Maximum Frequency Per Day Policy

Transcription

1 Policy Number 2016R0060N Maximum Frequency Per Day Policy Annual Approval Date 7/13/2016 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 at you are reimbursed based on e code or codes at correctly describe e heal care services provided. UnitedHealcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT *), Centers for Medicare and Medicaid Services (CMS) or oer coding guidelines. References to CPT or oer sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all heal care services billed on CMS 1500 forms and, when specified, to ose billed on UB04 forms. Coding meodology, industry-standard reimbursement logic, regulatory requirements, benefits design and oer factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealcare Community Plan s reimbursement policy for e services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealcare Community Plan may use reasonable discretion in interpreting and applying is policy to heal care services provided in a particular case. Furer, e policy does not address all issues related to reimbursement for heal care services provided to UnitedHealcare Community Plan enrollees. Oer factors affecting reimbursement supplement, modify or, in some cases, supersede is policy. These factors include, but are not limited to: federal &/or state regulatory requirements, e physician or oer provider contracts, e enrollee s benefit coverage documents, and/or oer reimbursement, medical or drug policies. Finally, is policy may not be implemented exactly e same way on e different electronic claims processing systems used by UnitedHealcare Community Plan due to programming or oer constraints; however, UnitedHealcare Community Plan strives to minimize ese variations. UnitedHealcare Community Plan may modify is reimbursement policy at any time by publishing a new version of e policy on is Website. However, e information presented in is policy is accurate and current as of e date of publication. UnitedHealcare Community Plan uses a customized version of e Optum Claims Editing System known as ices Clearinghouse to process claims in accordance wi UnitedHealcare Community Plan reimbursement policies. *CPT is a registered trademark of e American Medical Association Proprietary information of UnitedHealcare Community and State Copyright 2016 United HealCare Services, Inc. Application This reimbursement policy applies to UnitedHealcare Community Plan Medicaid and Medicare products. This policy applies to services reported using e 1500 Heal Insurance Claim Form (a/k/a ) or its electronic equivalent or its successor form. This policy applies to all products and all network and nonnetwork physicians and oer qualified heal care professionals, including, but not limited to, nonnetwork auorized and percent of charge contract physicians and oer qualified heal care professionals. The MFD portion of is policy does not apply to: network home heal services and supplies/home heal agencies; anesesia management; ambulance services; network physicians and oer qualified heal care professionals contracted at a case rate (in some markets known as a flat rate)

2 unless e code description for e service or supply indicates it should be reported only once daily. For HCPCS codes reported wi rental modifiers (KH, KI, KJ, KR, or RR) or e Maintenance and Service modifier (MS) by a by a participating network and non-network durable medical equipment (DME), orotics or prosetics vendor, please refer to UnitedHealcare Community Plan s Durable Medical Equipment, Orotics and Prosetics Multiple Frequency Policy. Payment Policies for Medicare & Retirement and Employer & Individual please use is link. Medicare & Retirement Policies are listed under Medicare Advantage Reimbursement Policies. Employer & Individual are listed under Reimbursement Policies-Commercial. Table of Contents Application Policy Overview Reimbursement Guidelines MFD Determination Part I Part II Reimbursement Modifiers Anatomic Modifiers State Exceptions Questions and Answers Attachments Resources History Policy Overview The purpose of is policy is to ensure at UnitedHealcare Community Plan reimburses physicians and oer heal care professionals for e units billed wiout reimbursing for obvious billing submission, data entry errors or incorrect coding based on anatomic considerations, HCPCS/CPT code descriptors, CPT coding instructions, established UnitedHealcare policies, nature of a service/procedure, nature of an analyte, nature of equipment, and unlikely clinical treatment. The term units refers to e number of times services wi e same Current Procedural Terminology (CPT ) or Healcare Common Procedure Coding System (HCPCS) codes are provided per day by e same individual physician or oer heal care professional. To do is, UnitedHealcare Community Plan has established maximum frequency per day (MFD) values, which are e highest number of units eligible for reimbursement of services on a single date of service. Reimbursement also may be subject to e application of oer UnitedHealcare Community Plan Reimbursement policies such as "Laboratory Rebundling" or "Professional/Technical Component." This policy applies wheer a physician or oer heal care professional submits one CPT or HCPCS code wi multiple units on a single claim line or multiple claim lines wi one or more unit(s) on each line. It is common coding practice for some CPT and HCPCS codes to be submitted wi multiple units. MFD values will be evaluated and/or updated quarterly to reflect new, changed, and deleted codes. Review of MFD values for existing CPT and HCPCS codes based on criteria wiin is policy will be completed annually. For e purpose of is policy, e same individual physician or oer heal care professional is e same individual rendering heal care services reporting e same Federal Tax Identification number.

