Coding and Billing Guidelines

Procedure coding used for the submission of a healthcare services claim consists of two industry standard coding systems:

• CPT codes: The American Medical Association (AMA) updates and publishes the Current Procedural Terminology annually. The CPT lists descriptive terms and identifying codes for reporting medical services and procedures performed by physicians. CPT Codes provide a uniform language that accurately designates medical, surgical, and diagnostic services-enabling reliable nationwide communication among physicians, patients, and third parties. You can order a CPT book by calling the AMA Service Center at 800-621-8335.
• HCPCS codes: The Centers for Medicare and Medicaid Services (CMS) maintains the Healthcare Common Procedure Coding System. HCPCS codes begin with a single letter (A through V) followed by four numbers. The codes are grouped by the type of service or supply they represent.

When a CPT and a HCPCS code have very similar descriptions for a procedure or service, use the CPT code. If the code descriptions are not identical, select the code with the more specific description that reflects the service rendered.

Select diagnosis coding from the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM).

• The diagnosis code should be coded to the highest level of specificity/digits to accurately represent the medical condition.
• The laterality identified in the diagnosis code must not conflict with the laterality identified by the modifiers appended to the submitted procedure codes, and
• Age banded diagnosis codes should be reflective of the age of the patient at the time the service was rendered.

We abide by federal and state regulations concerning fraud, as well as our contract obligations to members and providers. To support this commitment, we have a Special Investigations Unit to prevent fraud and abuse. If you suspect fraud, call the Anti-Fraud Hotline at 800-848-0244.

We apply the following claims coding guidelines:

• We use Health Information Portability and Accountability Act (HIPAA) as the benchmark for accepting standard codes.
• We accept one primary diagnosis code per line item (CMS-1500 form: box #21).
• Each line item can have a different primary diagnosis code as long as that diagnosis is included in box #21 of the CMS-1500 form. The individual claim lines should be tagged with a specific diagnosis code, included in box #21 on the claim form.
• We recognize standard modifiers.

Because we cannot provide coding advice, we recommend that you maintain current copies of coding reference books or current versions of coding software in your office.

We only reimburse current effective procedure codes in the CPT book published by the AMA and HCPCS Codes as maintained by CMS that are effective at the time of service in the year the service was rendered.

If you submit a claim with a deleted code, it will be processed as a denial and the line item will indicate the corresponding denial code. Then you will need to correct the claim to reflect the appropriate code effective for the date of service on the claim and resubmit the claim as described in “Rebilling” below. Denied claims will be considered a physician or provider write-off until the corrected claim is processed.

We use the following definitions established by the AMA and found in the current CPT codebook:

• New patient: A person who has not received any professional service from a physician or other qualified healthcare practitioner or another physician of the same specialty in the same group practice within the past three years.
• Established patient: A person who received professional services from the physician or other qualified healthcare practitioner or another physician of the same specialty in the same group practice within the past three years.

We adopted a policy addressing the use of new and established patient evaluation and management codes. We rely on the physician or other qualified healthcare practitioner to use the code that most accurately reflects the service rendered. We may perform random audits to ensure services are billed appropriately per provider's documentation. As part of the audit process, we may request medical records supporting use of these codes.

After-hours services (codes 99050 through 99060) are provided in the physician or provider’s office outside posted office hours, on Sundays, or on holidays. We don’t reimburse these codes unless provider contract terms specifically include and allow reimbursement. These codes are Medicare Status B codes and are included in the allowance of another service(s).

