West Virginia Reimbursement Policies Table of Contents

Transcription

1 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Administration Claims Requiring Additional Documentation 4 Claims Submission - Required Information for Facilities 7 Claims Submission - Required Information for Professional Providers 10 Claims Timely Filing: Participating and Nonparticipating 13 Code and Clinical Editing Guidelines 15 Documentation Standards for Episodes of Care 18 Duplicate or Subsequent Services on Same Date of Service 21 Eligible Charges 24 Emergency Services: Nonparticipating Providers and Facilities 26 Inpatient Facility Transfers 29 Inpatient Readmissions 31 Locum Tenens Physicians 33 Other Provider Preventable Conditions 35 Present on Admission Indicator for Health Care-Acquired Conditions 37 Requirements for Documentation of Proof of Timely Filing 40 Reimbursements for Items under Warranty 43 Reimbursements of Claims with Charge Discrepancies 45 Reimbursement of Sanctioned and Opt-Out Providers 47 Scope of Practice 49 Site of Service Payment Differential - Professionals 51 Anesthesia Professional Anesthesia Services 53 Coding West Virginia Reimbursement Policies Table of Contents Assistant at Surgery (Modifiers 80/81/82/AS) 57 Diagnoses Used in DRG Computation 59 Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) 61 UniCare Health Plan of West Virginia, Inc. July

2 Modifier 22: Increased Procedural Services 64 Modifier 24: Unrelated Evaluation and Management Services by the Same Physician 66 Modifier 25: Significant, Separately Identifiable Evaluation and Management Service 68 Modifier 57: Decision for Surgery 70 Modifier 62: Co-Surgeons 75 Modifier 63: Procedures Performed on Infants less 4kg 77 Modifier 66: Surgical Teams 80 Modifier 76: Repeat Procedure by the Same Physician 83 Modifier 77: Repeat Procedure by Another Physician 85 Modifier 78: Unplanned Return to the Operating/Procedure Room 88 Modifier 91: Repeat Clinical Diagnostic Laboratory Test 91 Modifier LT and RT: Left Side/Right Side Procedures 93 Modifier Usage 95 Multiple Bilateral Surgery: Professional and Facility Reimbursement 98 Reimbursement for Reduced and Discontinued Services 101 Reimbursement of Services with Obsolete Codes 104 Robotic Assisted Surgery 106 Split-Care Surgical Modifiers 108 Unlisted or Misc. Codes (aka Dump Codes) 111 Drugs Drug and Injectable Limits 113 Facility Take-Home Drugs 115 Evaluation and Management Consultations 117 Physician Standby Services 122 Preventive Medicine and Sick Visits on the Same Day 124 Facilities Preadmission Services for Inpatient Stays 126 Prevention Early and Periodic Screening, Diagnostic Treatment 129

3 Vaccines for Children Program 131 Prosthetics & Orthotic Prosthetic and Orthotic Devices 135 Radiology Portable/Mobile/Handheld Radiology Services 138 Surgery Abortion 141 Global Surgical Package for Professional Providers 143 Hysterectomy 147 Maternity Services 150 Sterilization 152 Transportation Transportation Services: Ambulance and Nonemergent Transport 155

4 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Claims Requiring Additional Documentation Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claims submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy Professional providers and facilities are required to submit additional documentation for adjudication of applicable types of claims. If the required documentation is not submitted, the claim may be denied. Applicable types of claims include: Upon request, claims for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), and home health and rehabilitation therapies (e.g., physical, occupational, speech) UniCare Health Plan of West Virginia, Inc. WEB-UWV

5 Reimbursement Policy: Claims Requiring Additional Documentation Page 5 of 160 Claims with unlisted or miscellaneous codes Claims for services requiring clinical review (e.g., complicated or unusual procedures, emergency room services, etc.) Claims for services found to possibly conflict with covered benefits to covered persons after validity review of member s medical records (e.g., member eligibility) Claims for services found to possibly conflict with medical necessity of covered benefits to covered persons (e.g., new technology, potential experimental or investigational procedures, devices, potential cosmetic procedures, etc.) Claims requesting an extension of benefits Claims being reviewed for potential fraud, abuse or demonstrated patterns of billing/coding inconsistent with peer benchmarks Claims for services that require an invoice (e.g., custom DME/ prosthetics that are reimbursed based on purchase price) Claims for services that require an itemized bill (e.g., stop-loss, denied inpatient days, carve-out services) Claims for beneficiaries with other health insurance Claims requiring documentation of the receipt of an informed consent form (e.g., sterilization,) Claims requiring a certificate of medical necessity (e.g., motorized wheelchairs, lymphedema pumps, oxygen, etc.) Appealed claims where supporting documentation may be necessary for determination of payment Other documentation required by the CMS and state or federal regulation UniCare may request additional documentation or notify the provider or facility of additional documentation required for claims, subject to contractual obligations. If documentation is not provided following the request or notification, UniCare may: Deny the claim, as provider failed to provide required prepayment documentation. Recoup monies previously paid on the claim if the provider failed to provide required documentation for postpayment review. UniCare is not liable for interest or penalties when payment is denied or recouped because the provider fails to submit required or requested documentation. History UniCare review approved and effective 03/01/15

6 Reimbursement Policy: Claims Requiring Additional Documentation Page 6 of 160 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Claims timely filing Documentation standards for episodes of care Unlisted or miscellaneous codes (aka: dump codes) Related materials None

7 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Claims Submission Required Information for Facilities Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claims submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy Institutional providers (facilities) are required, unless otherwise stipulated in their contract, to submit the original CMS 1500/UB92 uniform institutional provider bill to UniCare for payment of health care services. Providers must submit a properly completed UB-04/CMS-1450 for services performed or items/devices provided. If the required information is not provided, the claim is not considered a clean claim and UniCare can delay or deny payment without being liable for interest or penalties. The UB-04/CMS-1450 claim form must include the following information, if UniCare Health Plan of West Virginia, Inc. WEB-UWV

8 Reimbursement Policy: Claims Submission Required Information for Facilities Page 8 of 160 applicable: Facility information (i.e., name and address) Bill type Federal tax ID number (TIN) Date period the UB-04/CMS-1450 covers Patient information (i.e., name, subscriber number, address, date of birth, gender and marital status) Admission date and type Admission hour for inpatient services only Point of origin for admission or visit Discharge hour for inpatient services only Patient discharge status code Condition code(s) Accident state, if applicable Occurrence code(s) and date(s) Occurrence span code(s) and date(s) Revenue code(s) and description(s) and applicable corresponding CPT/HCPCS codes, if necessary. Applicable claims billed only with the revenue code will be denied. Providers will be asked to resubmit with the correct CPT/HCPCS code in conjunction with the applicable revenue code Date(s), unit(s) and total charge(s) of service(s) rendered Insurance payer s information (i.e., name, provider number and coordination of benefits secondary and tertiary payer information) Prior payments payers, if applicable Insured s information (i.e., name, relationship to patient, member ID number, insurance group name and number, date of birth, employer name and location) Principal, admitting and other ICD-9 diagnosis codes, including 4th and 5th digit when required Present on admission (POA) indicator, as applicable Code (ICD-9 procedure) and date of principal procedure for inpatient services, if applicable National provider identifier state Medicaid provider number (in accordance with the applicable state requirements) Encounter reporting data elements in accordance with applicable state

9 Reimbursement Policy: Claims Submission Required Information for Facilities Page 9 of 160 compliance requirements, including: o Admission source code o Applicable value code for billed admission type code o Birth weight with applicable value and admission type codes o Facility type code o National drug code(s) (NDC) to include the NDC number, unit price, quantity and composite measure per drug UniCare cannot accept claims with alterations to billing information (e.g., using correction fluid/tape, crossing out or writing over mistakes). Claims that have been altered will be returned to the provider with an explanation of the reason for the return. Although UniCare prefers the submission of claims electronically through the electronic data interchange, UniCare will accept paper claims. A paper claim must be submitted on an original claim form with dropout red ink, computer-printed or typed, in a large, dark font in order to be read by optical character reading technology. All claims must be legible. If any field on the claim is illegible, the claim will be rejected or denied. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Acceptance of altered claim forms Claims requiring additional documentation Claims submission Required information for professional providers Other provider preventable conditions (OPPC) Present on admission indicator for health-care acquired conditions Related materials UniCare electronic data interchange manual

10 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care UniCare Health Plan of West Virginia, Inc. WEB-UWV Reimbursement Policy Subject: Claims Submission Required Information for Professional Providers Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy Professional providers of health care services are required, unless otherwise stipulated in their contract, to submit an original CMS-1500 health insurance claim form to UniCare for payment of health care services. Providers must submit a properly completed CMS-1500 for services performed or items/devices provided. If the required information is not submitted, the claim is not considered a clean claim, and UniCare will deny payment without being liable for interest or penalties. The CMS-1500 claim form must include the following information, if

11 Reimbursement Policy: Claims Submission Required Information for Professional Providers Page 11 of 160 applicable: Patient information (i.e., name, address, date of birth, gender, relationship to insured, medical condition as related to employment or an accident, marital status, employment and student status) Insured s information (i.e., member ID number, subscriber number, name, address including ZIP code, telephone number, policy group or FECA number, date of birth, name of employer or school, name of insurance plan or program and name of other health benefit plan) Coordination of benefits/other insured s information (i.e., name, date of birth, policy or group number, name of employer or school and name of insurance plan or program) Name of referring physician or source Indication of outside laboratory ICD-9 diagnosis code(s), including 4th and 5th digit when required Clinical Laboratory Improvement Act certification number Date(s) of service(s) rendered Place of service/location code(s) Description of services rendered using CPT-4 codes/hcpcs codes and appropriate modifiers Charge(s) for service(s) rendered Day(s) or unit(s) related to service(s) rendered Total charges, amount paid by patient (i.e., copay), and balance due Federal tax ID number Name and address of facility where services were rendered and the NPI of the service facility, if applicable National provider identifier: o Individual servicing provider s NPI must be reported as the rendering provider ID, if applicable o When billing is from a group, the group s NPI must be reported as the billing provider, if applicable Remittance information (i.e., name, address, telephone) Indication of signature on file or a handwritten or computer generated signature for the provider of service or his/her representative and date the form was signed National drug code(s) (NDC) to include the NDC number, unit price, quantity and composite measure per drug State Medicaid provider number as required by state regulation (in

12 Reimbursement Policy: Claims Submission Required Information for Professional Providers Page 12 of 160 accordance with the applicable state requirements) UniCare cannot accept claims with alterations to billing information (e.g., using correction fluid/tape, crossing out or writing over mistakes). Altered claims will be returned to the provider with an explanation of the reason for the return. Although UniCare prefers the submission of claims electronically through the electronic data interchange, UniCare will accept paper claims. A paper claim must be submitted on an original claim form with drop out red ink, computer-printed or typed, in a large, dark font in order to be read by optical character reading technology. All claims must be legible. If any field on the claim is illegible, the claim will be rejected or denied. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Acceptance of altered claim forms Claims requiring additional documentation Claims submission Required information for facilities Modifier usage Other provider preventable conditions Related materials UniCare electronic data interchange manual

13 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Claims Timely Filing: Participating and Nonparticipating Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claims submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of claims for covered services for covered members in compliance with federal and/or state mandates regarding claims timely filing requirements. UniCare follows the standard of 12 months for participating and nonparticipating providers and facilities. Timely filing is determined by subtracting the date of service from the date UniCare receives the claim and comparing the number of days to the applicable federal or state mandate. If there is no applicable federal UniCare Health Plan of West Virginia, Inc. WEB-UWV