3 Reimbursement Guidelines REIMBURSEMENT POLICY MUE Editing **NOTE: MUE values always supersede MFD values listed in is policy except in Arizona. ** UnitedHealcare Community Plan will follow e CMS MUE values before any oer MFD criteria is applied. If ere is not a CMS MUE value or e CMS MUE value is not exceeded, en e following criteria has been used to establish MFD values. See UnitedHealcare Community Plan s Medically Unlikely Edits Policy Part I The following criteria are first used to determine e MFD values for codes to which ese criteria are applicable: The service is classified as bilateral (CMS Indicators 1 or 3) on e Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule (NPFS) or e term 'bilateral' is included in e code descriptor. For e majority of ese codes, e MFD value is 1. There are some codes at describe more an one anatomical site or vertebral level at can be treated bilaterally where e MFD value may be more an 1. Where e CPT or HCPCS code description/verbiage references reporting e code once per day, e MFD value is 1. The service is anatomically or clinically limited wi regard to e number of times it may be performed, in which case e MFD value is established at at value. The CPT or HCPCS code description/verbiage indicates e number of times e service can be performed, in which case e MFD value is set at at value. CMS Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Local Coverage Determination (LCD) assigns an MFD value in which case e MFD value is set at at value. Where e criteria above has not defined an MFD value, e CMS Medically Unlikely Edits (MUE) value, where available, will be utilized to establish an MFD value. Where no oer definitive value has been established based on e criteria above, drug HCPCS codes will have an MFD value of 999 which indicates ey are exempt from e MFD policy. Where no oer definitive value has been established based on e criteria above, unlisted CPT and HCPCS codes will have an MFD value of 999 which indicates ey are exempt from e MFD policy. Where no oer definitive value has been established based on e criteria above, new CPT codes released by e American Medical Association and new HCPCS codes released by CMS since e last MFD value update (not covered by any of e above criteria), will have an MFD value of 100. Part II When none of e criteria listed in Part I apply to a code, data analysis is conducted to establish MFD values according to common billing patterns. When a code has 50 or more claim occurrences in a data set, e MFD values are determined rough claim data analysis and are set at e 100 percentile (i.e. e highest number of units billed for at CPT or HCPCS code in e data set). If e 100 percentile exceeds e 98 percentile by a factor of four, e MFD value will be set at e 98 percentile. When a code has less an 50 claim occurrences in a data set, e MFD values will be set at e default of 100 until e next annual analysis. In any case where, in UnitedHealcare Community Plan's judgment, e 98 percentile does not account for e clinical circumstances of e services billed, e MFD for a code may be increased so as to capture only obvious billing submission and data entry errors. The "MFD CPT Values" and e "MFD HCPCS Values" lists below contain e most current MFD values. UnitedHealcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List