We use American Society of Anesthesiologists (ASA) codes (codes 00100-01999) to establish anesthesia base units. Use only ASA codes when billing anesthesia. Please note the following:

• Anesthesia Modifiers: We require that the appropriate anesthesia modifier (modifiers AA, AD, QK, QX, QY, or QZ) be added to all anesthesia codes to identify the level of the provider rendering the service (e.g. Certified Registered Nurse Anesthetist, Resident Physician, supervising or directing Physician Anesthesiologist). Anesthesia codes submitted without an anesthesia modifier will be denied reimbursement.
• Physical status modifiers: Additional time units are added for physical status modifiers P1-P6, based on the guidelines published annually in the ASA Relative Value Guide.
• ASA codes 99100-99140 (Qualifying Circumstance codes): These codes are Medicare Status B services and are not eligible for reimbursement.
• ASA add-on codes: These codes are reimbursed based on guidelines published annually in the Relative Value Guide from the ASA and must be billed in conjunction with an appropriate base/primary anesthesia code.
• Obstetrical anesthesia: We allow standard base units for obstetrical delivery of epidural anesthesia (code 01967).
• Labor management anesthesia: We allow three time units for labor management for the initial hour and two time units for each additional hour.
• Conversion of time to units: Anesthesia units are calculated based on a four-unit hour. We convert reported anesthesia time to units by dividing the total anesthesia minutes reported by 15 and standard rounding to the nearest hundredth decimal point (example: 4.33).
• Nerve blocks: We reimburse nerve blocks based on Relative Value Units only. Anesthesia time is not required for nerve blocks.
• Moderate Sedation: Moderate sedation provided by a physician or other qualified healthcare professional that is also performing the surgical procedure would be billed using codes 99151, 99152, and 99153. Use codes 99155, 99156, and 99157 to bill for moderate sedation provided by a physician or other qualified healthcare professional who's not performing the surgical procedure.

We limit reimbursement of blood draws (36415) to one per provider, per patient, per day regardless of the number of specimens drawn. We’ll deny CPT code 36416 as a Medicare Status B code.

Lab Panel Codes and Proprietary Lab Panels

• Lab panel codes and proprietary lab panels pertain to CPT codes 80047-80081 and the codes defined in appendix O-Multianalyte assays with algorithmic analyses and proprietary analyses code in the CPT codebook 
• All tests listed in the organ or disease-oriented panel code must be performed if the lab panel code is to be billed
• Each lab panel code must be submitted on a single claim with a single unit.
• ALL other lab tests rendered to the same member on the same date of service by the same lab must also be billed on the SAME claim form in order to be reimbursed.  Failure to bill all of the lab services on the same claim may result in a denial of reimbursement.
• Proprietary lab panels also rendered to the same patient by the same lab on the same date of service must ALSO be billed on the same claim in order to be reimbursed.

Surgical pathology (88300-88309)

• Surgical pathology codes include accession, examination and reporting
• The unit of service for these codes is the specimen, the tissue(s) that are submitted
• When duplicate specimens are reported with the same surgical pathology code, report the second and subsequent codes with one of the following modifiers:
  • XS – Separate structure
  • XU – Unusual non-overlapping service
  • 91 – Repeat clinical diagnostic lab test

Professional and technical components:

Review the current National Physician Fee Schedule maintained by CMS to identify those laboratory/pathology codes that have a professional and/or technical components as defined by the “PC/TC” indicator flag in the Fee Schedule

All hospital outpatient facility services billed with revenue codes 0760 – 0769 (outpatient treatment/observation room) are processed subject to the hospital outpatient facility medical benefit cost shares. You must bill hospital outpatient facility surgical services with revenue codes 0360, 0361, 0369, 0490-0499, or 0750 and the appropriate surgical CPT procedure code in order to be subject to the hospital outpatient facility surgical benefit cost shares.

Outpatient facility diagnostic services will apply to the diagnostic services benefit when not impacted by a pricing mechanism that packages or bundles based on a procedure.

All other outpatient facility service (except diagnostic) will apply toward the applicable services benefit (i.e. surgical services, rehab, ER, etc.), when not impacted by a pricing mechanism that packages or bundles based on a procedure.

A locum tenens physician does not need to be credentialed because he/she is considered a temporary provider; however, if a locum tenens physician provides services for more than 90 days, he/she must be credentialed. A locum tenens physician bills under the name of the absent, contracted physician appending modifier Q6 to all services rendered.