14 Reimbursement Policy: Claims Timely Filing: Participating and Nonparticipating Page 14 of 160 or state mandate, then the number of days is compared to the company standard. If services are rendered on consecutive days, such as for a hospital confinement, the limit will be counted from the last day of service. Limits are based on calendar days unless otherwise specified. If the member has other health insurance that is primary, then timely filing is counted from the date of the explanation of payment (EOP) of the other carrier. Providers resubmitting paper claims for corrections must clearly mark the claim Corrected Claim. Corrected claims submitted electronically must have the applicable frequency code. Failure to mark the claim appropriately may result in denial of the claim as a duplicate. Corrected claims must be received within the applicable timely filing requirements of the originally submitted claim due to the original claim not being considered a clean claim. Claims filed beyond federal or state-mandated, or UniCare standard timely filing limits will be denied as outside the timely filing limit. Services denied for failure to meet timely filing requirements are not subject to reimbursement unless the provider presents documentation proving a clean claim was filed within the applicable filing limit. UniCare reserves the right to waive timely filing requirements on a temporary basis following documented natural disasters or under applicable state guidance. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Eligible charges Requirements for documentation of proof of timely filing Related materials None

15 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Code and Clinical Editing Guidelines Reimbursement Policy Effective Date: TBD Committee Approval Obtained: TBD Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare applies code and clinical editing guidelines (CCEG) to evaluate claims for accuracy and adherence to nationally accepted industry standards and plan benefits unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. UniCare uses software products that ensure compliance with standard code edits and rules. These products increase consistency of payment for providers by ensuring correct coding and billing practices are followed. CCEG consists of the following measures, including but not limited to: UniCare Health Plan of West Virginia, Inc. WEB-UWV

16 Reimbursement Policy: Code and Clinical Editing Guidelines Page 16 of 160 Code editing software, CMS National Correct Coding Initiative edits and outpatient code edits Clinical criteria Licensed clinical medical review Claims processing platform Per state requirements, UniCare publishes its use of specific commercial code editing software. UniCare only customizes applicable CCEG measures due to compelling business reasons. CCEG measures are updated as applicable and as needed to incorporate new codes, code definition changes and edit rule changes. All claims submitted after the configuration implementation date, regardless of service date, will be processed according to up-to-date CCEG measures. No retrospective payment changes, adjustments, and/or requests for refunds will be made when processing changes are a result of new code editing rules within a module update. The member is not responsible and should not be balance billed for any procedures for which payment has been denied or reduced as the result of CCEG measures. UniCare uses CCEG to analyze outpatient services, including those that are considered: Rebundled or unbundled services Mutually exclusive services Incidental procedures or items Inappropriately billed visits Diagnosis to procedure mismatch Upcoded services Other procedures and categories that are reviewed include: Cosmetic procedures Obsolete or unlisted procedures Age/gender mismatch procedures Investigational or experimental procedures Procedure eligibility (e.g., assistant at surgery, co-surgeons, surgical teams, multiple fee reductions, etc.) Procedures billed with inappropriate modifiers UniCare does not allow reimbursement for services, procedures, items, etc., that conflict with CCEG. History UniCare review approved and effective TBD

17 Reimbursement Policy: Code and Clinical Editing Guidelines Page 17 of 160 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies None Related materials None

18 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Documentation Standards for Episodes of Care Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare requires that upon request for clinical documentation to support claims payment for services, the provided information should: Identify the member Be legible Reflect all aspects of care To be considered complete, documentation for episodes of care will UniCare Health Plan of West Virginia, Inc. WEB-UWV

19 Reimbursement Policy: Documentation Standards for Episodes of Care Page 19 of 160 include, at a minimum, the following elements: Patient identifying information Consent forms Health history, including applicable drug allergies Physical examinations Diagnoses and treatment plans for individual episodes of care Physician orders Face-to-face evaluations, when applicable Progress notes Referrals, when applicable Consultation reports, when applicable Laboratory reports, when applicable Imaging reports (including X-ray), when applicable Surgical reports, when applicable Admission and discharge dates and instructions, when applicable Preventive services provided or offered, appropriate to member s age and health status Evidence of coordination of care between primary and specialty physicians, when applicable Working diagnoses consistent with findings and test results Treatment plans consistent with diagnoses Providers should refer to standard data elements to be included for specific episodes of care as established by The Joint Commission, formerly the Joint Commission on Accreditation of Healthcare Organizations. A single episode of care refers to continuous care or a series of intervals of brief separations from care to a member by a provider or facility for the same specific medical problem or condition. Documentation for all episodes of care must meet the following criteria: Legible to someone other than the writer Information identifying the member must be included on each page in the medical record Each entry in the medical record must be dated and include author identification, which may be a handwritten signature, unique electronic identifier or initials

20 Reimbursement Policy: Documentation Standards for Episodes of Care Page 20 of 160 Other documentation not directly related to the member Other documentation not directly related to the member, but relevant to support clinical practice, may be used to support documentation regarding episodes of care, including: Policies, procedures and protocols Critical incident/occupational health and safety reports Statistical and research data Clinical assessments Published reports/data UniCare may request that providers submit additional documentation, including medical records or other documentation not directly related to the member, to support claims submitted by the provider. If documentation is not provided following the request or notification, or if documentation does not support the services billed for the episode of care, UniCare may: Deny the claim Recover and/or recoup monies previously paid on the claim UniCare is not liable for interest or penalties when payment is denied or recouped because the provider fails to submit required or requested documentation. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract The Joint Commission standards Definitions General Reimbursement Policy Definitions Related policies Claims requiring additional documentation Claims submission Required information for facilities Claims submission Required information for professional providers Related materials None

21 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Duplicate or Subsequent Services on the Same Date of Service Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of a duplicate or subsequent service provided on the same date of service if billed with an appropriate modifier or with additional units, as applicable within benefit limits unless otherwise noted by provider, state, federal or CMS contracts and/or requirements. Reimbursement of a duplicate or subsequent service Reimbursement of duplicate or subsequent services is based on the correct usage of the modifiers below that indicate the service was UniCare Health Plan of West Virginia, Inc. WEB-UWV

22 Reimbursement Policy: Duplicate or Subsequent Services on the Same Date of Service Page 22 of 160 appropriately repeated or additionally billed for the same member: Modifier 62: Co-surgeons Modifier 66: Surgical teams Modifier 76: Repeat procedure by the same physician Modifier 77: Repeat procedure by another physician Modifier 80: Assistant at surgery providing full assistance to the primary surgeon Modifier 81: Assistant at surgery providing minimal assistance to the primary surgeon Modifier 82: Assistant at surgery, when a qualified resident surgeon is not available to assist the primary surgeon Modifier AS: Assistant at surgery who is a nonphysician (e.g., physician assistant, nurse practitioner) Modifier 91: Repeat clinical diagnostic laboratory test Modifier GG: Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day Modifier GH: Diagnostic mammogram converted from screening mammogram on same day UniCare may deny a duplicate or subsequent service provided on the same date of service billed on the same or separate claims unless billed with an appropriate modifier. UniCare will review claims billed with suspected duplicate or subsequent services. Claims will be denied for services determined to be duplicate or subsequent claims without the appropriate modifier. Reimbursement of bundled services When a service is unbundled from a more complex or comprehensive service and billed individually on the same date of service as the more comprehensive service: The claim line for the individual service will be denied through code editing if billed on the same claim. The claim will be reviewed if billed on separate claims. The following modifiers indicate an individual service is distinct and separate from the more comprehensive service: Modifier 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Modifier 59: Distinct procedural service

23 Reimbursement Policy: Duplicate or Subsequent Services on the Same Date of Service Page 23 of 160 History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract Duplicate Services: A service is considered a definite duplicate if some or all of the following elements on the claim match: o Member o Date of service o Charge amount o Provider of service o Type of service, based on procedure or revenue codes used A service is suspected duplicate if the following elements on the claim match: o Member o Procedure code o Date of service Subsequent Service: For purposes of this policy, it is a medically necessary service that is performed or provided for the same member more than once on the same date of service General Reimbursement Policy Definitions Assistant at surgery (Modifiers 80/81/82/AS) Code and clinical editing guidelines Modifier 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Modifier 59: Distinct procedural service Modifier 62: Co-surgeons Modifier 66: Surgical teams Modifier 76: Repeat procedure by the same physician Modifier 77: Repeat procedure by another physician Modifier 91: Repeat clinical diagnostic laboratory test Modifier usage Related materials None

24 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Eligible Charges Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of eligible charges unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Eligible charges are those charges billed by the provider subject to conditions and requirements which make the service eligible for reimbursement. Eligibility for reimbursement of the service is dependent upon application of the following conditions and requirements: UniCare Health Plan of West Virginia, Inc. WEB-UWV

25 Reimbursement Policy: Eligible Charges Page 25 of 160 Member program eligibility Provider program eligibility Benefit coverage Authorization requirements Provider manual guidelines UniCare administrative policies UniCare clinical policies UniCare reimbursement policies Code editing logic The allowed amount reimbursed for the eligible charge is based on the applicable fee schedule or contracted/negotiated rate after application of coinsurance, copayments, deductibles and coordination of benefits. UniCare will not reimburse providers for: Items the provider receives free of charge. Items the provider provides to the member free of charge. In the absence of clear language or specific reference to eligible charges in provider contracts, the use of the following terms will default to eligible charges as stated within this policy: Billed charges Covered charges Billed charges for covered services Allowed charges Percent of charge History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract National Association of Insurance Commissioners (NAIC) Model Regulation, 2013 Definitions General Reimbursement Policy Definitions Related policies Claims submission Required information for professional providers Related materials None

26 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Emergency Services: Nonparticipating Providers and Facilities Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for emergency services provided by nonparticipating providers and facilities unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Unless otherwise required by federal and/or state regulation or contract, reimbursement is based on no more than: Medicaid product lines only: The amount that would have been reimbursed to the provider by the beneficiary s state fee-for-service Medicaid program UniCare Health Plan of West Virginia, Inc. WEB-UWV

27 Reimbursement Policy: Emergency Services: Nonparticipating Providers and Facilities Page 27 of 160 All other product lines: The applicable out-of-network emergency rate for nonparticipating providers and facilities UniCare adheres to the requirements of the Emergency Medical Treatment and Labor Act (EMTALA) and the Federal Medicaid Managed Care Regulations. UniCare will act in accordance with the Deficit Reduction Act (DRA) of 2005, Section 6085, with an effective date of January 1, 2007, that states: Any provider of emergency services that does not have in effect a contract with a Medicaid managed care entity that establishes payment amounts for services furnished to a beneficiary enrolled in the entity s Medicaid managed care plan must accept as payment in full no more than the amounts (less any payments for indirect costs of medical education and direct costs of graduate medical education) that it could collect if the beneficiary received medical assistance under this title other than through enrollment in such an entity. In a State where rates paid to hospitals under the State plan are negotiated by contract and not publicly released, the payment amount applicable under this subparagraph shall be the average contract rate that would apply under the State plan for general acute care hospitals or the average contract rate that would apply under such plan for tertiary hospitals. UniCare shall develop and maintain a record, pursuant to DRA stipulations, for West Virginia s payment methodology according to its FFS Medicaid program. DRA applicability will apply to the Medicaid product line. UniCare will not limit consideration of reimbursement for emergency services on the basis of lists of diagnoses or symptoms; however, additional medical record documentation may be required in order to clearly identify and determine appropriate reimbursement of emergency services. Claims for emergency services are subject to UniCare s eligible charges, code and clinical editing and claims requiring additional documentation policies. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Deficit Reduction Act of 2005 (Pub.L. No ) Emergency Medical Treatment and Labor Act (EMTALA)

28 Reimbursement Policy: Emergency Services: Nonparticipating Providers and Facilities Page 28 of 160 Definitions General Reimbursement Policy Definitions Related policies Claims requiring additional documentation Claims submissions - Required information for facilities Claims submissions - Required information for professional providers Code and clinical editing Eligible charges Related materials None

29 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Inpatient Facility Transfers Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows payment for services rendered by both the sending and the receiving facility when a patient is admitted to one acute care facility and subsequently transferred to another acute care facility for the same episode of care, in compliance with federal and/or state guidelines regarding facility transfers payment. UniCare will use the following criteria: Transferring facility will receive a calculated per diem rate based on length of stay not to exceed the amount that would have been UniCare Health Plan of West Virginia, Inc. WEB-UWV