4 UnitedHealcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List Reimbursement The MFD values apply wheer a physician or oer heal care professional submits one CPT or HCPCS code wi multiple units on a single claim line or multiple claim lines wi one or more unit(s) on each line. It is common coding practice for some CPT and HCPCS codes to be submitted wi multiple units. However, when reporting e same CPT or HCPCS code on multiple and/or separate claim lines, e claim line may be classified as a duplicate service and/or subject to additional UnitedHealcare Community Plan reimbursement policies such as "Laboratory Rebundling" or "Professional/Technical Component." Services provided are reimbursable services up to and including e MFD value for an individual CPT or HCPCS code. In some instances, a modifier may be necessary for correct coding and corresponding reimbursement purposes. See Q & A #3, 4 and 5. Bilateral payment via e use of modifiers LT or RT is inappropriate for procedures, services, and supplies where e concept of laterality does not apply. UnitedHealcare Community Plan will pay up to e maximum frequency per day value for codes wi "bilateral" or "unilateral or bilateral" in description or for codes where e concept of laterality does not apply, wheer submitted wi or wiout modifiers LT and/or RT by e same individual physician or oer healcare professional on e same date of service for e same member. Use of modifiers LT and/or RT on e codes identified in e "Codes Restricting Modifiers LT and RT" list will be considered informational only. UnitedHealcare Community Plan Codes Restricting Modifiers LT and RT There may be situations where a physician or oer healcare professional reports units accurately and ose units exceed e established MFD value. In such cases, UnitedHealcare Community Plan will consider additional reimbursement if reported wi an appropriate modifier such as modifier 59, 76,91, XE, XS or XU. Medical records are not required to be submitted wi e claim when modifiers 59, 76,91, XE, XS or XU are appropriately reported. Documentation wiin e medical record should reflect e number of units being reported and should support e use of e modifier. Modifiers Modifier Modifier Description Distinct Procedural Service Under certain circumstances, it may be necessary to indicate at a procedure or service was distinct or independent from oer non-e/m services performed on e same day. Modifier 59 is used to identify procedures or services, oer an E/M services, at are not normally reported togeer but are appropriate under e circumstances. Documentation must support a different session, different procedure or surgery, different size or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on e same day by e same individual. However, when anoer already established modifier is appropriate it should be used raer an modifier 59. Only if no more descriptive modifier is available and e use of modifier 59 best explains e circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service performed on e same date, see modifier 25. Repeat Procedure or Service by Same Physician or Oer Qualified Heal Care Professional It may be necessary to indicate at a procedure or service was repeated by e same physician or oer qualified heal care professional subsequent to e original procedure or service. This circumstance may be reported by adding modifier 76 to e repeated procedure or service. Note: This modifier should not be appended to an E/M service. To report a separate and

5 91 XE XS XU REIMBURSEMENT POLICY distinct E/M service performed on e same date, see modifier 25. It is also inappropriate to use modifier 76 to indicate repeat laboratory services. Modifiers 59 or 91 should be used to indicate repeat or distinct laboratory services, as appropriate according to e AMA and CMS. Separate consideration for reimbursement will not be given to laboratory codes reported wi modifier 76. Repeat Clinical Diagnostic Laboratory Test In e course of treatment of e patient, it may be necessary to repeat e same laboratory test on e same day to obtain subsequent (multiple) test results. Under ese circumstances, e laboratory test performed can be identified by its usual procedure number and e addition of modifier 91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems wi specimens or equipment; or for any oer reason when a normal, one-time, reportable result is all at is required. This modifier may not be used when oer code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more an once on e same day on e same patient. Separate Encounter: A Service That Is Distinct Because It Occurred During A Separate Encounter Separate Structure: A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure Unusual Non-Overlapping Service: The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service Anatomic Modifiers Modifier Modifier Description Modifier Modifier Description E1 Upper left, eyelid E3 Upper right, eyelid E2 Lower left, eyelid E4 Lower right, eyelid F1 Left hand, second digit F5 Right hand, umb F2 Left hand, ird digit F6 Right hand, second digit F3 Left hand, four digit F7 Right hand, ird digit F4 Left hand, fif digit F8 Right hand, four digit FA Left hand, umb F9 Right hand, fif digit T1 Left foot, second digit T5 Right foot, great toe T2 Left foot, ird digit T6 Right foot, second digit T3 Left foot, four digit T7 Right foot, ird digit T4 Left foot, fif digit T8 Right foot, four digit TA Left foot, great toe T9 Right foot, fif digit LC Left circumflex coronary artery RC Right coronary artery LD Left anterior descending coronary artery LM Left main coronary artery RT Right side LT Left side RI Ramus intermedius coronary artery