We'll reimburse one global obstetric birthing procedure (routine prenatal obstetric care, delivery, and postpartum care) for the first birth, whether vaginal or cesarean delivery and one delivery-only procedure for the second and subsequent births, whether vaginal or cesarean delivery. Note that the level of reimbursement is subject to our payment policy on multiple procedures.

Bill the delivery of each baby on a separate line on the claim. Each subsequent birth after the initial birth should be billed with modifier 59-Distinct Procedural Service in order to prevent an edit indicating a duplicate service.

Include an additional diagnosis code to indicate the outcome of the delivery was for multiple births for the second and subsequent births after the initial birth.

Chiropractic and osteopathic manipulation are a form of manual treatments applied to eliminate or alleviate somatic dysfunction and related disorders. Please note the following:

• Chiropractic manipulations:
  • We limit chiropractic manipulative treatment to one spinal code to one or more regions and one extra-spinal code, per provider, per patient, per day.
  • A new patient Evaluation and Management (E&M) code will be reimbursed consistent with the new/established patient guidelines.  All E&M services billed on the same day as a chiropractic manipulation will be reimbursed when billed consistent with Modifier 25 payment policy if the E&M service represents a service above and beyond the usual preservice/post service work associated with the chiropractic service.  Documentation must support the use of modifier 25.
• Osteopathic Manipulations:
  • We limit osteopathic manipulative therapy to one manipulation code, per provider, per patient, per day.
  • A new patient Evaluation and Management (E&M) code will be reimbursed consistent with the new/established patient guidelines.  All E&M services billed on the same day as an osteopathic manipulation will be reimbursed when billed consistent with Modifier 25 payment policy if the E&M service represents a service above and beyond the usual preservice/post service work associated with the osteopathic service.  Documentation must support the use of modifier 25.

Evaluation and management services provided the date before or on the date of a major surgical procedure will be considered part of the global surgery reimbursement and are not eligible for separate reimbursement. If the visit resulted in the initial decision to perform surgery separate reimbursement will be allowed for the evaluation and management service when appended with Modifier 57.

For significant, separately identifiable and documented E/M services billed on the same day as a surgical procedure, use modifier 25 on the evaluation and management service to indicate the service was a distinct and unrelated procedural service from the surgical procedure. Documentation in the member’s medical record must support that the evaluation and management services was truly distinct, unrelated, and separate from the surgical procedure performed.

Screening PAP smear:

• A screening PAP smear is allowed when billed alone
• A screening PAP smear is not allowed when billed by the same provider on the same date of service as a preventive medicine exam or with an annual gynecological exam code
• A separately identifiable new or established patient problem focused E&M office visit billed by the same provider on the same date of service as a screening PAP smear procedure will be allowed with modifier 25.  Separate supporting documentation in the member’s record must indicate the need for a separate unrelated problem focused office visit

Cervical/vaginal cancer screening, pelvic and clinical breast exams:

• A cervical or vaginal cancer screening; pelvic and clinical breast exam is allowed when billed alone
• A cervical or vaginal cancer screening; pelvic and clinical breast exam is not allowed when billed by the same provider on the same date of service as a preventive medicine exam or with an annual gynecological exam code
• A separately identifiable new or established patient problem focused E&M office visit billed by the same provider on the same date of service as a cervical or vaginal cancer screening; pelvic and clinical breast exam procedure will be allowed with modifier 25.  Separate supporting documentation in the member’s record must indicate the need for a separate unrelated problem focused office visit

Prostate cancer screening with digital rectal exam:

• A prostate cancer screening with digital rectal exam is allowed when billed alone
• A prostate cancer screening with digital rectal exam is not allowed when billed by the same provider on the same date of service as a preventive medicine exam or with an annual gynecological exam code
• A separately identifiable new or established patient problem focused E&M office visit billed by the same provider on the same date of service as a prostate cancer screening with digital rectal exam procedure will be allowed with modifier 25.  Separate supporting documentation in the member’s record must indicate the need for a separate unrelated problem focused office visit