30 Reimbursement Policy: Inpatient Facility Transfers Page 30 of 160 paid if the patient had been discharged to another setting. Receiving facility will receive full diagnosis related group (DRG) payment. This policy only affects those facilities reimbursed for inpatient services by a DRG methodology. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Diagnoses used in DRG computation Documentation standards for episodes of care Inpatient readmissions Other provider preventable conditions Present on admission facility acquired conditions Transportation services Related materials None

31 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Inpatient Readmissions Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare does not allow separate reimbursement for claims that have been identified as a readmission to the same hospital for the same, similar, or related condition unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. In the absence of UniCare Health Plan of West Virginia, Inc. WEB-UWV

32 Reimbursement Policy: Inpatient Readmissions Page 32 of 160 federal, state and/or contract mandates, UniCare will use the following standards: Readmission up to seven days from discharge Same or related diagnoses related group (DRG) Readmissions occurring on the same day for symptoms related to, or for evaluation and management of, the prior stay s medical condition are considered part of the original admission and will be combined. UniCare considers a readmission to the same hospital for the same, similar or related condition on the same date of service to be a continuation of initial treatment. UniCare reserves the right to recoup and/or recover monies previously paid on a claim that falls within the guidelines of a readmission for a same, similar or related condition as defined above. Exclusions Admissions for the medical treatment of cancer, primary psychiatric disease and rehabilitation care Planned readmissions Patient transfers from one acute care hospital to another Patient discharged from the hospital against medical advice This policy only affects those facilities reimbursed for inpatient services by a DRG methodology. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Diagnoses used in DRG computation Documentation standards for episodes of care Other provider preventable conditions Present on admission hospital acquired conditions Related materials None

33 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Locum Tenens Physicians Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of locum tenens physicians in accordance with CMS guidelines unless provider, state or federal contracts and/or requirements indicate otherwise. UniCare will reimburse the member s regular physician or medical group for all covered services (including emergency visits) provided by a locum tenens physician during the absence of the regular physician, in cases where the regular physician pays the locum tenens physician UniCare Health Plan of West Virginia, Inc. WEB-UWV

34 Reimbursement Policy: Locum Tenens Physicians Page 34 of 160 on a per diem or similar fee-for-time basis. Reimbursement to the regular physician or medical group is based on the applicable fee schedule or contracted/negotiated rate. The locum tenens physician may not provide services to a member for longer than 60 continuous days. Services included in a global fee payment are not eligible for separate reimbursement when provided by a locum tenens physician (i.e., postoperative only services). A member s regular physician or medical group should bill the appropriate procedure code(s) identifying the service(s) provided by the locum tenens physician with a Modifier Q6 appended to each procedure code. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Modifier usage Reimbursement of sanctioned and opt-out provider Scope of practice Related materials None

35 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Other Provider Preventable Conditions Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare does not reimburse for other provider preventable conditions (OPPC) as identified by CMS contracts and/or requirements. Procedures identified as OPPC will be rejected or denied. OPPC is defined and categorized as one of the following: Surgical or other invasive procedure performed on the wrong body part Surgical or other invasive procedure performed on the wrong UniCare Health Plan of West Virginia, Inc. WEB-UWV

36 Reimbursement Policy: Other Provider Preventable Conditions Page 36 of 160 patient Wrong surgical or other invasive procedure performed on a patient Erroneous surgical events occurring during an inpatient stay should be reflected on Type of Bill 0110 (nopay claim) along with all services or procedures related to the surgery. All other inpatient procedures and services should be submitted in a separate claim. Note: The PC modifier is defined as wrong surgery on a patient. It should not be used to represent the professional component of a service. Claims that incorrectly use this modifier may be denied. Claims with this modifier used incorrectly must be resubmitted as a corrected claim and indicate the appropriate coding for the service(s) rendered. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Claims requiring additional documentation Claims submission Required information for facilities Claims submission Required information for professional provider Documentation standards for episodes of care Global surgical package Present on admission indicator for health-care acquired conditions Related materials None

37 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Present on Admission Indicator for Health Care-Acquired Conditions Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare requires the identification of hospital-acquired conditions and health care-acquired conditions (both referred to as health care acquired conditions [HCAC]) through the submission of a present on admission (POA) indicator for all diagnoses on all facility claims unless otherwise noted by CMS. In accordance with the Deficit Reduction Act of 2005, POA indicators (see exhibit A) are required for all inpatient discharges on or after October 1, The POA indicator is required for all primary and UniCare Health Plan of West Virginia, Inc. WEB-UWV

38 Reimbursement Policy: Present on Admission Indicator for Health-Acquired Conditions Page 38 of 160 secondary diagnosis codes but is not required on the admitting diagnosis. Failure to include the POA indicator with the primary and secondary diagnosis codes may result in the claim being denied or rejected. If the POA indicator identifies an HCAC, the reimbursement for that episode of care may be reduced or denied. UniCare will not apply payment reduction if a condition defined as HCAC for a particular patient existed prior to the initiation of treatment for that patient by that provider. Unless noted in exhibit B, this requirement applies to all facilities. If an HCAC is caused by one provider or facility (primary), payment will not be denied to the secondary provider or facility that treated the HCAC. UniCare reserves the right to request additional records to support documentation submitted for reimbursement. Note: Claims may be subject to clinical review for appropriate reimbursement consideration. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Code of Federal Regulations (CFR) Subpart A-Payments Federal Register Vol. 76, No A. The Medicare Program and Quality Improvements Made in the Deficit Reduction Act of 2005 (DRA) (Pub. L ) and E. Section 2702 of the Affordable Care Act Federal Register Vol. 76, No I. Implementation of Hospital- Acquired Condition (HAC) Reduction Program for FY 2015 Definitions General Reimbursement Policy Definitions Related policies Claims requiring additional documentation Claims submission Required information for facilities Claims submission Required information for professional providers Documentation standards for episodes of care Global surgical package

39 Reimbursement Policy: Present on Admission Indicator for Health-Acquired Conditions Page 39 of 160 Related materials Exhibit A: Present on admission indicators and description Exhibit B: Medicare exempt facilities Exhibit C: Healthcare-acquired condition categories

40 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Requirements for Documentation of Proof of Timely Filing Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare will reconsider reimbursement of a claim that is denied for failure to meet timely filing requirements, unless provider, state, federal or CMS contracts and/or requirements indicate otherwise, when a provider can: Provide a date of claim receipt compliant with applicable timely filing requirements Demonstrate good cause exists UniCare Health Plan of West Virginia, Inc. WEB-UWV

41 Reimbursement Policy: Requirements for Documentation of Proof of Timely Filing Page 41 of 160 Documentation of claim receipt The following information will be considered proof that the claim was received timely. If the claim is submitted: By United States mail: First class, return receipt requested or by overnight delivery service - The provider must provide a copy of the claim log that identifies each claim included in the submission Electronically: The provider must provide the clearinghouse assigned receipt date from the reconciliation reports By fax: The provider must provide proof of facsimile transmission By hand delivery: The provider must provide a claim log that identifies each claim included in the delivery and a copy of the signed receipt acknowledging the hand delivery The claims log maintained by providers must include the following information: Name of claimant Address of claimant Telephone number of claimant Claimant's federal tax ID number Name of addressee Name of carrier Designated address Date of mailing or hand delivery Subscriber name Subscriber ID number Patient name Date(s) of service/occurrence, total charge and delivery method Good cause Good cause may be established by the following: If the claim includes an explanation for the delay (or other evidence which establishes the reason), UniCare will determine good cause based primarily on that statement or evidence. If the evidence leads to doubt about the validity of the statement, UniCare will contact the provider for clarification or additional information necessary to make a good cause determination. Good cause may be found when a physician or supplier claim filing delay was due to:

42 Reimbursement Policy: Requirements for Documentation of Proof of Timely Filing Page 42 of 160 Administrative error incorrect or incomplete information furnished by official sources (e.g., carrier, intermediary, CMS) to the physician or supplier Incorrect information furnished by the member to the physician or supplier resulting in erroneous filing with another care management organization plan or with the state Unavoidable delay in securing required supporting claim documentation or evidence from one or more third parties despite reasonable efforts by the physician/supplier to secure such documentation or evidence Unusual, unavoidable or other circumstances beyond the service provider s control which demonstrate that the physician or supplier could not reasonably be expected to have been aware of the need to file timely Destruction or other damage of the physician s or supplier s records unless such destruction or other damage was caused by the physician s or supplier s willful act of negligence History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Acknowledgement of receipt and received date for EDI submission Claims timely filing: Participating and nonparticipating Related materials None

43 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Reimbursement for Items under Warranty Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare does not allow reimbursement for repair or replacement of rented or purchased items during the warranty period designated by the applicable manufacturer unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Items include: Durable medical equipment Supplies UniCare Health Plan of West Virginia, Inc. WEB-UWV

44 Prosthetics Orthotics West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc. Reimbursement Policy: Reimbursement for Items Under Warranty Page 44 of 160 The manufacturer and/or distributor is responsible for: Repairing the item or providing an acceptable replacement item All fees associated with shipment of the defective item All fees associated with delivery of the repaired item In circumstances where UniCare has reimbursed the provider for repair or replacement of an item during the warranty period, UniCare is entitled to recoup fees from the manufacturer and/or distributor holding the warranty. Providers are required to supply members with information concerning the manufacturer s warranty for all items dispensed to members. UniCare will consider reimbursement for replacement of the item through another manufacturer, after review, only in circumstances where both the member and member s provider deem the manufacturer s replacement of the applicable item unacceptable. The design, materials, measurements, fabrications, testing, fitting and training in the use of another manufacturer s replacement item are included in the reimbursement of the item and are not separately reimbursable expenses. If the manufacturer offers an acceptable reduced-price replacement, but either the member prefers another replacement at full price or a provider did not utilize the reduced-price offer, UniCare allows reimbursement only up to the cost of the reduced-price item under the prudent buyer rule. If the manufacturer offers an acceptable replacement, but imposes a charge or pro rata payment, UniCare allows reimbursement for the partial payment imposed by the manufacturer, subject to approval. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies None Related materials None

45 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Reimbursement of Claims with Charge Discrepancies Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for claims submitted with an itemized statement where there is a discrepancy in total charges less than $100 unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Itemized claims with discrepancies totaling more than $100 or claims submitted that are not itemized and contain a discrepancy between the line item and the total amount billed will be denied and returned to the provider as an unclean claim. The provider will be required to resubmit UniCare Health Plan of West Virginia, Inc. WEB-UWV

46 Reimbursement Policy: Reimbursement of Claims with Charge Discrepancies Page 46 of 160 a corrected claim for reimbursement. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid American Medical Association State contract Definitions General Reimbursement Policy Definitions Related policies Claims timely filing: Participating and nonparticipating Related materials None

47 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Reimbursement of Sanctioned and Opt-Out Providers Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare does not allow reimbursement to providers who are excluded or debarred from participation in state and federal health care programs. UniCare also does not allow reimbursement to providers who have rendered services to members enrolled in any Medicare program if such provider has opted out from participation in Medicare. Services that are rendered by such a provider that is sanctioned or has opted out of participation in Medicare may only be reimbursed in urgent or emergent situations. Claims received for services other than emergency services submitted by sanctioned or opt-out providers as UniCare Health Plan of West Virginia, Inc. WEB-UWV

48 Reimbursement Policy: Reimbursement of Sanctioned and Opt-Out Providers Page 48 of 160 provided herein will be denied. UniCare will allow reimbursement to a sanctioned or opt-out provider for emergency items or services only if the claim is accompanied by a sworn statement of the person furnishing the items or services specifying: The nature of the emergency Why the items or services could not have been furnished by a provider eligible to furnish or order such items or services Note: Payment may not be made for services furnished by an opt-out physician or practitioner who has signed a private contract with a Medicare beneficiary for emergency or urgent care items. UniCare screens providers through all applicable state and federal exclusion lists. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of medical necessity, generally accepted standards of medical practice and review of medical literature and government approval status, in addition to the following: CMS State Medicaid State contract Code of Federal Regulations Social Security Act Definitions General Reimbursement Policy Definitions Related policies Related materials None Claims requiring additional documentation Emergency services: Nonparticipating providers and facilities

49 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Scope of Practice Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare Health Plan of West Virginia, Inc. WEB-UWV UniCare allows reimbursement for services that are within the provider s scope of practice under state law in accordance with CMS guidelines unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. The provider shall be licensed in or hold a license recognized in the jurisdiction where the patient encounter occurs. UniCare allows reimbursement for telemedicine performed within the provider s scope of practice as regulated by state law.

