Supply Policy. Approved By 1/27/2014

Transcription

1 Supply Policy Policy Number 2014R0006A Annual Approval Date 1/27/2014 Approved By National Reimbursement Forum United HealthCare Community & State Payment Policy Committee IMPORTANT NOTE ABOUT THIS You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT *), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider contracts, and/or the enrollee s benefit coverage documents. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. UnitedHealthcare Community Plan uses a customized version of the Ingenix Claims Editing System known as ices Clearinghouse to process claims in accordance with UnitedHealthcare Community Plan reimbursement policies. *CPT is a registered trademark of the American Medical Association Proprietary information of UnitedHealthcare Community and State Copyright 2014 United HealthCare Services, Inc. Application This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a ) or its electronic equivalent or its successor form. This policy applies to all products, all network and non-network physicians and other qualified health care professionals. This includes nonnetwork authorized and percent of charge contract physicians and other health care professionals. Payment Policies for Medicare & Retirement and Employer & Individual please use this link. Medicare & Retirement Policies are listed under Medicare Advantage Reimbursement Policies. Employer & Individual are listed under Reimbursement Policies-Commercial.

2 Policy Overview Healthcare Common Procedure Coding System (HCPCS) supply codes are considered included in the Evaluation and Management (E/M) service and/or procedure performed in a physician's or other qualified health care professional's office. This policy describes reimbursement for HCPCS supply codes reported in a physician or other qualified health care professional s office, as well as drugs submitted with HCPCS J codes submitted on a claim form in facility places of service (POS) 21, 22, 23, and 24. Non-specific Current Procedural Terminology (CPT ) code is not a reimbursable service in any setting. The appropriate Level II HCPCS code must be submitted for reimbursement of covered medical and surgical supplies. Reimbursement Guidelines Supply Reimbursement in a Physician s or Other Qualified Healthcare Professional s Office Pursuant to Centers for Medicare and Medicaid Services (CMS) policy, HCPCS supply codes are not separately reimbursable as the cost of supplies is incorporated into the practice expense Relative Value Unit (RVU) for the E/M service or procedure code. Consistent with CMS, UnitedHealthcare Community Plan will not separately reimburse the HCPCS supply codes when those supplies are provided on the same day as an E/M service and/or procedure performed in a physician's or other health care professional's office. The UnitedHealthcare Community Plan Supply Policy list of non-reimbursable codes is developed based on the CMS National Physician Fee Schedule (NPFS) Relative Value File and consists of codes with status indicators P (Bundled/Excluded Codes), and several codes with indicator B (Bundled Code) and those codes that based on their descriptions CMS considers part of the practice expense and not separately reimbursable. Please refer to the attachment below for a list of those HCPCS supply codes that are not separately reimbursable under this policy. Casting and Splint Supplies HCPCS codes A4570, A4580, and A4590 which were previously used for billing of splints and casts are invalid for Medicare use effective July 1, 2001, and new temporary Q codes were established to reimburse physicians and other practitioners for the supplies used in creating casts. Consistent with CMS, UnitedHealthcare Community Plan will no longer reimburse HCPCS codes A4570, A4580, and A4590 for casting and splint supplies. Physicians and other practitioners should be using the temporary Q codes (Q4001-Q4051) for reimbursement of casting and splint supplies. Supplies and Drugs submitted with a J Code Reported with a Facility Place of Service Consistent with CMS, UnitedHealthcare Community Plan will not allow separate reimbursement for specific HCPCS supplies and drug codes reported with a HCPCS J code when submitted on a claim form by any physician or other qualified healthcare professional in the following facility POS 21, 22, 23, and 24. CMS follows a Prospective Payment System (PPS) where Medicare payment is based on a predetermined, fixed amount payable to a facility for inpatient or outpatient hospital services. In addition, CMS reimburses ambulatory surgery centers under an Ambulatory Payment Classification (APC) payment methodology. With these fixed rates all costs associated with drugs and supplies are also considered inclusive in the global payment to the facility and not considered separately reimbursable when reported on a claim form by a physician or other qualified healthcare professional. Please refer to the attachments below for a list of those HCPCS supplies and drugs that are not

