based on the global days indicator for the surgical procedure being performed as listed in the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule.
Modifier 25 is appropriate on an E&M office visit code when provided in conjunction with a minor surgical procedure code which has a global period of 10 days after the surgical procedure.
Modifier 57 is appropriate on an E&M Office visit code when provided in conjunction with a major surgical procedure code which has a global period of 90 days after the surgical procedure.
Global day assignments can be found on the National Physician Fee Schedule on the CMS website viewing the most current version of the fee schedule.
Sequential IV push codes
Following coding guidelines in the CPT codebook, CPT code 96376 - Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility will no longer be allowed when billed on a professional claim. This code represents a facility charge per the code description and shouldn’t be submitted on a professional claim form.
Reason for visit on outpatient facility claims
On an outpatient facility claim, the reason for the visit is required in Field 14-Admission Type when one of the following revenue codes is submitted:
- 045x – emergency room
- 0516 – clinic-urgent care clinic
- 0526 – freestanding clinic-urgent care clinic
- 0762 – specialty services – observation hours
The reason for the visit should be one of the following:
- 1 – emergency
- 2 – urgent
- 3 – elective
If a reason for the visit is not present in Field 14 on the claim form, the claim will be denied. See further details in the Official UB-04 Data Specification Manual available on the National Uniform Billing Committee website.
All of the above edits are sourced to one or more of the following industry coding and billing resources:
- National Uniform Billing Committee (NUBC)
- Official UB-04 Data Specification Manual
- Medicare Claims Processing Manual, Publication 100-04, Chapter 13
- National Correct Coding Initiative Manual, 2020 Edition
- CMS Transmittals
- CPT Codebook and CPT Assistant