50 Reimbursement Policy: Scope of Practice Page 50 of 160 Scope of practice is determined by: Advanced practice education in a role and specialty Legal implications Scope of practice statements as published by national professional specialty and advanced organizations State medical licensure requirements Federal regulations Services provided outside of a practitioner s scope of practice are not covered or reimbursable. UniCare allows reimbursement for providers with nonresidency but who have advanced training performing services in a medically underserved area as allowed by state law. UniCare allows reimbursement for providers when no board-certified physicians are available to meet local requirements as allowed by state law. History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract 42 CFR Code of Federal Regulations on Scope of Practice Scope of Practice refers to: o The extent to which providers may render health care services and the extent they may do so independently o The type of diseases, ailments, and injuries a health care provider may address (American Medical Association glossary of terms). General Reimbursement Policy Definitions Locum tenens physicians Professional anesthesia services Reimbursement of sanctioned and opt-out providers Related materials None

51 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Site of Service Payment Differential Professional UniCare Health Plan of West Virginia, Inc. WEB-UWV Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare applies site of service payment differential for professional services based on the setting in which they were provided unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on one of the following: The applicable fee schedule or contracted/negotiated rate in line with the state or provider contract, which may include a site of service differential The applicable out-of-network reimbursement rate for nonparticipating providers

52 Reimbursement Policy: Site of Service Payment Differential - Professionals Page 52 of 160 Some services, by nature of their description, are performed only in certain settings and have only one maximum allowable fee per code. History UniCare review approved and effective 03/01/15 References and research materials Definitions This policy has been developed through consideration of the following: CMS State Medicaid State contract Site of Service Differential: Some professional services may be provided either in a facility or a non-facility. When a professional service is provided in a facility, the costs of the clinical personnel, equipment and supplies are incurred by the facility, not the physician practice. For this reason, reimbursement for professional services provided in a facility may be lower than if the services were performed in a non-facility setting. This difference in reimbursement, based on where the professional service is performed, is often referred to as a site of service differential. Facility Rate: The rate paid for professional services performed in a facility setting Non-facility Rate: The rate paid for professional services performed in a setting that is not a facility General Reimbursement Policy Definitions Related policies None Related materials None

53 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Professional Anesthesia Services Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Anesthesia ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for anesthesia services rendered by professional providers for covered members unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on: The reimbursement formula for the allowance and time increments in accordance with CMS. Proper use of applicable modifiers. UniCare Health Plan of West Virginia, Inc. WEB-UWV

54 Reimbursement Policy: Professional Anesthesia Services Page 54 of 160 Providers must report anesthesia services in minutes. Anesthesia claims submitted with an indicator other than minutes may be rejected or denied. Start and stop times must be documented in the member s medical record. Anesthesia time starts with the preparation of the member for administration of anesthesia and stops when the anesthesia provider is no longer in personal and continuous attendance. The reimbursement formula for anesthesia allowance is based upon CMS guidelines, unless otherwise noted in the exemption section. Anesthesia modifiers Anesthesia modifiers are appended to the applicable procedure code to indicate the specific anesthesia service or who performed the service. Modifiers identifying who performed the anesthesia service must be billed in the primary modifier field to receive appropriate reimbursement. Additional or reduced payment for modifiers is based on state requirements, as applicable. If there is no state requirement, UniCare will default to the following CMS guidelines. Claims submitted for anesthesiology services without the appropriate modifier will be denied. Modifier AA: Anesthesiology service performed personally by an anesthesiologist reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate Modifier AD: Medical supervision by a physician; more than four concurrent anesthesia procedures reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate for up to three base units for anesthesiologists who supervise three or more concurrent or overlapping procedures Modifier QK: Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals reimbursement is based on 50% of the applicable fee schedule or contracted/negotiated amount Modifier QX: Certified registered nurse anesthetist (CRNA) service with medical direction by a physician reimbursement is based on 50% of the applicable fee schedule or contracted/ negotiated amount Modifier QY: Anesthesiologist medically directs one CRNA reimbursement is based on 50% of the applicable fee schedule or contracted/negotiated amount Modifier QZ: CRNA service without medical direction by a physician reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated amount Modifier 23: Denotes a procedure that must be done under general anesthesia due to unusual circumstances although normally done under local or no anesthesia reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate of the

55 Reimbursement Policy: Professional Anesthesia Services Page 55 of 160 procedure. Modifier 23 does not increase or decrease reimbursement; it substantiates billing anesthesia associated with the procedure in cases where anesthesia is not usually appropriate Modifier 47: Denotes regional or general anesthesia services provided by the surgeon performing the medical procedure. UniCare does not allow reimbursement of anesthesia services by the provider performing the medical procedure other than obstetrical (see obstetrical anesthesia section of this policy); therefore, it is not appropriate to bill Modifier 47. Multiple anesthesia procedures UniCare allows reimbursement for professional anesthesia services during multiple procedures. Reimbursement is based on the anesthesia procedure with the highest base unit value and the overall time of all anesthesia procedures. Obstetrical anesthesia UniCare allows reimbursement for professional neuraxial epidural anesthesia services provided in conjunction with labor and delivery for up to 300 minutes by either the delivering physician or a qualified provider other than the delivering physician based on the time the provider is physically present with the member. Providers must submit additional documentation upon dispute for consideration of reimbursement of time in excess of 300 minutes. Reimbursement is based on one of the following: For the delivering physician based on a flat rate or fee schedule using the surgical CPT pain management codes for epidural analgesia For a qualified provider other than the delivering physician based on: o The allowance calculation o The inclusion of catheter insertion and anesthesia administration Services provided in conjunction with anesthesia UniCare allows separate reimbursement for the following services provided in conjunction with the anesthesia procedure or as a separate service. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate with no reporting of time. Swan-Ganz catheter insertion Central venous pressure line insertion Intra-arterial lines Emergency intubation (must be provided in conjunction with the

56 Reimbursement Policy: Professional Anesthesia Services Page 56 of 160 anesthesia procedure to be considered for reimbursement) Critical care visits Transesophageal echocardiography Nonreimbursable UniCare does not reimburse for: Use of patient status modifiers or qualifying circumstances codes denoting additional complexity levels Anesthesia consultations on the same date as surgery or the day prior to surgery if part of the preoperative assessment Anesthesia services performed for noncovered procedures, including services considered not medically necessary, experimental and/or investigational Anesthesia services by the provider performing the basic procedure, except for a delivering physician providing continuous epidural analgesia Local anesthesia considered incidental to the surgical procedure Standby anesthesia services History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract American Society of Anesthesiologists Optum Learning: Understanding Modifiers, 2014 edition Anesthesia: Drugs or substances that cause a loss of consciousness or sensitivity to pain Base unit: Relative value unit associated with each anesthesia procedure code as assigned by CMS Time unit: An increment of 15 minutes where each 15-minute increment constitutes one time unit Conversion factor: A geographic-specific amount that varies by the locality where the anesthesia is administered General Reimbursement Policy Definitions Modifier usage Scope of practice Related materials None

57 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Assistant at Surgery (Modifiers 80/81/82/AS) Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding / Surgery ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for one assistant surgeon when eligible procedures are billed with Modifiers 80, 81, 82 or AS, as applicable unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. UniCare uses code editing software to process claims billed for assistant at surgery. If an applicable modifier is not billed appropriately, the procedure may be denied. When multiple procedures are performed where only some of the procedures are eligible for assistant at surgery reimbursement, only assistant at surgery services for the eligible procedures will be UniCare Health Plan of West Virginia, Inc. WEB-UWV

58 Reimbursement Policy: Assistant at Surgery Page 58 of 160 considered for reimbursement. The same multiple-procedure fee reductions and clinical edits apply to both the assistant at surgery and the primary surgeon. The assistant at surgery should not report procedure codes different from the procedure codes reported by the primary surgeon, except if the primary surgeon bills a global code (e.g., maternity antepartum, delivery and postpartum); then the assistant at surgery would bill the specific surgery code (e.g., delivery only) with the appropriate modifier. Assistant surgeon services are eligible for reimbursement as follows: Modifier 80: 16% Modifier 81: 16% Modifier 82: 16% Modifier AS: 14% History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract Optum Learning: Understanding Modifiers, 2014 edition Modifier 80: Denotes an assistant at surgery providing full assistance to the primary surgeon Modifier 81: Denotes an assistant at surgery providing minimal assistance to the primary surgeon Modifier 82: Denotes an assistant at surgery when a qualified resident surgeon is not available to assist the primary surgeon Modifier AS: denotes an assistant at surgery who is a nonphysician (e.g., physician assistant, nurse practitioner) General Reimbursement Policy Definitions Code and clinical editing guidelines Modifier usage Related materials None

59 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Diagnoses Used in DRG Computation UniCare Health Plan of West Virginia, Inc. WEB-UWV Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare ensures that the diagnosis and procedure codes that generate the diagnosis related groups (DRG) are accurate, valid and sequenced in accordance with national coding standards and specified guidelines unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. UniCare performs DRG audits to determine that the diagnostic and procedural information that led to the DRG assignment is substantiated by the medical record. The audits utilize coding criteria to limit the billed diagnosis used in DRG computation to the

60 following: West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc. Reimbursement Policy: Diagnoses Used in DRG Computations Page 60 of 160 Those that are relevant to the patient s care Those that impact the patient s outcome, treatment, intensity of service or length of stay Those that are supported by documentation within the medical record. UniCare routinely monitors DRG billing patterns to ensure that hospitals perform fair and equitable coding and utilization. History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract American Medical Association Diagnosis Related Groups (DRG) are a patient classification method which provides a means of relating the type of patients a hospital treats to the costs incurred by the hospital. General Reimbursement Policy Definitions Documentation standards for an episode of care Present on admission indicator for health-care acquired conditions Related materials None

61 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care UniCare Health Plan of West Virginia, Inc. WEB-UWV Reimbursement Policy Subject: Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) Effective Date: 08/24/15 Committee Approval Obtained: 08/24/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claim submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or Centers for Medicare & Medicaid Services (CMS) contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for a procedure or service that is distinct or independent from other service(s) performed on the same day by the same provider when billed with Modifier 59, XE, XP, XS or XU unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise. Modifier 59 should be used when a more descriptive modifier, like an XE, XP, XS or XU, collectively referred to as X{EPSU} is not available. The X{EPSU} modifiers are more selective versions of Modifier 59; it would be incorrect to include both modifiers on the

62 Reimbursement Policy: Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) Page 62 of 160 same claim line. Modifier Description 59 Used to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures or services that are not normally reported together, but are appropriate under the circumstances XE XP XS XU Separate Encounter, used to indicate a service that is distinct because it occurred during a separate encounter Separate Practitioner, used to indicate a service is distinct because it was performed by a different practitioner Separate Structure, used to indicate a service 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 UniCare reserves the right to perform post-payment review of claims submitted with Modifier 59 and X{EPSU}. UniCare may request that providers submit additional documentation, including medical records or other documentation not directly related to the member, to support claims submitted by the provider. If documentation is not provided following the request or notification, or if documentation does not support the services billed for the episode of care, we may: Deny the claim Recover and/or recoup monies previously paid on the claim UniCare is not liable for interest or penalties when payment is denied or recouped because the provider fails to submit required or requested documentation. Nonreimbursable UniCare does not allow reimbursement for the above listed modifiers in the following circumstances: The modifier is billed with Evaluation & Management (E&M) codes The modifier is billed with radiation therapy management codes A different modifier would describe the situation more accurately