3 separately reimbursable in POS 21, 22, 23 and 24. Implantable Tissue Markers CMS clarifies that implantable tissue markers (HCPCS code A4648) and implantable radiation dosimeters (HCPCS code A4650) are separately billable and payable when used in conjunction with CPT codes 19499, 32553, or on a claim for physician services. Consistent with CMS, UnitedHealthcare Community Plan will allow separate reimbursement for HCPCS codes A4648 and A4650 when billed on the same date of service with either CPT codes 19499, 32553, or If not reported with at least one of these CPT codes, HCPCS codes A4648 and A4650 are not separately reimbursable. Surgical Tray Reimbursement UnitedHealthcare Community Plan follows CMS policy with regard to reimbursement of HCPCS code A4550 (Surgical trays). For more information on reimbursement of surgical trays, see UnitedHealthcare Community Plan's Rebundling and B Bundle Codes Policies. Supply Code For reimbursement of covered medical and surgical supplies, an appropriate Level II HCPCS code must be submitted. The non-specific CPT code (supplies and materials, except spectacles, provided by the physician over and above those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]) is not reimbursable in any setting. State Exceptions Arizona Kansas Nebraska Wisconsin Per State Regulations, HCPCS code A4550 is payable. Per State Regulations, CPT code is payable within specific parameters. Per State Regulations, codes A4263 and are payable within specific parameters. Per State Regulations, codes A4550 and are payable within specific parameters. Definitions National Physician Fee Schedule Relative Value File Practice Expense Relative Value Units Relative Value Units Status Code B Status Code P A public use file that contains information on services covered by the Medicare Physician Fee Schedule (MPFS). The file contains the associated Relative Value Units (RVUs), a fee schedule status indicator, and various payment policy indicators needed for payment adjustment (e.g, payment of assistant at surgery, team surgery, bilateral surgery). The assigned unit value of a particular CPT or HCPCS code for maintaining a practice including rent, equipment, supplies and nonphysician staff costs. The assigned unit value of a particular CPT or HCPCS code. The associated RVU is either from the CMS NPFS Non-Facility Total value or Facility Total value. Bundled Code. Payment for covered services are always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Bundled/Excluded Codes. There are no RVUs and no payment amounts for

4 these services. No separate payment should be made for them under the fee schedule. Questions and Answers Q: If a member obtains medical supplies such as blood glucose test strips or lancets from a medical supply company, what place of service should the medical supply company report? A: Since the items are for home use, the medical supply company should report with a CMS Place of Service code 12 (Home). Reporting any other place of service code than 12 would be inappropriate when the items are dispensed for home use. Q: Why does this policy not address all codes with an NPFS status code indicator of B? A: Codes from the NPFS with a status of "B," but otherwise addressed in other UnitedHealthcare Community Plan coverage documents or medical, reimbursement and other policies, are not included in this policy. Q: Does UnitedHealthcare Community Plan reimburse for Casting and Splint Supplies? A: Yes. UnitedHealthcare Community Plan will only reimburse for Casting and Splint Supplies when billed with the temporary Q codes (Q4001-Q4051). Attachments 2014A UnitedHealthcare Community Plan NON REIMBURSABLE SUPPLY CODE LIST 2014A UnitedHealthcare Community Plan Facility J-Code Denial Code List A List of HCPCS supply codes that are not separately reimbursable A list of HCPCS drug codes not separately reimbursable in POS 21, 22, 23 and 24. Resources Individual state Medicaid regulations, manuals & fee schedules American Medical Association, Current Procedural Terminology ( CPT ) Professional Edition and associated publications and services Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets

5 History 1/27/2014 Annual Policy Renewal Approved by United HealthCare Community & State Payment Policy Committee 1/1/2014 Annual Version Change Policy List Change: Supply Facility J-Code Denial Code List Defined Terms Capitalized 9/14/2013 Policy Approval Date Change Application Section: Addition of the word qualified. Policy Verbiage Change: Overview and Reimbursement Section Updated. Attachments Section: Added Supply Facility J-Code Denial Code List. History prior to 11/14/2011 archived 9/11/2013 Annual Policy Renewal Approved by National Reimbursement Forum 1/1/2013 Annual Policy Version Change Definitions Section: Updated Policy List Change: Supply Nonreimbursable Code List Updated History prior to 9/22/2008 archived 12/10/12 Annual Policy Renewal Approved by United HealthCare Community & State Payment Policy Committee 1/1/2012 Annual Policy Version Change 11/14/2011 Policy Change: Reimbursement Section Updated; Implantable Tissue Markers added. 1/6/2006 Policy implemented by UnitedHealthcare Community & State 2014A UnitedHealthcare Community Plan NON REIMBURSABLE SUPPLY CODE LIST A4211 A4314 A4356 A4557 A5105 A6208 A6229 A6251 A4212 A4315 A4357 A4558 A5112 A6209 A6230 A6252 A4220 A4316 A4358 A4649 A5113 A6210 A6234 A6253 A4253 A4320 A4361 A5051 A5114 A6211 A6235 A6254 A4256 A4322 A4362 A5052 A5121 A6212 A6236 A6255 A4258 A4326 A4364 A5053 A5122 A6213 A6237 A6256 A4259 A4327 A4367 A5054 A5126 A6214 A6238 A6257 A4262 A4328 A4397 A5055 A5131 A6215 A6239 A6258 A4263 A4330 A4398 A5061 A6154 A6216 A6240 A6259 A4265 A4335 A4399 A5062 A6196 A6217 A6241 A6260 A4300 A4338 A4400 A5063 A6197 A6218 A6242 A6261 A4301 A4340 A4402 A5071 A6198 A6219 A6243 A6262 A4305 A4344 A4404 A5072 A6199 A6220 A6244 A6266 A4306 A4346 A4455 A5073 A6203 A6221 A6245 A6402 A4310 A4351 A4465 A5081 A6204 A6222 A6246 A6403 A4311 A4352 A4470 A5082 A6205 A6223 A6247 A6404

6 2014A UnitedHealthcare Community Plan NON REIMBURSABLE SUPPLY CODE LIST A4312 A4354 A4480 A5093 A6206 A6224 A6248 V2520 A4313 A4355 A4556 A5102 A6207 A6228 A A UnitedHealthcare Community Plan Facility J-Code Denial Code List J0120 J0697 J1440 J2001 J2796 J7050 J7629 J9100 J0129 J0698 J1441 J2010 J2800 J7060 J7631 J9120 J0130 J0702 J1442 J2020 J2805 J7070 J7632 J9130 J0131 J0706 J1446 J2060 J2810 J7100 J7633 J9150 J0132 J0710 J1450 J2150 J2820 J7110 J7634 J9151 J0133 J0712 J1451 J2170 J2850 J7120 J7635 J9155 J0135 J0713 J1452 J2175 J2910 J7131 J7636 J9160 J0150 J0715 J1453 J2180 J2916 J7178 J7637 J9165 J0151 J0716 J1455 J2185 J2920 J7180 J7638 J9171 J0152 J0717 J1457 J2210 J2930 J7183 J7639 J9175 J0171 J0718 J1458 J2212 J2940 J7185 J7640 J9178 J0178 J0720 J1459 J2248 J2941 J7186 J7641 J9179 J0180 J0725 J1460 J2250 J2950 J7187 J7642 J9181 J0190 J0735 J1556 J2260 J2993 J7189 J7643 J9185 J0200 J0740 J1557 J2265 J2995 J7190 J7644 J9190 J0205 J0743 J1559 J2270 J2997 J7191 J7645 J9200 J0207 J0744 J1560 J2271 J3000 J7192 J7647 J9201 J0210 J0745 J1561 J2275 J3010 J7193 J7648 J9202 J0215 J0760 J1562 J2278 J3030 J7194 J7649 J9206 J0220 J0770 J1566 J2280 J3060 J7195 J7650 J9207 J0221 J0775 J1568 J2300 J3070 J7196 J7657 J9208 J0256 J0780 J1569 J2310 J3095 J7197 J7658 J9209 J0257 J0795 J1570 J2315 J3101 J7198 J7659 J9211 J0270 J0800 J1571 J2320 J3105 J7199 J7660 J9212 J0275 J0833 J1572 J2323 J3110 J7300 J7665 J9213 J0278 J0834 J1573 J2325 J3120 J7301 J7667 J9214 J0280 J0840 J1580 J2353 J3130 J7302 J7668 J9215 J0282 J0850 J1590 J2354 J3140 J7303 J7669 J9216 J0285 J0878 J1595 J2355 J3150 J7304 J7670 J9217 J0287 J0881 J1599 J2357 J3230 J7306 J7674 J9218 J0288 J0882 J1600 J2358 J3240 J7307 J7676 J9219