6 State Exceptions Arizona Delaware Florida Iowa Kansas Arizona Heal Care Cost Containment System (AHCCCS) publishes a unit limit list specific to Arizona Medicaid. Arizona does not exclude network home heal services and supplies/home heal agencies; anesesia management; ambulance services. Arizona unit values are allowed even if ey are greater an e CMS MUE values. If Arizona has not published a unit limit for a code, e MUE value will be followed.. Delaware has an MFD exception for codes S9128, S9129, S9131 Florida has an exception from CMS for CPT codes & Florida reimburses speech erapy in 15 minute time increments and allows a maximum of 4 units for each code. (CHECK) Iowa has an MFD exception for code 92507, 92508, A4253, T1031, S9443, and T2018 Due to State requirements, MFD is not applied on codes when e MUE value is greater an e MFD allowance. Refer to UnitedHealcare Community Plan s Medically Unlikely Edits Policy for MUE values. Kansas allows 6 units of code A4253 per mon and all can be billed on e same date of service. Louisiana Louisiana has an MFD exception for HCPC codes H0015, H2034, H2036, and Michigan MI allows 8 units of in place of service 71. Mississippi MS Can has exceptions for codes 96101, 96110, 96118, 96372, H0031, H0032, H0036, H0038, H0039, H2011, H2012, H2017, H2021, H2030, T1002, T1017, T1025 and L0980 L3600. Nebraska Nebraska has an exception for HCPC code T1015 Ohio Ohio MME has an exception from CMS for codes 90792, 90863, H0001, H0007, H0016, and H0020 when billed in a place of service 53 to be exempt from MUE/MFD edit limits. Pennsylvania Nebraska Pennsylvania has an exception from CMS for code T1028 to be exempt from MUE/MFD edit limits. Nebraska has an exception for code to be exempt from MFD New Jersey New Jersey has an MFD exemption for codes B4220, B4222. B4224 and S9343. New Mexico New Mexico has an exception for code Rhode Island Tennessee Rhode Island has an exception from CMS for code S9446 to be exempt from MUE edit limits. Tennessee has an exception for codes G9004,G9005,G9006,G9007,G9010,and G9011 when billed wi modifiers UB or UA Texas Multiple units allowed for codes 90460, 90461, & Texas providers are required to bill additional vaccine administration codes on separate lines wi only one unit. For code A4253 Texas allows 2 units per mon for insulin dependent diabetics and 1 unit per mon for noninsulin dependent diabetics. For codes A4253 and A9275 Texas allows a combined total of 2 units per mon for insulin dependent diabetics and a combined total of 1 unit per mon for noninsulin

7 dependent diabetics. Texas does not apply MFD to providers in POS 12 Exempt from MFD for Texas:: H0020, S5101 S REIMBURSEMENT POLICY Washington Per state regulations, Washington Medicaid allows a higher unit value for codes 95870, 95885, 95886, and an what is allowed per e policy, erefore, ese codes are exempt from e MFD value listed in e policy. S9430 is exempt from MFD. Wisconsin Rhode Island Wisconsin Department of Heal Services publish separate unit limits specific to Wisconsin Medicaid for specific physical, occupational, and speech erapy services. Please refer to e C&S Physical Medicine & Rehabilitation: Maximum Combined Frequency per Day Policy. RI has an exception for code for Behavioral Heal Questions and Answers 1 2 Q: Why do you exclude network home heal services and supplies/home heal agencies, anesesia management, and ambulance providers from is policy? A: There are many contracts specific to ese physicians and oer heal care professionals at permit codes to be used in a different manner an intended by CPT and HCPCS, which make e application of is policy unworkable. Billing practices may also dictate at e units field is used to report someing oer an how many times a service was performed (i.e. mileage), which again may make e application of is policy unworkable. These providers were excluded until contract language and/or billing practices can be reviewed and changed. Q: When e frequency of a billed service on a date of service is greater an e established MFD value, will ere be additional reimbursement? A: When a physician or oer healcare professional reports units accurately, yet ose units exceed e established MFD value, an appropriate modifier such as 59, 76, 91, XE, XS, or XU may be utilized. The MFD value is a reshold set solely to avoid overpayment due to billing and data entry errors. UnitedHealcare Community Plan intends to reimburse all services performed and reported wi proper coding in accordance wi its reimbursement policies and benefit or provider contracts. Medical records do not need to be submitted for e purposes of is policy, unless e processed claim is being submitted on appeal. When reporting e same CPT or HCPCS code on multiple and/or separate claim lines, e claim line may be classified as a duplicate service and subject to additional UnitedHealcare Community Plan reimbursement policies such as "Laboratory Rebundling" or "Professional/Technical Component." 3 Q: Why has UnitedHealcare Community Plan set e MFD value at 1 for bilateral procedures?