63 Reimbursement Policy: Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) Page 63 of 160 NOTE: Refer to individual modifier policies for specific modifier requirements, guidelines, and exemptions. History Initial UniCare review approved and effective 08/24/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract American Medical Association: Coding with Modifiers, Fifth Edition Optum Learning: Understanding Modifiers, 2015 Edition U.S. Department of Health & Human Services, Office of the Inspector General, Semiannual Report to Congress, 1 October March 2006 U.S. Department of Health & Human Services, Office of the Inspector General, Use of Modifier 59 to Bypass Medicare s National Correct Coding Initiative Edits, OEI , November 2005 Definitions General Reimbursement Policy Definitions Related policies Professional Anesthesia Services Claims Requiring Additional Documentation Code and Clinical Editing Guidelines Maternity Services Modifier 24: Unrelated Evaluation and Management Service by Same Physician during Postoperative Period Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by Same Physician on Same Day of Procedure or Other Service Modifier 57: Decision for Surgery Modifier 78: Unplanned Return to Operating/Procedure Room by Same Physician Following Initial Procedure for a Related Procedure during Postoperative Period Modifier Usage Multiple and Bilateral Surgery: Professional and Facility Reimbursement Related materials None

64 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Modifier 22: Increased Procedural Service Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for procedure codes appended with Modifier 22 when the procedure or service provided is greater than what is usually required for the listed procedure code unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. UniCare performs prepayment review to support the use of Modifier 22. If medical review of the documentation submitted with the claim supports Modifier 22, reimbursement is based on 120% of the fee schedule or contracted/negotiated rate for the procedure appended with UniCare Health Plan of West Virginia, Inc. WEB-UWV

65 Modifier 22. West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc. Reimbursement Policy: Modifier 22: Increased Procedural Services Page 65 of 160 If the documentation does not support the use of Modifier 22 or there is no documentation submitted with the claim, reimbursement will not exceed 100% of the fee schedule or contracted/negotiated rate of the procedure. Modifier 22 is appropriate to use only with surgery, radiology, pathology, laboratory and medicine procedure codes with a global period of 0, 10, or 90 days. Nonreimbursable UniCare does not allow reimbursement for use of Modifier 22: With an inappropriate procedure code With procedures that do not have a global period (i.e., add-on codes) To indicate a procedure performed by a specialist UniCare does not allow additional reimbursement for anesthesia services billed with Modifier 22. History UniCare review approved and effective 03/01/15 References and research materials Definitions This policy has been developed through consideration of the following: CMS State Medicaid State contract American Medical Association: Coding with Modifiers, Fifth Edition Optum Learning: Understanding Modifiers, 2014 edition Modifier 22: Indicates that the work required to provide a service is substantially greater than typically required General Reimbursement Policy Definitions Related policies Modifier usage Related materials None

66 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during the Postoperative Period Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows limited reimbursement for physician claims billed with Modifier 24 unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate for the evaluation and management (E&M) service performed during the postoperative period of the original procedure if the following criteria are met: UniCare Health Plan of West Virginia, Inc. WEB-UWV

67 Reimbursement Policy: Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during the Postoperative Period Page 67 of 160 The appropriate level of E&M service is billed and appended with Modifier 24. A diagnosis code unrelated to the original procedure is indicated for the E&M service. The reason for the E&M service is clearly documented in the member s medical record. Failure to use Modifier 24 correctly may result in denial of the E&M service, and/or claim payments may be recouped and/or recovered. History UniCare review approved and effective 03/01/15 References and research materials Definitions This policy has been developed through consideration of the following: CMS State Medicaid State contract Optum Learning: Understanding Modifiers, 2014 edition Modifier 24: Used to indicate that the same physician needed to perform an evaluation and management (E&M) service unrelated to the original procedure during the postoperative period of the original service. E&M services performed during the postoperative period of the original service usually are considered part of the global surgical package. General Reimbursement Policy Definitions Related policies Modifier usage Related materials None

68 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows limited reimbursement for physician claims billed with Modifier 25 unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate for the significant, separately identifiable evaluation and management (E&M) service performed by the same provider on the same day of the original service or procedure if the UniCare Health Plan of West Virginia, Inc. WEB-UWV

69 Reimbursement Policy: Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service Page 69 of 160 following criteria are met: The appropriate level of E&M service is billed. Modifier 25 is appended to the E&M service, which is above and beyond the other service or procedure provided (including usual preoperative and postoperative care associated with the procedure). The reason for the E&M service is clearly documented in the member s medical record. The documentation supports that the member s condition required the significantly separate E&M service. Failure to use Modifier 25 correctly may result in denial of the E&M service. UniCare reserves the right to perform postpayment review of claims submitted with Modifier 25. History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract Optum Learning: Understanding Modifiers, 2014 edition Modifier 25: Used to indicate that on the day a procedure or service was performed, the member s condition required a significant, separately identifiable E&M service above and beyond the original service, or above and beyond the usual preoperative and postoperative care associated with the original procedure. The E&M service may be prompted by the symptom or condition for which the procedure and/or service was performed, so separate diagnoses codes are not required to report E&M codes on the same date. E&M services are not separately reimbursed from surgical and procedural services since these require appropriate provider involvement. General Reimbursement Policy Definitions Modifier 57: Decision for surgery Modifier usage Preventive medicine and sick visits on the same day Related materials None

70 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Modifier 57: Decision for Surgery Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows separate reimbursement for an evaluation and management (E&M) visit provided on the day prior to or the day of a major surgery, when billed with Modifier 57 to indicate the E&M visit resulted in the initial decision to perform the major surgical procedure unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. A major surgery has a 90-day global period. Reimbursement for the E&M visit is based on 100% of the applicable fee schedule or contracted/negotiated rate. UniCare reserves the right to UniCare Health Plan of West Virginia, Inc. WEB-UWV

71 Reimbursement Policy: Modifier 57: Decision for Surgery Page 71 of 160 request medical records for review to support payment for the E&M visit. Failure to use this modifier when appropriate may result in denial of the claim for the visit. Nonreimbursable UniCare does not allow reimbursement for services billed with Modifier 57 in the following circumstances unless state, federal or CMS contracts and/or requirements indicate otherwise: An E&M visit the day before or day of the surgery (e.g., preoperative evaluation) when the decision to perform the surgery was made prior to the E&M visit An E&M visit for minor surgeries (0- or 10-day global period); since the decision to perform a minor surgery is usually reached the same day or day before the procedure, is considered a routine preoperative service A service with non-e&m codes History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract American Medical Association: Coding with Modifiers, Fifth Edition Optum Learning: Understanding Modifiers, 2014 edition Definitions General Reimbursement Policy Definitions Related policies Global surgical package Modifier 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Modifier usage Related materials None

72 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Modifier 59: Distinct Procedural Service UniCare Health Plan of West Virginia, Inc. WEB-UWV Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for a procedure or service that is distinct or independent from other service(s) performed on the same day by the same provider when billed with Modifier 59 unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. UniCare reserves the right to perform postpayment review of claims submitted with Modifier 59. UniCare may request additional documentation or notify the provider of additional documentation required for claims, subject to contractual obligations. If documentation

73 Reimbursement Policy: Modifier 59: Distinct Procedural Service Page 73 of 160 is not provided following the request or notification, UniCare may recoup or recover monies previously paid on the claim, as the provider failed to submit required documentation for postpayment review. Nonreimbursable UniCare does not allow reimbursement for Modifier 59 when: Billed with evaluation & management (E&M) codes Billed with radiation therapy management codes A different modifier would describe the situation more accurately Note: Refer to individual modifier policies for specific modifier requirements and guidelines. History UniCare review approved and effective 03/01/15 References and research materials Definitions This policy has been developed through consideration of the following: CMS State Medicaid State contract American Medical Association: Coding with Modifiers, Fifth Edition Optum Learning: Understanding Modifiers, 2014 Edition U.S. Department of Health & Human Services, Office of the Inspector General, Semiannual Report to Congress, 1 October March 2006 U.S. Department of Health & Human Services, Office of the Inspector General, Use of Modifier 59 to Bypass Medicare s National Correct Coding Initiative Edits, OEI , November 2005 Modifier 59: Used to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures or services that are not normally reported together, but are appropriate under the circumstances. This may represent any of the following: o A different session o A different procedure or surgery o A different site or organ system o A separate incision or excision o A separate lesion o A separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual General Reimbursement Policy Definitions

74 Reimbursement Policy: Modifier 59: Distinct Procedural Service Page 74 of 160 Related policies Claims requiring additional documentation Code and clinical editing guidelines Maternity services Modifier 24: Unrelated evaluation and management service by same physician during postoperative period Modifier 25: Significant, separately identifiable evaluation and management service by same physician on same day of procedure or other service Modifier 57: Decision for surgery Modifier 78: Unplanned return to operating/procedure room by same physician following initial procedure for a related procedure during postoperative period Modifier usage Multiple and bilateral surgery: Professional and facility reimbursement Related materials None

75 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Modifier 62: Co-Surgeons Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of procedures eligible for co-surgeons when billed with Modifier 62 unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement to each surgeon is based on 62.5% of the applicable fee schedule or contracted/negotiated rate. Co-surgeons may be from the same specialty, or they may be from different specialties operating on separate body systems. Co-surgery is always performed during the same operative session. UniCare Health Plan of West Virginia, Inc. WEB-UWV

76 Reimbursement Policy: Modifier 62: Co-Surgeons Page 76 of 160 Each surgeon must bill the same procedure code(s) with Modifier 62. If one or both surgeons fail to use the modifier appropriately, it is possible that one surgeon may receive 100% of the applicable fee schedule or negotiated/contracted rate, and the other surgeon s claim may be denied or pended due to a duplicate or suspected duplicate service, respectively. Assistant surgeon and/or multiple procedures rules and fee reductions apply if: A co-surgeon acts as an assistant in performing additional procedure(s) during the same surgical session. Multiple procedures are performed. History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract Optum Learning: Understanding Modifiers, 2014 edition Modifier 62: Used to indicate two surgeons, usually from different specialties, where the participation of both surgeons is necessary in performing a specific operative procedure. Two surgeons may be necessary due to the complex nature of the procedure(s) or the member s condition. General Reimbursement Policy Definitions Assistant at surgery (Modifiers 80/81/82/AS) Duplicate or subsequent services on the same date of service Modifier usage Multiple and bilateral surgery reimbursement Related materials None

77 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Modifier 63: Procedure Performed on Infants less than 4 kg Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows additional reimbursement for surgery on neonates and infants up to a present body weight of 4 kg when billed with Modifier 63, unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on 120% of the applicable fee schedule (not to exceed the billed charges) or contracted/negotiated rate for the procedure code when the modifier is valid for services performed. Medical records may be requested for review to support the additional payment. The UniCare Health Plan of West Virginia, Inc. WEB-UWV

78 Reimbursement Policy: Modifier 63: Procedures Performed on Infants Less than 4 kg Page 78 of 160 neonate weight should be documented clearly in the report for the service. When an assistant surgeon is used and/or multiple procedures are performed on neonates or infants less than 4 kg in the same operative session, assistant surgeon and/or multiple procedure rules and fee reductions apply. Nonreimbursable UniCare does not allow reimbursement for Modifier 63 billed in the following circumstances: For facility billing With evaluation and management codes With anesthesia codes With radiology codes With pathology/laboratory codes With medicine codes With Modifier 63-exempt codes In addition to Modifier 22 (unusual services) for the same procedure code(s) With codes denoting invasive procedures that include neonate or infant in the description (e.g., surgery to correct a congenital abnormality), since the reimbursement rate for the code already reflects the additional work History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract Optum Learning: Understanding Modifiers, 2014 edition The Essential RBRVS, 2014 edition Modifier 63: Used to indicate a surgical procedure was performed on a neonate or infant up to a present body weight of 4 kg. The modifier is intended to capture procedures performed on neonates and infants within a certain weight limit, as these procedures may involve significantly increased complexity and physician work. General Reimbursement Policy Definitions Assistant at surgery (Modifiers 80/81/82/AS) Modifier usage

79 Related materials None West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc. Reimbursement Policy: Modifier 63: Procedures Performed on Infants Less than 4 kg Page 79 of 160 Multiple and bilateral surgery