We have payment policies that define how to use Modifiers -80, -81, -82 and -AS to indicate when surgical assistance is provided to a primary surgeon. Bill all surgical assistance services under the name of the performing provider or the person who assisted the primary surgeon. Bill the charges for the primary surgeon and the assisting surgeon on separate claims

Modifier -80, Assistant Surgeon. This modifier indicates that the assisting surgeon is actively assisting a primary surgeon. Add Modifier -80 to the surgical procedure to identify surgical assistant services when appropriate. Only one physician may assist another physician in performing a procedure. If an assistant surgeon assists a primary surgeon and is present for the entire operation, then the assisting physician reports the same surgical procedure as the primary surgeon with Modifier -80 appended. Modifier 80 and modifier AS can't be billed on the same claim by the same provider.

Modifier -81, Minimum Assistant Surgeon. This modifier is used when the surgical assistant does not participate in the entire surgical procedure. Add Modifier -81 to the surgical procedure to identify minimum surgical assistant services when appropriate. There are times when a primary operating physician may plan to perform a surgical procedure alone, but during the operation, circumstances may require surgical assistance for a relatively short time. In this instance, the second surgeon provides minimal assistance, for which he/she reports the same surgical procedure as the operating surgeon with Modifier -81 appended. Modifier 81 and modifier AS can't be billed on the same claim by the same provider.

Modifier -82, Assistant Surgeon (when qualified resident surgeon is not available). The prerequisite for adding Modifier -82 to the surgical procedure is the unavailability of a qualified resident surgeon. In certain programs (e.g., teaching hospital), the physician acting as the assistant surgeon is usually a qualified resident surgeon. However, there may be times (e.g., during rotation change) when a qualified resident surgeon is not available and another surgeon assists in the operation. In this instance, the services of the nonresident-assistant surgeon should be reported with Modifier -82 appended to the appropriate code to show that another surgeon assisted the operating surgeon instead of a qualified resident surgeon. Modifier 82 and modifier AS can't be billed on the same claim by the same provider.

Modifier -AS. Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery. This modifier is used when a “non-physician” provider assists the primary surgeon. Use this modifier when a physician assistant, nurse practitioner, or clinical nurse specialist provides surgical assistance. Add the HCPCS modifier -AS to the same surgical procedure code as the primary surgeon. Modifier AS and modifiers 80, 81, or 82 can't be billed on the same claim by the same provider.

Telehealth services are described as medical information exchanged from one site to another via electronic modes of communication between a practitioner and patient in a manner other than an in office face-to-face encounter. Such services can be delivered via:

Audio and Video Real-Time Interactive or Synchronous Technology

• Includes systems that transmit interactive audio and video information and permit two-way, real-time communication instantly or with very little or no noticeable delay.
• The patient must be present and participating in the telehealth visit (Example: a videoconference).

Audio only/Telephone Assessment and Management

• Non-face to face E/M provided to a patient using a telephone by a physician or other non-physician healthcare professional who may report E/M services.
• The encounter is the equivalent of a low-level office visit.
• Such encounters are not used for renewing prescriptions or triaging a patient in order to set up an office visit within 24 hours.

Online/Internet Communications

• Non-face to face electronic digital online encounters by a physician or other qualified healthcare professional in a non-clinical setting.
• Such encounters include all of the provider's accumulated personal time wit the patient over a seven day period of time.

An Originating Site is where the patient is physically located during a telehealth encounter, whether being physically hosted in a Clinic while interacting with a Distant Site provider or by themselves in their home or private residence.  We recognize HCPCS Code Q3014-Telehealth originating site facility fee (without any modifier) as the code designated to indicate the originating facility fee. This code cannot be billed by the “distant site” provider

We recognize the following appropriate modifiers appended to a telehealth service:

Audio/video services only

• 95-Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system
• GT-Via interactive audio and video telecommunication systems to be used to indicate the services were provided using a telecommunications system
• FR-Supervising practitioner present through two-way audio/video communication technology

Audio only services

• 93-Synchronous telemedicine services rendered via telephone or other real-time interactive audio-only telecommunications system
• FQ - Service furnished using audio-only communication technology

Store and forward services

• GQ-Via asynchronous telecommunications system

Inpatient services

• G0-Telehealth services for diagnosis, evaluation, or treatment of symptoms of an acute stroke.