8 A: UnitedHealcare Community Plan has set e MFD value for most bilateral procedures at 1. The preferred meod of billing a bilateral eligible procedure is wi 1 unit on one claim line wi modifier 50. Modifier 50 indicates at one procedure was performed bilaterally. Bilateral eligible procedures may also be billed on two lines wi 1 unit each and modifiers RT and LT. There are some codes at describe more an one anatomical site or vertebral level at can be treated bilaterally where e MFD value may be more an Q: Would e MFD value for bilateral procedures remain at 1 unit if it is possible to perform ese procedures more an once per day? A: If e bilateral procedure is provided more an once per day, modifiers 59, 76, XE, XS, or XU may be appropriate to bill depending on e circumstance. Additional reimbursement will be considered wi e use of ese modifiers. Q: Would e MFD value for hand or foot bilateral procedures remain at 1 unit if it is possible to perform e procedure on multiple digits such as fingers or toes? A: The MFD value would remain at 1 unit, however, HCPCS modifiers FA or F1-9 may be used to report specific fingers; TA or T1-9 may be used to report specific toes. Q: Will UnitedHealcare Community Plan allow more an 1 unit for a CPT or HCPCS code wi per diem or per day in e code description? A: UnitedHealcare will allow 1 unit of a procedure code wi per diem or per day or oer verbiage describing once daily in e code description. There are no modifiers at will override e MFD value. For example, if a patient requires home infusion antibiotic erapy twice daily, it would be more appropriate to report 1 unit of HCPCS code S9501 raer an 2 units of S9500. The MFD applies wheer a physician or oer heal care professional submits one CPT or HCPCS code wi multiple units on a single claim line or multiple claim lines wi one or more unit(s) on each line. S9500 Home infusion erapy, antibiotic, antiviral, or antifungal erapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem S9501 Home infusion erapy, antibiotic, antiviral, or antifungal erapy; once every 12 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Q: What is an example of a code at is limited because of anatomical or clinical reasons? A: CPT code Appendectomy would be set at e MFD value of 1 unit because a person only has one appendix. Q: How should and/or be reported when multiple immunizations wi face-to-face counseling are performed on e same date of service? For example, if e physician or oer heal care professional administers immunizations for a 2-mon-old infant on e same date of service according to e current immunization schedule, how should e following immunizations be reported? Immunization Components CPT Code DtaP intramuscular administration x 2 Rotavirus oral administration

9 Hepatitis B and Hemophilus influenza b intramuscular administration 2 REIMBURSEMENT POLICY Poliovirus intramuscular administration Pneumococcal conjugate vaccine A: Coding practices may vary by physician or oer healcare professional offices. It is appropriate to report e immunization administration of e first and additional vaccine/toxoid component wi face-to-face counseling on one line wi multiple units and a link to all associated ICD-9-CM codes or report each component on a separate line. In e example above, e claim could be reported as wi 5 units on one line and wi 3 units on a separate line wi e associated ICD-9- CM diagnoses linked to each line. It is also appropriate to report e administration of each vaccine component on separate lines; e.g. reporting 5 lines for wi 1 unit each and 3 lines for wi 1 unit each. However, when reporting e same CPT or HCPCS code on multiple lines and/or on separate claims, e additional claim line(s) reported wi e same procedure code may be denied as a duplicate service Q: How are MFD values for immunization administration CPT codes and determined? A: UnitedHealcare Community Plan follows e recommendations from e Center for Disease Control's (CDC) Advisory Committee on Immunization Practices (ACIP) to set e MFD value for additional immunization administration codes. Q: What is an example of a CPT or HCPCS codes where e "description/verbiage" clearly indicates e number of units at can be performed on a single date of service? A: Two examples are CPT Codes and Code Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless oerwise listed; single lesion. Because e code description includes "single lesion", it should only be billed wi one (1) unit. Code Drug screen, any number of drug classes from Drug Class List A; single drug class meod, by instrumented test systems (e.g., discrete multichannel chemistry analyzers utilizing immunoassay or enzyme assay), per date of service. The code description includes "per date of service", erefore it should only be billed wi one (1) unit per date of service. 11 Q: Why are unlisted CPT and HCPCS codes set at an MFD value of 999? A: Unlisted CPT and HCPCS codes are set at an MFD value of 999 because unlisted codes are individually reviewed. The review of documentation will identify e accurate number of services performed for e unlisted code. 12 Q: Why are many new CPT and HCPCS codes set at an MFD value of 100? A: There is no data or previous claim history for new codes. Setting e MFD value at 100 allows claims to be processed and prevents most overpayments from occurring due to billing errors and data entry errors. Once claims data is available on a code, e MFD value will be established.