80 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Modifier 66: Surgical Teams Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of procedures eligible for surgical teams when billed with Modifier 66 unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. UniCare performs a prepayment review to support the use of Modifier 66. Providers must submit documentation with claims billed with Modifier 66. Claims submitted without documentation will be denied. Each physician participating in the surgical team must bill the applicable procedure code(s) for their individual services with Modifier UniCare Health Plan of West Virginia, Inc. WEB-UWV

81 Reimbursement Policy: Modifier 66: Surgical Teams Page 81 of If any or all physicians participating in the surgery fail to use the modifier appropriately, claims may be denied or pended for duplicate or suspected duplicate services, respectively. Multiple procedure rules and fee reductions apply if the surgical team performs multiple procedures unless surgeons of different specialties are each performing a different procedure. Assistant surgery rules and fee reductions apply if any member of the surgical team acts as an assistant performing additional procedure(s) during the same surgical session. History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract Optum Learning: Understanding Modifiers, 2014 edition Modifier 66: Used in circumstances where highly complex procedures or the nature of the member s condition require the services of a surgical team. A surgical team consists of: o More than two physicians from different specialties performing different procedures (identified by different procedure codes) o Other highly skilled, specially trained personnel o Various types of complex equipment The surgical team concept is performed during the same operative session. Surgical teams may be appropriate for procedures including, but not limited to, organ transplants, surgeries on multiple organ systems, amputation, coronary artery bypass, surgery of the skull base to remove tumors or certain vertebral body resections. General Reimbursement Policy Definitions Assistant at surgery (Modifiers 80/81/82/AS) Claims requiring additional documentation Duplicate or subsequent services on the same date of service Modifier usage Multiple and bilateral surgery reimbursement Related materials None

82 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Modifier 76: Repeat Procedure by the Same Physician Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for applicable procedure codes appended with Modifier 76 to indicate a procedure or service was repeated by the same physician: Subsequent to the original procedure or service for professional provider claims. On the same date as the original procedure or service for facility claims. Unless provider, state, federal or CMS contracts and/or requirements UniCare Health Plan of West Virginia, Inc. WEB-UWV

83 Reimbursement Policy: Modifier 76: Repeat Procedure by Same Physician Page 83 of 160 indicate otherwise, reimbursement is based on the following use of Modifier 76: For a nonsurgical procedure or service: 100% of the applicable fee schedule or contracted/negotiated rate For a surgical procedure: 100% of the applicable fee schedule or contracted/negotiated rate for the surgical component only limited to a total of two surgical procedures Professional services, other than radiology which is excluded from this requirement, will be subject to clinical review for consideration of reimbursement. Providers must submit supporting documentation for the use of Modifier 76 with the claim. If a claim is submitted with Modifier 76 without supporting documentation, the claim will be denied. Providers will be asked to submit the required documentation for reconsideration of reimbursement. Failure to use Modifier 76 when appropriate may result in denial of the procedure or service. If a repeated surgical procedure is performed with an assistant surgeon or in conjunction with multiple surgeries, assistant surgeon and/or multiple procedure rules and fee reductions apply. Nonreimbursable UniCare does not allow reimbursement for use of Modifier 76: With an inappropriate procedure code(e.g., laboratory/pathology) For a surgical procedure repeated more than once For the preoperative or postoperative components of a surgical procedure History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract Code editing guidelines Optum Learning: Understanding Modifiers, 2014 edition Subsequent: The time period after the initial procedure or service is performed and within the global period designated for that procedure or service. General Reimbursement Policy Definitions Assistant at surgery (Modifiers 80/81/82/AS) Modifier usage Multiple and bilateral surgery reimbursement

84 Related materials None West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc. Reimbursement Policy: Modifier 76: Repeat Procedure by Same Physician Page 84 of 160

85 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Modifier 77: Repeat Procedure by Another Physician Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for applicable procedure codes appended with Modifier 77 to indicate a procedure or service was repeated by another physician: Subsequent to the original procedure or service for professional claims. On the same date as the original procedure or service for facility claims. Unless provider, state, federal or CMS contracts and/or requirements UniCare Health Plan of West Virginia, Inc. WEB-UWV

86 Reimbursement Policy: Modifier 77: Repeat Procedure by Another Physician Page 86 of 160 indicate otherwise, reimbursement is based on the following use of Modifier 77: For a nonsurgical procedure or service: 100% of the applicable fee schedule or contracted/negotiated rate For a surgical procedure: 100% of the applicable fee schedule or contracted/negotiated rate for the surgical component only limited to a total of two surgical procedures Professional services, other than radiology which are excluded from this requirement, will be subject to clinical review for consideration of reimbursement. Providers must submit supporting documentation for the use of Modifier 77 with the claim. If a claim is submitted with Modifier 77 without supporting documentation, the claim will be denied. Providers will be asked to submit the required documentation for reconsideration of reimbursement. Failure to use Modifier 77 when appropriate may result in denial of the procedure or service. If a repeated surgical procedure is performed with an assistant surgeon or in conjunction with multiple surgeries, assistant surgeon and/or multiple procedure rules and fee reductions apply. Nonreimbursable UniCare does not allow reimbursement for use of Modifier 77: With an inappropriate procedure code (e.g., laboratory/pathology) For a surgical procedure repeated more than once For the preoperative or postoperative components of a surgical procedure When appended to evaluation and management codes History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract Optum Learning: Understanding Modifiers, 2014 edition Subsequent: The time period after the initial procedure or service is performed and within the global period designated for that procedure or service. General Reimbursement Policy Definitions Assistant at surgery (Modifiers 80/81/82/AS) Modifier usage Multiple and bilateral surgery reimbursement

87 Related materials None West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc. Reimbursement Policy: Modifier 77: Repeat Procedure by Another Physician Page 87 of 160

88 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure during the Postoperative Period Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for claims billed with Modifier 78 unless provider, state, federal or CMS contracts and/or requirements indicate otherwise, when the following criteria are met: The return to the operating or procedure room is unplanned The procedure appended with Modifier 78 is: UniCare Health Plan of West Virginia, Inc. WEB-UWV

89 Reimbursement Policy: Modifier 78: Unplanned Return to the Operating/Procedure Room Page 89 of 160 o The appropriate surgical code for the procedure performed. o Performed by the same physician who provided the initial procedure. o Related to the initial procedure. o Performed during the postoperative period of the initial procedure. Reimbursement is based on 100% of the fee schedule or contracted/ negotiated rate of the surgical procedure code when the modifier is valid for the service performed. Reimbursement is based on the surgical procedure only, not including preoperative or postoperative care. Procedures rendered during the postoperative period and not billed with Modifier 78 are normally denied as included in the global surgical package. When an assistant surgeon is used and/or multiple procedures are performed during the global period in the same operative session, assistant surgeon and/or multiple procedure rules and fee reductions apply. Nonreimbursable UniCare does not allow reimbursement for Modifier 78 billed in the following circumstances including, but not limited to: With non-surgical codes With codes denoting subsequent, related or redo in the description History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract Optum Learning: Understanding Modifiers, 2014 edition The Essential RBRVS, 2014 edition Modifier 78: Used to indicate that a subsequent procedure was performed during the postoperative period of the original surgical procedure. The subsequent procedure must be related to the original procedure and must require a return trip to the operating or procedure room. General Reimbursement Policy Definitions Assistant at surgery (Modifiers 80/81/82/AS) Modifier usage Multiple and bilateral surgery: Professional and facility reimbursement

90 Reimbursement Policy: Modifier 78: Unplanned Return to the Operating/Procedure Room Page 90 of 160 Related materials None

91 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Modifier 91: Repeat Clinical Diagnostic Laboratory Test Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of claims for repeat clinical diagnostic laboratory tests appended with Modifier 91 unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on 100% of the applicable fee schedule or contracted/negotiated rate of the clinical diagnostic laboratory test billed with Modifier 91. Medical documentation may be requested to support the use of Modifier 91. Failure to use the modifier appropriately may result in UniCare Health Plan of West Virginia, Inc. WEB-UWV

92 Reimbursement Policy: Modifier 91: Repeat Clinical Diagnostic Laboratory Test Page 92 of 160 denial of the repeated laboratory test as a duplicate service. History UniCare review approved and effective 03/01/15 References and research materials Definitions This policy has been developed through consideration of the following: CMS State Medicaid State contract Optum Learning: Understanding Modifiers, 2014 Edition The Essential RBRVS, 2014 Edition Modifier 91: Used to indicate a clinical diagnostic laboratory test was repeated on the same day for the same member to obtain multiple test results. Modifier 91 may not be used in the following situations: o To repeat a test to confirm initial results, or because there was a problem with the specimen or equipment when performing the initial test o When other code(s) describe a series of test results General Reimbursement Policy Definitions Related policies Modifier usage Related materials None

93 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Modifiers LT and RT: Left Side/Right Side Procedures Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for procedure codes appended with Modifier LT and/or RT when indicating the side of the body for which the item, supply or procedure will be used unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on 100% of the fee schedule or contracted/ negotiated rate of the procedure. Modifiers LT and RT are informational modifiers and therefore do not increase or decrease reimbursement of the procedure. UniCare Health Plan of West Virginia, Inc. WEB-UWV

94 Reimbursement Policy: Modifier LT and RT: Left Side/Right Side Procedures Page 94 of 160 It is inappropriate to use Modifier LT or Modifier RT when billing for bilateral procedures, or with procedure codes containing bilateral or unilateral or bilateral in their description. Modifiers LT and RT do not indicate a bilateral service. Claims submitted with Modifiers LT and RT appropriately indicating a surgical procedure was performed on both the left side and right side of the body are subject to multiple surgery rules. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Optum Learning: Understanding Modifiers, 2014 edition Definitions General Reimbursement Policy Definitions Related policies Modifier usage Multiple and bilateral surgery reimbursement Related materials None

95 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Modifier Usage Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for covered services provided to eligible members when billed with appropriate procedure codes and appropriate modifiers when applicable unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on the code-set combinations submitted with the correct modifiers. The use of certain modifiers requires the provider to submit supporting documentation along with the claim. Refer to the specific modifier policies (exhibit A) for guidance on documentation UniCare Health Plan of West Virginia, Inc. WEB-UWV

96 submission. West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc. Reimbursement Policy: Modifier Usage Page 96 of 160 Applicable electronic or paper claims billed without the correct modifier in the correct format may be rejected or denied. The modifier must be in capital letters, if alpha or alphanumeric. Rejected or denied claims must be resubmitted with the correct modifier in conjunction with the code-set to be considered for reimbursement. Corrected and resubmitted claims are subject to timely filing guidelines. The use of correct modifiers does not guarantee reimbursement. Reimbursement modifiers Reimbursement modifiers affect payment and denote circumstances when an increase or reduction is appropriate for the service provided. The modifiers must be billed in the primary or first modifier field locator. Informational modifiers impacting reimbursement Informational modifiers determine if the service provided will be reimbursed or denied. Modifiers that impact reimbursement should be billed in modifier locator fields after reimbursement modifiers, if any. Informational modifiers not impacting reimbursement Informational modifiers are used for documentation purposes. Modifiers that do not impact reimbursement should be billed in the subsequent modifier field locators. UniCare reserves the right to reorder modifiers to reimburse correctly for services provided. In the absence of state-specific modifier guidance, UniCare will default to CMS guidelines. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Optum Learning: Understanding Modifiers, 2014 edition The Essential RBRVS, 2014 edition Definitions General Reimbursement Policy Definitions Related policies Assistant at surgery (80/81/82/AS) Claims timely filing Consultations Duplicate services on the same date of service Early and periodic screening, diagnostic and treatment Modifier 22: Increased procedural service Modifier 24: Unrelated evaluation and management service by