7 2014A UnitedHealthcare Community Plan Facility J-Code Denial Code List J0289 J0885 J1602 J2360 J3243 J7308 J7680 J9225 J0290 J0886 J1610 J2370 J3246 J7309 J7681 J9226 J0295 J0890 J1620 J2400 J3250 J7310 J7682 J9228 J0300 J0894 J1626 J2405 J3260 J7311 J7683 J9230 J0330 J0895 J1630 J2410 J3262 J7312 J7684 J9245 J0348 J0897 J1631 J2425 J3265 J7315 J7685 J9250 J0350 J0900 J1640 J2426 J3280 J7316 J7686 J9260 J0360 J0945 J1642 J2430 J3285 J7321 J7699 J9261 J0364 J1000 J1644 J2440 J3300 J7323 J7799 J9262 J0365 J1020 J1645 J2460 J3301 J7324 J8498 J9263 J0380 J1030 J1650 J2469 J3302 J7325 J8499 J9264 J0390 J1040 J1652 J2501 J3303 J7326 J8501 J9265 J0395 J1050 J1655 J2503 J3305 J7330 J8510 J9266 J0400 J1060 J1670 J2504 J3310 J7335 J8515 J9268 J0401 J1070 J1675 J2505 J3315 J7500 J8520 J9270 J0456 J1080 J1700 J2507 J3320 J7501 J8521 J9280 J0461 J1094 J1710 J2510 J3350 J7502 J8530 J9293 J0470 J1100 J1720 J2513 J3355 J7504 J8540 J9300 J0475 J1110 J1725 J2515 J3357 J7505 J8560 J9302 J0476 J1120 J1730 J2540 J3360 J7506 J8562 J9303 J0480 J1160 J1740 J2543 J3364 J7507 J8565 J9305 J0485 J1162 J1741 J2545 J3365 J7508 J8597 J9306 J0490 J1165 J1742 J2550 J3370 J7509 J8600 J9307 J0500 J1170 J1743 J2560 J3385 J7510 J8610 J9310 J0515 J1180 J1744 J2562 J3396 J7511 J8650 J9315 J0520 J1190 J1745 J2590 J3400 J7513 J8700 J9320 J0558 J1200 J1750 J2597 J3410 J7515 J8705 J9328 J0561 J1205 J1756 J2650 J3411 J7516 J8999 J9330 J0583 J1212 J1786 J2670 J3415 J7517 J9000 J9340 J0585 J1230 J1790 J2675 J3420 J7518 J9002 J9351 J0586 J1240 J1800 J2680 J3430 J7520 J9010 J9354 J0587 J1245 J1810 J2690 J3465 J7525 J9015 J9355 J0588 J1250 J1815 J2700 J3470 J7527 J9017 J9357 J0592 J1260 J1817 J2710 J3471 J7599 J9019 J9360 J0594 J1265 J1826 J2720 J3472 J7604 J9020 J9370 J0595 J1267 J1830 J2724 J3473 J7605 J9025 J9371 J0597 J1270 J1835 J2725 J3475 J7606 J9027 J9390

8 2014A UnitedHealthcare Community Plan Facility J-Code Denial Code List J0598 J1290 J1840 J2730 J3480 J7607 J9031 J9395 J0600 J1300 J1850 J2760 J3485 J7608 J9033 J9400 J0610 J1320 J1885 J2765 J3486 J7609 J9035 J9600 J0620 J1324 J1890 J2770 J3487 J7610 J9040 J9999 J0630 J1325 J1930 J2778 J3488 J7611 J9041 J0636 J1327 J1931 J2780 J3489 J7612 J9042 J0637 J1330 J1940 J2783 J3490 J7613 J9043 J0638 J1335 J1945 J2785 J3520 J7614 J9045 J0640 J1364 J1950 J2788 J3530 J7615 J9047 J0641 J1380 J1953 J2790 J3535 J7620 J9050 J0670 J1410 J1955 J2791 J3570 J7622 J9055 J0690 J1430 J1956 J2792 J3590 J7624 J9060 J0692 J1435 J1960 J2793 J7030 J7626 J9065 J0694 J1436 J1980 J2794 J7040 J7627 J9070 J0696 J1438 J1990 J2795 J7042 J7628 J9098 Back To Top