Unlisted Services Policy

Transcription

1 Policy Number 2016R7101B Annual Approval Date Unlisted Services Policy 11/11/2015 Approved By Payment Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY 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, the enrollee s benefit coverage documents, and/or other reimbursement, medical or drug policies. 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 Optum 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 2016 United HealthCare Services, Inc. Application This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid and Medicare products. 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 and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified 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 An unlisted code may be submitted for a procedure or service that does not have a valid, more descriptive CPT or HCPCS code assigned. A procedure/service may not have a CPT or HCPCS code if it is new, rare or unusual. The unlisted code must be from the appropriate anatomic section of codes. Documentation is required for all unlisted codes submitted for reimbursement. Documentation is to include, but is not limited to: Complete description of what the unlisted code is being used for along with: Procedure report for unlisted surgical/procedure codes or Invoice for unlisted DME/supply codes NDC #, dose and route of administration for unlisted drug codes Reimbursement Guidelines Documentation will be reviewed for appropriate coding, existence of a more appropriate code, coverage, reimbursement allowance and prior notification if needed. Unlisted codes that do not have documentation will be denied. State Exceptions Arizona Delaware Iowa E1399 with modifiers NU, CC, CR, GB, KF, LL, NR, Q6, RP, RR, 22, 52, 59, 76, and 77 AZ Long Term Care S5130 and S with TH modifier is allowed for OB providers without documentation and can be allowed without review. T2025 & S5130 is allowed for LTC LOB without documentation and can be allowed without review. State regulations do not require records to be submitted for procedure code H0046 when billed by Mental Health or Maternity Services providers Nebraska Nebraska has a list of additional codes that require documentation review to determine reimbursement. These codes are identified as RNE (Rate Not Established) codes. These codes require an invoice for pricing. New Jersey New York Ohio NJ LTC does not require documentation or review for code 90899, S5130 and T2025 with modifier SE. In addition to the NDC code unlisted drug codes require the infusion record and a copy of the invoice showing the actual cost of the drug. Removed procedure code no documentation required. Code J8499 billed with DX V25.01 and V25.41: Birth Control Pills. A6459 Ohio s MME product does not require documentation and review for code T1999 with modifier UA S5130 with modifier UA

3 Pennsylvania Texas T2025 with modifier UA T2025 with modifier UB REIMBURSEMENT POLICY 99429: State requires providers to bill unlisted code when providing dental varnish so documentation and review are not needed Documentation and review is not needed for code A4335 when billed with an U9 modifier. Tennessee for DSNP/Medicare TN SNP on CSP S5130, S5131, S5181, S5497, S9542 Definitions Unlisted Codes Codes that have non-specific descriptors such as unlisted, unspecified, miscellaneous, NOS, NOS in their description. Many unlisted codes end in - 99 Attachments: Please right-click on the icon to open the file Community Plan Unlisted CPT Codes List of all CPT codes to which this policy applies Community Plan Unlisted HCPCS Codes List of all HCPCS codes to which this policy applies Community Plan NE RNE code list List of all codes that require documentation review for Nebraska 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

4 Release and Code Sets REIMBURSEMENT POLICY History 6/12/2016 State Exceptions Section updated: Added exception Iowa 5/22/2016 State Exceptions Section updated 4/3/2016 State Exceptions Section updated: Added exception for AZ LTC, added information regarding NY unlisted drugs. 3/21/2016 State Exceptions Section updated: Added exception for Michigan 2/14/2016 Unlisted CPT code list updated; unlisted HCPCS code list updated 1/1/2016 Annual Version Change Updated Annual Approval Date History Section: Entries prior to 1/1/13 archived 11/22/2015 State Exceptions Section updated: Added exception for New York 7/19/2015 Unlisted CPT code list updated; unlisted HCPCS code list updated State Exceptions Section updated: Removed exception for Kansas 5/17/2015 Unlisted CPT code list updated; unlisted HCPCS code list updated State Exceptions Section Updated: Added exception for TX, Added exception for TN 3/22/2015 State Exceptions Section updated: Removed exception for Mississippi CAN. Added State Exception for Arizona. 3/8/2015 State Exceptions Section updated: Added exception for Mississippi CAN 3/1/2015 Application Section updated: removed reference to location of policy for MS Chip 2/15/2015 Application Section: Updated State Exceptions Section updated: Added exception for Kansas 1/1/2015 Annual Version Change History Section: Entries prior to 1/1/13 archived 12/14/2014 State Exceptions Section updated: Added exception for Ohio 12/04/2014 State Exceptions Section updated: Tax ID corrected in Michigan line. 11/30/2014 State Exceptions Section updated: Added exception for Tennessee DSNP on CSP regarding codes S5130 S5131 S5181 S5497 S /12/2014 Annual review of policy approved by Payment Policy Oversight Committee (PPOC). 9/28/2014 State Exceptions Section updated: Added exception for Texas regarding code A4335 and modifier U9. 8/31/2014 Application Section: Revised State Exceptions section updated: added exception for Ohio and New Jersey. 8/4/2014 Application Section: Removed reference to location of policy for Florida Medicaid and Rhode Island Medicaid and added including, but not limited to verbiage. 6/8/2014 State Exceptions section updated: added exception for New Jersey regarding code S5130 5/18/2014 Application Section: Added verbiage stating this policy applies to UnitedHealthcare Community Plan Medicaid and Medicare products

5 State Exceptions section updated: added exception for Ohio regarding code S9379 4/13/2014 State Exceptions section updated: added exception for Kansas regarding CPT /31/2014 Disclaimer: Revised 2/15/2014 Unlisted CPT code list updated; unlisted HCPCS code list updated Overview section updated: added clarification regarding required documentation 1/27/2014 Annual renewal of policy approved by United HealthCare Community & State Payment Policy Committee 1/1/2014 Annual Version Change State Exceptions: update made for Arizona 11/22/2010 Policy published by UnitedHealthcare Community & State Back To Top