97 Reimbursement Policy: Modifier Usage Page 97 of 160 same physician during postoperative period Modifier 25: Significant, separately identifiable evaluation and management service by same physician on same day of procedure or other service Modifier 57: Decision for surgery Modifier 59: Distinct procedural service Modifier 62: Co-surgeons Modifier 63: Procedure on infants less than 4kg Modifier 66: Surgical teams Modifier 76: Repeat procedure by same physician Modifier 77: Repeat procedure by another physician Modifier 78: Unplanned return to operating/ procedure room by same physician following initial procedure for a related procedure during postoperative period Modifier 91: Repeat laboratory test Modifier LT and RT left side-right side procedures Multiple bilateral surgery professional and facility reimbursement Physician standby services Portable-mobile-handheld radiology Preadmission services Preventive medicine and sick visits on the same day Professional anesthesia services Reduced or discontinued services (52/53/73/74) Robotic assisted surgery Split-care modifiers (54/55/56) Transportation services Vaccines for children Related materials Exhibit A: Reimbursement modifiers listing

98 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Multiple and Bilateral Surgery: Professional and Facility Reimbursement Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement to professional providers and facilities for multiple and bilateral surgery unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on Medicaid-based multiple fee reductions in accordance with applicable contracts or state guidelines for applicable surgical procedures performed at the same session by the same provider. Multiple surgery Professional provider claims for applicable surgical procedures must be UniCare Health Plan of West Virginia, Inc. WEB-UWV

99 Reimbursement Policy: Multiple and Bilateral Surgery: Professional and Facility Reimbursement Page 99 of 160 billed with Modifier 51 to denote a multiple surgery. Facility claims should not be billed with Modifier 51. However, the following fee reductions apply to both physician and facility claims. Medicaid-based reimbursement is the total of: 100% of the fee schedule or contracted/negotiated rate for the primary (i.e., highest valued) procedure 50% for the secondary procedure 50% for 3rd through 5th procedures, with the 6th and additional procedures only if determined to be medically necessary through clinical review UniCare does not apply multiple fee reduction reimbursement to Modifier 51 - exempt (also known as MS-exempt ) or add-on procedure codes since the fee allowance and/or relative value is already reduced for the procedure itself. Bilateral surgery Professional provider and facility claims with applicable surgical procedures must be billed with Modifier 50 to denote a bilateral surgery. It is inappropriate to use Modifier LT or RT to identify bilateral procedures. Medicaid-based reimbursement is 150% of the fee schedule or contracted/negotiated rate of the procedure. For procedure codes containing bilateral or unilateral in their description, no modifier is used and reimbursement is based on 100% of the fee schedule or contracted/negotiated rate for the procedure. In the instance when more than one bilateral procedure or multiple and bilateral procedures are performed during the same operative session, the multiple fee reductions apply. Claims with applicable surgical procedures billed without the correct modifier to denote either multiple or bilateral surgery may be denied. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract National uniform billing committee guidelines Optum Learning: Understanding Modifiers, 2014 edition Definitions General Reimbursement Policy Definitions Related policies Assistant at surgery (Modifiers 80/81/82/AS) Modifier usage

100 Reimbursement Policy: Multiple and Bilateral Surgery: Professional and Facility Reimbursement Page 100 of 160 Related materials None

101 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Reimbursement for Reduced and Discontinued Services Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement to professional providers and facilities (i.e., outpatient hospital/ambulatory surgery center) for reduced or discontinued services when appended with the appropriate modifier unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Append Modifier 52 to indicate o Procedures for which services performed are significantly less than usually required. UniCare Health Plan of West Virginia, Inc. WEB-UWV

102 Reimbursement Policy: Reimbursement for Reduced and Discontinued Services Page 102 of 160 o Reimbursement is reduced to 50% of the applicable fee schedule or contracted/negotiated rate. o Do not report on evaluation and management (E&M) and consultation codes. Append Modifier 53 to indicate o The physician elects to terminate a surgical or diagnostic procedure due to extenuating circumstances that threaten the well-being of the patient. o Reimbursement is reduced to 50% of the applicable fee schedule or contracted/negotiated rate. o Modifier 53 is not applicable for facility billing. o Modifier 53 is not valid when billed with E&M code or timebased codes. Append Modifier 73 to indicate o The physician canceled the surgical or diagnostic procedure prior to administration of anesthesia and/or surgical preparation of the patient. o Reimbursement is reduced to 50% of the applicable fee schedule or contracted/negotiated rate. o Modifier 73 is not applicable for professional provider billing. Append Modifier 74 to indicate o A procedure was stopped after the administration of anesthesia or after the procedure was started (i.e., incision made, intubation started, scope inserted). o Reimbursement is 100% of the applicable fee schedule or contracted/negotiated rate. o Modifier 74 is not applicable for professional provider billing. If the reduced or discontinued procedure is performed with an assistant surgeon or in conjunction with multiple surgeries, assistant surgeon and/or multiple procedure rules and fee reductions apply. We reserve the right to perform postpayment review of claims submitted with Modifiers 52, 53, 73 and 74. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status, in addition to the following: CMS

103 Reimbursement Policy: Reimbursement for Reduced and Discontinued Services Page 103 of 160 State Medicaid State contract Optum Learning: Understanding Modifiers, 2014 edition Definitions General Reimbursement Policy Definitions Related policies Assistant at surgery (Modifiers 80/81/82/AS) Modifier usage Multiple and bilateral surgery reimbursement Related materials None

104 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Reimbursement of Services with Obsolete Codes Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare does not allow reimbursement for services billed with obsolete codes, in compliance with industry standard coding practices according to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Billing with obsolete codes is not HIPAA-compliant. Claims submitted for services using obsolete codes will be denied. Providers must resubmit claims with applicable new or replacement codes to have services considered for reimbursement. Resubmitted claims are subject to claims timely filing guidelines. UniCare Health Plan of West Virginia, Inc. WEB-UWV June 2015

105 Reimbursement Policy: Reimbursement of Services with Obsolete Codes June 2015 Page 105 of 160 History UniCare review approved and effective 03/01/15 References and Research Materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Federal Register Vol. 65, No CFR Parts 160 and 162 Health Insurance Reform: Standards for Electronic Transactions National Correct Coding Initiative HIPAA Compliance Guidelines Definitions General Reimbursement Policy Definitions Related Policies Claims Timely Filing: Participating and Nonparticipating Code and clinical editing guidelines Related Materials None

106 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Robotic Assisted Surgery Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare Health Plan of West Virginia, Inc. WEB-UWV UniCare does not allow separate or additional reimbursement for the use of robotic surgical systems unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Surgical techniques requiring use of robotic surgical systems will be considered integral to surgical services and not a separate service. Reimbursement will be based on the payment for the standard surgical procedure(s). Providers should not append surgery codes with Modifier 22, increased procedural service, to indicate robotic assisted surgery in order to receive separate or additional reimbursement for use of robotic surgical

107 Reimbursement Policy: Robotic Assisted Surgery Page 107 of 160 systems. Claims billed with Modifier 22 solely for the purpose of reporting robotic assisted surgery will be denied or subject to recoupment. Modifier 22 should only be used to report unusual complications or complexities which occurred during the surgical procedure that are unrelated to the use of a robotic assistance system and must be supported by documentation. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract U.S. Food and Drug Administration (FDA) Definitions General Reimbursement Policy Definitions Related policies Modifier 22: Increased procedural service Related materials None

108 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Split-Care Surgical Modifiers Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our Reimbursement Policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of surgical codes appended with splitcare modifiers, unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on a percentage of the fee schedule or contracted/negotiated rate for the surgical procedure. The percentage is determined by which modifier is appended to the procedure code: Modifier 54 (surgical care only): 70% UniCare Health Plan of West Virginia, Inc. WEB-UWV

109 Reimbursement Policy: Split-Care Surgical Modifiers Page 109 of 160 Modifier 55 (postoperative management only): 20% Modifier 56 (preoperative management only): 10% The global surgical package consists of preoperative services, surgical procedures, and postoperative services. Total reimbursement for a global surgical package is the same regardless of how the billing is split between the different physicians involved in the member s care. When more than one physician performs services that are included in the global surgical package, the total amount reimbursed for all physicians may not be higher than what would have been paid if a single physician provided all services. Correct coding guidelines require that the same surgical procedure code (with the appropriate modifier) be used by each physician to identify the services provided when the components of a global surgical package are performed by different physicians. Claims received with split-care modifiers after a global surgical claim has been paid will be denied. When an assistant surgeon is used and/or multiple procedures are performed, assistant surgeon and/or multiple procedure rules and fee reductions apply. History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract Optum Learning: Understanding Modifiers, 2014 edition Modifier 54: Used to indicate that a surgeon performed only the surgical component of a global surgical package (i.e., another physician provides postoperative care) Modifier 55: Used to indicate that a physician other than the surgeon performed only the postoperative management component of a global surgical package Modifier 56: Used to indicate that a physician other than the surgeon performed only the preoperative evaluation component of a global surgical package General Reimbursement Policy Definitions Assistant at surgery (Modifiers 80/81/82/AS) Clinical code editing guidelines Modifier usage Multiple and bilateral surgery reimbursement

110 Related materials None West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc. Reimbursement Policy: Split-Care Surgical Modifiers Page 110 of 160

111 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Unlisted or Miscellaneous Codes (aka: Dump Codes) Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Coding ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for unlisted or miscellaneous codes (aka dump codes) in accordance with specified guidelines unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Unlisted or miscellaneous codes should only be used when an established code does not exist to describe the service, procedure, or item rendered. Reimbursement is based on review of the unlisted or miscellaneous code(s) on an individual claim basis. Claims submitted with unlisted or UniCare Health Plan of West Virginia, Inc. WEB-UWV

112 Reimbursement Policy: Unlisted or Miscellaneous Codes Page 112 of 160 miscellaneous codes must contain the following information and/or documentation for consideration during review: A written description, office notes or operative report describing the procedure or service performed An invoice and written description of items and supplies The corresponding national drug code number for an unlisted drug code History UniCare review approved and effective 03/01/15 References and research materials Definitions This policy has been developed through consideration of the following: CMS State Medicaid State contract Unlisted or Miscellaneous Codes are used for service(s) or item(s): o Not having a designated code fitting the description of the service(s) or item(s) rendered (aka catch-all code) o To circumvent: Code edit software logic, such as: Duplicate claim Incident to Mutually exclusive Unbundling logic Benefit limitations and exclusions (e.g., noncovered services) Fee allowances (i.e., maximize reimbursement) Unlisted or miscellaneous codes may be used for a variety of services or items. As new and advanced approaches and techniques are under development, the unlisted category is used for auditing purposes until these procedures become accepted in medical practice and are routinely performed by providers. Specific fee allowances and/or relative value units cannot be established for unlisted services or items. General Reimbursement Policy Definitions Related policies None Related materials None

113 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Drugs and Injectable Limits Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Drugs ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare Health Plan of West Virginia, Inc. WEB-UWV UniCare allows reimbursement for drug claims received with HCPCS/CPT procedure codes that do not contain medically unlikely edit (MUE) limits and are within the physical quantities of drugs (also known as units) unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Drug claims must be submitted as required with applicable HCPCS or CPT procedure code(s), national drug codes, appropriate qualifier, unit of measure, number of units and price per unit. Units should be reported in the multiples included in the code descriptor used for the

114 Reimbursement Policy: Drug and Injectable Limits Page 114 of 160 applicable HCPCS codes. Reimbursement will be considered up to the clinical unit limits (CUL) allowed for the prescribed/administered drug. UniCare utilizes the CMS MUE value. When there is no MUE assigned by CMS, identified codes will have a CUL assigned or calculated based on the prescribing information, the Food and Drug Administration and established reference compendia. Claims that exceed the CUL will be reviewed for documentation to support the additional units. If the documentation does not support the additional units billed, the additional units will be denied. History UniCare review approved and effective TBD References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract Food and Drug Administration The appropriateness of the specific treatment for which a drug is being prescribed is recognized and supported in one of the following established reference compendia: a) American hospital formulary service-drug information b) National comprehensive cancer network drugs and biologics compendium c) Thomson Micromedex DrugDex d) Elsevier/Gold Standard clinical pharmacology General Reimbursement Policy Definitions Claims submission- Required information for professional providers Unlisted and miscellaneous codes Related materials None