To identify where the patient receiving telehealth services is physically located, one of the following Place of Service (POS) codes is required:

• 02 – Telehealth Provided Other than in Patient’s Home The location where health services and health related services are provided or received, through telecommunication technology. Patient is not located in their home when receiving health services or health related services through telecommunication technology
• 10 – Telehealth Provided in Patient’s Home  The location where health services and health related services are provided or received through telecommunication technology. Patient is in their home (which is a location other than a hospital or other facility where the patient received care in a private residence) when receiving health services or health related services through telecommunication technology

We require documentation to be permanently stored in the member's record to support any encounter conducted as an audio/video office visit, an audio only telephone assessment or an online/internet communication/text, and that it be made available for review in the event of an audit. Documentation in the members record should include the following: 

• Location of the patient, location and name of the distant site provider, telehealth modality used, names of persons present with the patient (when hosting a patient at an originating site)
• Summary of information discussed with patient, plan of care/treatment, prescriptions/lab tests ordered, referrals made and to whom
• Time spent with patient/duration of telehealth encounter
• Any store and forward communications/files/documents from the patient, with a consultant/specialist brought in to review records or received directly from a patient;
• A summary of any interprofessional telephone/internet/electronic health record discussions on a patient’s care and the results of the discussion
• Patient’s consent, when applicable, to be seen via a virtual visit or to consult with another specialist without the patient being present during the encounter
• Text messages or emails sent to and received from a patient permanently stored and retrievable
• Any interaction with a patient utilizing a HIPAA approved telecommunications system and the results of the interaction

We do not reimburse for professional services or supplies that are usually provided free because of the relationship to the patient.

As a reminder, physicians, providers or suppliers who are our members are not reimbursed by us for professional services for any of the following when services are

• Performed on themselves
• Rendered to family members residing in the home
• Provided to the following immediate relatives: spouse, natural or adoptive parent, child, sibling, stepparent, stepchild, stepsibling, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, grandparent, grandchild, spouse of grandparent, or spouse of a grandchild

An ARNP or nurse practitioner provides services to members via one of the following methods:

• Clinic practice: Bills under the name of a contracted, supervising physician-credentialing not required (a clinic can be one or more physicians)
• Solo ARNP: Bills under his/her own name (credentialing required)
• Surgical assistant ARNP: Bills under his/her own name (must complete a Data Request form prior to performing services)

A Physician Assistant provides services to members via one of the following methods:

• Clinic practice: bills under the name of a contracted, supervising physician-credentialing not applicable to Pas (a clinic can be one or more physicians)
• Surgical assistant Physician Assistant: bills under his/her own name (must complete a Data Request form prior to performing services is required).

Some procedures in the CPT codebook are performed in addition to a primary service code. These services are notated as an add-on code by the symbol “ + “ in the CPT codebook and are listed in Appendix D of the CPT Codebook. Add-on codes are always performed in conjunction with a primary code/procedure. Instructions identifying the correct primary code are listed after the add-on code in the CPT codebook.

If an add-on code is billed without an appropriate primary code or billed by itself without a primary code, the add-on code will be denied reimbursement.   In addition, if the appropriate primary code is denied reimbursement, the add-on code will also be denied reimbursement.

Add-on codes are exempt from multiple procedure reductions so modifier 51-Multiple Procedures should not be appended to these codes.  No modifiers appended to an add-on code will bypass a denial of an add-on code.

Healthcare professionals may render procedures and services for which there is no specific CPT or HCPCS code available. Providers may use unlisted codes, unspecified codes, or miscellaneous codes, which usually end in XXX99. These codes don’t have specific language that describes the service. These codes should only be used as a last resort if there is not a more specific CPT or HCPCS code available.