10 REIMBURSEMENT POLICY Q: What is an example of determining e MFD value at e 100 percentile unless e 100 percentile exceeds e 98 percentile by greater an a factor of 4? A: Statistical calculation: (A) x 4 = (C); if (B) is greater an (C), en e 98 percentile is set for e MFD value. If (B) is less an or equal to (C), en e 100 percentile is set for e MFD value. Here are two examples of determining MFD values based on a factor of Code (A) 98 (B) 100 (C) Factor of 4 Set MFD at: E Q: What is an example of a clinical circumstance where UnitedHealcare Community Plan would assign a specific MFD value? 14 A: A4595-Electrical stimulator supplies, 2 lead, per mon, (e.g. TENS, NMES). According to standard criteria, e data showed e 98 percentile at 10 units and e 100 percentile at 72 units. The statistical calculation would have set e MFD value at 10. However, based on e code description allowance of per mon and subject to e UnitedHealcare Community Plan Time Span Codes Reimbursement Policy, e MFD value was decreased to one (1). Attachments: Please right click on e icon to open e file UnitedHealcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List UnitedHealcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List UnitedHealcare Community Plan Codes Restricting Modifiers LT and RT Designates e maximum frequency per day value assignments for CPT codes. Designates e maximum frequency per day value assignments for HCPCS codes. Codes at allow up to e MFD value at have "bilateral" or "unilateral or bilateral" in e description or where e concept of laterality does not apply. 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 oer CMS publications and services

11 Centers for Medicare and Medicaid Services, Healcare Common Procedure Coding System, HCPCS Release and Code Sets History 12/11/2016 State exceptions: Added Rhode Island 11/20/2016 State exceptions: Added New Mexico 11/13/2016 State exceptions: Added Nebraska 10/2/2016 Policy List Change: MFD CPT, HCPCS and Codes Restricting Modifiers LT and RT Policy 9/25/2016 State Exceptions: Updated exceptions for MS 9/4/2016 State Exceptions: Updated exceptions for IA and LA 7/13/2016 Policy Approval Date Change (No new version) 7/9/2016 State Exceptions: Added exceptions for IA 7/3/2016 Attachments: All 5/29/2016 State Exceptions: Added exceptions for LA 5/22/2016 State Exceptions: Added exceptions for TX and MI. Policy List Change: MFD HCPCS Policy list updated 4/17/2016 Policy List Change: MFD CPT, HCPCS and Codes Restricting Modifiers LT and RT Policy 02/15/2016 State Exceptions Section: Added exception for PA 2/2/2016 State Exceptions Section: Updated verbiage for DE, FL, KS, MS, and TX. Added exceptions for NE and NJ. 1/1/2016 Annual Version update. Application section: Updated verbiage to include non-network DME vendors Policy List Change: MFD CPT, HCPCS and Codes Restricting Modifiers LT and RT Policy 11/22/2015 Policy List Change: MFD CPT, HCPCS and Codes Restricting Modifiers LT and RT Policy 10/4/2015 Policy List Change: MFD CPT, HCPCS and Codes Restricting Modifiers LT and RT Policy 8/23/2015 Policy List Change: MFD HCPCS Policy list updated 7/8/2015 Policy Approval Date Change (No new version) 7/5/2015 Policy List Change: MFD CPT, HCPCS and Codes Restricting Modifiers LT and RT Policy 5/17/2015 State Exceptions Section: Added exception for Texas and Washington. 4/1/2015 State Exceptions Section: Added exception for Arizona 3/29/2015 State Exceptions Section Added Mississippi exception

12 3/8/2015 Application Section updated: removed reference to location of policy for MS Chip. 2/22/2015 State Exceptions Section: Added exceptions for Pennsylvania and Kansas. 2/16/2015 Policy verbiage change: Reimbursement Guidelines Section updated to remove language regarding MUE to a separate policy; Questions and Answers Section updates, Q&A #15 removed to separate MUE policy. 2/14/2015 Application Section: Updated Policy Change: Application and Reimbursement Guidelines Sections updated Questions and Answers Section: Q&A #6 added and oer items renumbered and Q&A #10 updated. 1/1/2015 Annual Policy Version Change Policy Change: Reimbursement and Modifier Sections updated Questions and Answers: Q&A s # 2 and 4 updated Policy List Change: MFD CPT, HCPCS and Codes Restricting Modifiers LT and RT Policy Entries prior to 1/1/2013 archived 1/6/2006 Policy implemented by UnitedHealcare Community & State Back To Top