If an unlisted code is submitted, we require that you submit supporting detailed documentation with claims to describe the service(s) rendered, identifying what was performed as part of the service. Critical documentation should include:

• A clear description of the service performed
• Identification as to whether the service performed was independent form other services performed at the same time or performed at the same surgical site or through the same surgical opening
• Any extenuating circumstances which may have complicated the service or procedure
• Time, effort and equipment necessary to provide the service, and
• Number of times this service has been performed

Failure to provide such detailed information will result in a delay or denial of the claim being processed.

All unlisted, non-specific, and miscellaneous CPT and HCPCS codes submitted on a claim, along with the supporting documentation described above, will be subject to clinical review at claims submission. Premera does not review unlisted, non-specific or miscellaneous CPT and HCPCS codes prior to service delivery; this subset of codes is not subject to prior authorization. During the review of each submitted unlisted, non-specific, or miscellaneous code, Premera will determine how that code will be priced (e.g. such as but not limited to basing on a comparable code, a comparable code with modifier 22 added, or on a percentage of charge) as part of the processing of the entire claim.

In the National Physician Fee Schedule (NPFS), as maintained by CMS, procedure codes that are identified with a Status Indicator code of B are not eligible for reimbursement, whether billed alone or with another service, and will be denied. To obtain a complete list of Status B codes, visit the CMS website and select the most current NPFS release.

We restrict the use of these prolonged service codes in maternity care. We don’t provide reimbursement separately when prolonged service codes are billed to indicate the management of labor, which is considered a component of the delivery care.

Prolonged services for both outpatient and inpatient care billed for labor management include the following codes:

• +99415 – Prolonged clinical staff services (the service beyond the highest time in the range of total time of the service) during and evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (list separately in addition to code for outpatient E&M services)
• +99416 - Prolonged clinical staff services (the service beyond the highest time in the range of total time of the service) during and evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; each additional 30 minutes (list separately in addition to code for outpatient E&M services)
• +99417 - Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205 or 99215 for office or other outpatient E&M services)
• +99354 – Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour. (List separately in addition to code for office or other outpatient Evaluation and Management service.)
• +99355 – each additional 30 minutes. (List separately in addition to code for prolonged service.)
• +99356 – Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour. (List separately in addition to code for inpatient Evaluation and Management service.)
• +99357 – each additional 30 minutes. (List separately in addition to code for prolonged service.)
• +G2212 - Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services) (Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes)
  “+” denotes an add-on code

Global surgery or global surgical package is a period that starts either with the day of or the day before the surgical procedure. It ends some timeframe after the surgical procedure based on whether the procedure is classified as minor or major surgery.

We use the global surgery indicator flag as established in the current version of the National Physician Fee Schedule (NPFS), maintained by CMS, to determine whether a procedure code does/doesn’t have a specified global surgery period (e.g., simple/minor procedures, minor surgical procedures, major surgical procedures, maternity codes, global periods do not apply, carrier/plan determined or add-on codes).

Services considered “included” in the global surgical package include but are not limited to such items as related preoperative visits, intraoperative services, follow up E&M related visits, supplies for postoperative complications/treatments and miscellaneous medical/surgical supplies.

Robotic surgery and computer-assisted navigation services are add-on techniques used to perform the main surgical procedure. As such, when these add-on codes are billed , the robotic surgical system code, the computer-assisted navigation codes and their related supplies and equipment will be considered bundled/included as part of the primary surgical procedure. They aren’t separately reimbursable, whether billed separately or in conjunction with a primary procedure.

Robotic surgical system services and computer-assisted navigation for musculoskeletal surgical services are billed using the following HCPCS or CPT codes:

• +S2900 – Surgical techniques requiring use of robotic surgical system. (List separately in addition to code for primary procedure.)
• +20985 – Computer assisted surgical navigational procedure for musculoskeletal procedures, image-less. (List separately in addition to code for primary procedure.)
• +0054T – Computer assisted musculoskeletal surgical navigational orthopedic procedure, with image guidance based on fluoroscopic images. (List separately in addition to code for primary procedure.)
• +0055T – Computer assisted musculoskeletal surgical navigational orthopedic procedure, with image guidance based on CT/MRI images. (List separately in addition to code for primary procedure.)
  “+”denotes an add-on code which must be billed with an appropriate primary procedure

When administering drugs from a single use vial or package only, any leftover portion of the drug that wasn't administered to a patient can be submitted for reimbursement. Include both the administered portion of the drug as well as the discarded or wasted portion of the single use drug vial or package.

Submit two lines with the same HCPCS or CPT code and the same NDC number, one line with the modifier JW to represent the non-administered/wasted portion and the other line without the modifier to represent the administered portion. Units on each line should represent the portions administered and the portion non-administered or wasted.

Modifiers are required on any piece of DME that is rental only, purchase only or rental to purchase/outright purchase. Add one of the following modifiers to reflect whether the equipment is either a purchase, a replacement, or a rented piece of equipment:

• Purchase modifiers
  • NU - new equipment
  • NR - new when rented. (Use when DME that was new when first rented is later purchased. Bill the purchase price of the equipment.)
  • RA - replacement of a DME, orthotic or prosthetic item
  • UE - used DME
• Rental modifiers
  • RR - rental
  • LL - Lease/rental
  • KR - rental item for a partial month. (Use to indicate daily rentals.)

Units of service must also match the type of DME rental to be correctly reimbursed:

• Monthly rentals
  • One month of rental equals one unit when modifier RR is added.
  • Each month should be billed on a single claim line (i.e. 1 service month rather than 30 units of service).
• Daily rentals
  • One day of rental equals one unit when modifier KR is appended.
  • “From” and “Through” dates of service must match the number of units billed.
  • Future dates of service will not be accepted; submit claims after the end of the rental period.

All related diagnostic and non-diagnostic services (preadmission testing) provided by an admitting hospital on the date of an inpatient admission or within 3 calendar days preceding the date of an inpatient admission including the 72-hour period that immediately precedes the time of admission are considered to be part of/incidental to the inpatient admission hospital claim. These services aren't separately billable or reimbursable. Related services rendered within the 3-calendar day window must be billed on the same claim as the inpatient admission.

Any services rendered within the 3-calendar day window or immediate 72-hour period prior to the admission that are not related to a planned inpatient admission must be identified on the UB-04 claim form as being unrelated by using Condition Code 51-Attestation of Unrelated Outpatient Non-diagnostic Services in Field Locator 18-28.

Any services rendered on the date of an unplanned inpatient admission as part of an emergency room visit that led to the unplanned inpatient admission should be included on the inpatient admission claim. Such an unplanned emergency inpatient admission should be identified using Admission Type Code 1-Emergency in Field Locator 14 of the UB-04 claim form.

Emergency room visits that occur within 3-calendar days or the immediate 72 hours prior to an inpatient admission that are diagnostically related to the inpatient admission will be considered part of the inpatient admission. These visits are denied separate reimbursement.

Services which are excluded from preadmission testing include:

• Ambulance services
• Maintenance renal dialysis
• Chemotherapy
• Outpatient surgery
• Radiation therapy
• Blood/RX products
• Physical, occupational, and speech therapies

The following hospitals, units and services are exempt from this policy criteria:

• Psychiatric Hospitals and Psychiatric units
• Inpatient Rehabilitation Hospitals and Rehabilitation Units
• Long term care Hospitals
• Children’s Hospitals
• Mother/Baby Claims
• Cancer Hospitals

When a member receives inpatient or outpatient care in a preferred/in-network hospital, all services associated with that hospital care performed by the following specialty categories will be covered at the preferred/in-network level of benefits based on the allowable charge:

• Anesthesiologists
• Pathologists
• Emergency physicians
• Radiologists
• Assistant surgeons

Take-home drugs supplied and billed by a hospital or facility and billed with revenue code 0253-Take Home Drugs are paid under the hospital ancillary benefit and not under the pharmacy benefit.