115 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Facility Take-Home Drugs Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Drugs ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc.(UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare does not allow reimbursement of take-home drugs those dispensed by a facility for take-home use under the inpatient or outpatient hospital benefit unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Claims submitted by a facility for drugs with revenue codes denoting take-home use will be denied. History UniCare review approved and effective 03/01/15 UniCare Health Plan of West Virginia, Inc. WEB-UWV

116 Reimbursement Policy: Facility Take-Home Drugs Page 116 of 160 References and research materials Definitions This policy has been developed through consideration of the following: CMS State Medicaid State contract Take-Home Use: Intended for use outside of a facility General Reimbursement Policy Definitions Related policies None Related materials None

117 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Consultations Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: E&M/Medicine ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for face-to-face medical consultations by physicians or qualified nonphysician practitioners (referred to as provider(s) ) in accordance with specified guidelines unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on the fee schedule or contracted/negotiated rate structured on one of the following: The appropriate code designating a consultation based on state Medicaid guidelines (i.e., for codes containing consultation in UniCare Health Plan of West Virginia, Inc. WEB-UWV

118 Reimbursement Policy: Consultations Page 118 of 160 their description) The appropriate code designating a consultation based on CMS guidelines Consultations Consultations are reimbursable according to the following guidelines: The consultation is requested in writing or verbally by the attending provider or appropriate source The consultation is provided within the scope and practice of the consulting provider The consultation includes a personal examination of the patient The consulting provider completes a written report that includes: o Member history, including chief diagnosis and/or complaint o Examination o Physical finding(s) o Recommendations for future management and/or ordered service(s) The member s medical record must contain: o o The attending provider s request for the consultation The reason for the consultation o Documentation that indicates the information communicated by the consulting provider to the member s attending provider and the member s authorized representative o The consulting provider s written report Laboratory consultations must relate to test results that are outside the clinically significant normal or expected range considering the member s condition During a consultation, the consulting provider may initiate diagnostic and/or therapeutic services o If the consulting provider performs a definitive therapeutic surgical procedure on the same day as the consultation for the same member, the consultation must be reported with Modifier 25 or Modifier 57, whichever is most appropriate. If the appropriate modifier is not reported, the consultation is considered included in the reimbursement for the therapeutic surgical procedure; therefore, not separately reimbursable. Preoperative clearance and postoperative evaluation

119 Reimbursement Policy: Consultations Page 119 of 160 A surgeon may request a provider perform a consultation as part of either a preoperative clearance or postoperative evaluation, as long as consultation guidelines are met in addition to the following: A consulting provider may be reimbursed for a postoperative evaluation only if: o The requesting surgeon requires a professional opinion for use in treating the member. o The consulting provider has not performed the preoperative clearance. Postoperative visits are considered concurrent care and do not qualify for reimbursement as consultations if: o A consulting provider performs a preoperative clearance. o Subsequent management of all or a portion of the member s postoperative care is transferred to the same consulting provider who performed the preoperative clearance. Note: The following do not qualify as consultations: Routine screenings Routine preoperative or postoperative management care including, but not limited to: o Member history and physical for the surgical procedure being performed o Services applicable to be billed with the surgical procedure code appended with Modifier 56 o Services applicable to be billed with the surgical procedure code appended with Modifier 55 Consultation by a primary care physician A primary care physician (PCP) may perform a consultation for his/her own patient in the following circumstances: A surgeon has specifically requested the PCP to perform either a preoperative clearance or a postoperative evaluation, as long as: o Consultation, preoperative clearance and/or postoperative evaluation guidelines are met o Preoperative and/or postoperative consultations rendered by the member s PCP are reimbursable services based on state guidance or the provider s contract The preoperative visit usually is included in the surgeon s global surgical allowance. Medical review may be required if the PCP is reimbursed for a service normally included in the global fee allowance

120 Reimbursement Policy: Consultations Page 120 of 160 (i.e., duplicate service). A behavioral health provider has specifically requested the PCP to perform a consultation to provide either a medical evaluation for a specific condition or a general medical evaluation (i.e., history and physical) on a member admitted to an inpatient psychiatric unit for behavioral health treatment. These occurrences usually are billed as evaluation and management (E&M) visits. Medical review may be required to ensure consultation guidelines are met. Note: A PCP is responsible for the care of his/her own patient and, therefore, does not usually qualify to perform consultations because: Such services are considered evaluations rather than consultations. The PCP has an established medical record and/or history on the member. Consultation within the same group practice A consultation may be considered for reimbursement if the attending provider requests a consultation from another provider of a different specialty or subspecialty within the same group practice, as long as consultation guidelines are met. Nonreimbursable UniCare does not allow reimbursement for the following with regard to a consultation: Performed by telephone (telephone calls are not considered telemedicine) Performed as a split or shared E&M visit Performed in addition to an E&M visit for the same member by the same provider, unless Modifier 25 is appropriate Performed as a second or third opinion requested by the member or member s authorized representative Performed for noncovered services When a transfer of care to the consulting provider occurs (i.e., subsequent visits for the same patient by the same consulting provider) For both preoperative clearance and postoperative evaluation of the same member by the same consulting provider When provided by a surgeon immediately prior to the procedure and resulted in the initial decision to perform surgery For which the specified guidelines are not met

121 Reimbursement Policy: Consultations Page 121 of 160 History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract American Medical Association Consultation: A deliberation by two or more providers with respect to the diagnosis, prognosis and/or treatment in any particular case where the expertise, professional opinion and medical judgment of the consulting provider are considered necessary. Second Opinion: An opinion obtained from an additional health care professional prior to the performance of a medical service or a surgical procedure. May relate to a formalized process, either voluntary or mandatory, which is used to help educate a patient regarding treatment alternatives and/or to determine medical necessity. General Reimbursement Policy Definitions Modifier 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Modifier 57: Decision for surgery Modifier usage Split care surgical modifiers Related materials None

122 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Physician Standby Services Effective Date: 03/01/15 Committee Approval Obtained: 03/19/15 Section: E&M ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare does not allow separate reimbursement for physician standby services unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement for physician standby services is included in the applicable facility rate. Professional or facility claims submitted for separate reimbursement for physician standby services will be denied. Providers should not append Modifier 59, distinct procedural service, to indicate physician standby services in order to receive separate or UniCare Health Plan of West Virginia, Inc. WEB-UWV June 2015

123 Reimbursement Policy: Physician Standby Services June 2015 Page 123 of 160 additional reimbursement. Claims billed with Modifier 59 to indicate physician standby services will be denied or subject to recovery or recoupment. If, during the standby period, the standby physician performs services, therefore rendering direct care to the member, the standby physician may be separately reimbursed only for the professional services, subject to service coverage. The standby service will not be separately reimbursed. Services for attendance and initial stabilization of a newborn at a vaginal or cesarean delivery, at the request of the delivering physician when there is documented fetal distress or reasonable anticipation of newborn distress, are not considered physician standby services. Note: Attendance and initial stabilization services are represented by a different procedure code than physician stabilization services. Attendance and initial stabilization of a newborn involves the physician rendering direct care to the newborn, and therefore may be a separately reimbursable expense from the facility rate. History References and Research Materials Definitions Related Policies Biennial Anthem review approved 03/19/15: History, related policies, and policy template updated Initial UniCare review approved and effective 03/01/15 This policy has been developed through consideration of the following: CMS State Medicaid State contract Physician Standby Services: Represents occasions where the physician is present and available for a prolonged period, at the request of the primary physician, in case the standby physician s specific expertise and skills become necessary in the treatment of a member. The physician is not rendering direct care to the respective, or any other, member during standby. General Reimbursement Policy Definitions Maternity Services Modifier 59: Distinct procedural service Related Materials None

124 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Preventive Medicine and Sick Visits on the Same Day Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: E&M ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for preventive medicine (i.e., well-child visits) and limited sick visits on the same day, unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on the fee schedule or contracted/negotiated rate for the preventive medicine and the allowed sick visit under the following conditions: Modifier 25 must be billed with the applicable evaluation and management code for the allowed sick visit if Modifier 25 is not UniCare Health Plan of West Virginia, Inc. WEB-UWV

125 Reimbursement Policy: Preventive Medicine and Sick Visits on the Same Day Page 125 of 160 billed appropriately, the sick visit will be denied. Appropriate diagnosis codes must be billed for respective visits. Federally qualified health centers and rural health centers reimbursed other than through UniCare s fee schedule or state encounter rates are not subject to this policy. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Code and clinical editing guidelines Modifier 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Related materials None

126 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Preadmission Services for Inpatient Stays Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Facilities ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for applicable services for a covered member prior to admission to an inpatient hospital (referred to as the payment window) unless provider, state, federal or CMS contracts and/or requirements indicate otherwise, based on CMS guidance as follows: For admitting hospitals, applicable preadmission services are included in the inpatient reimbursement for the three days prior to and including the day of the member s admission, and therefore, UniCare Health Plan of West Virginia, Inc. WEB-UWV

127 Reimbursement Policy: Preadmission Services for Inpatient Stays Page 127 of 160 are not separately reimbursable expenses Note: This includes any entity wholly owned or wholly operated by the admitting hospital or by another entity under arrangements with the admitting hospital (i.e., the admitting hospital owns the physician s practice performing the preadmission services). For other hospitals and units, applicable preadmission services are included in the inpatient reimbursement within one day prior to and including the day of the member s admission and, therefore, are not separately reimbursable expenses, including: o o o o o Psychiatric hospitals and units Inpatient rehabilitation facilities and units Long-term care hospitals Children s hospitals Cancer hospitals For critical access hospitals, outpatient diagnostic services are not subject to either the three-day or one-day payment window and, therefore, are separately reimbursable expenses from the inpatient stay reimbursement. The three-day or one-day payment window does not apply to outpatient diagnostic services included in the rural health clinic or federally qualified health center all-inclusive rate. Preadmission services Applicable preadmission services consist of all diagnostic outpatient services (including nonpatient laboratory tests) and clinically related nondiagnostic (i.e., therapeutic) services that are related to the inpatient stay and are included in the inpatient reimbursement. A hospital may attest to specific nondiagnostic services as being unrelated by adding a condition code 51 to the outpatient nondiagnostic service to be billed separately. Providers should append Modifier PD to diagnostic and nondiagnostic services that are subject to the preadmission payment window. Nonreimbursable UniCare does not consider the following services to be included in the payment window prior to an inpatient stay for preadmission services: Ambulance services Maintenance renal dialysis services Services provided by: o Skilled nursing facilities

128 o o West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc. Reimbursement Policy: Preadmission Services for Inpatient Stays Page 128 of 160 Home health agencies Hospices Unrelated diagnostic and nondiagnostic services (i.e., not directly related to the inpatient stay) Note: These services may be considered for separate outpatient reimbursement. History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract U.S. Department of Health and Human Services, Office of the Inspector General Final Report, Expansion of the Diagnosis Related Group Payment Window, A , August 2003 Condition Code 51: Denotes attestation of Unrelated Outpatient Non-Diagnostic Services Modifier PD: Indicates that the service is related to the inpatient admission General Reimbursement Policy Definitions Modifier usage Transportation services Related materials None

129 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Early and Periodic Screening, Diagnostic and Treatment Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Prevention ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of early and periodic screening, diagnostic and treatment (EPSDT) program services unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. UniCare Health Plan of West Virginia, Inc. WEB-UWV

130 Reimbursement Policy: Early and Periodic Screening, Diagnostic and Treatment Page 130 of 160 Reimbursement is based on the applicable fee schedule or contracted/negotiated rate. The following EPSDT component services are included in the reimbursement of the preventive medicine evaluation and management (E&M) visit, unless appended with Modifier 25, to indicate a significant, separately identifiable E&M service by the same physician on the same date of service: Comprehensive health history Comprehensive unclothed physical examination Health education Nutritional assessment Hearing screening with or without the use of an audiometer or other electronic device Dental screening Vision screening The following component services are separately reimbursable from the preventive medicine E&M visit: Developmental screening using a standardized screening tool Immunization and administration Laboratory tests: o Newborn metabolic screening test o Tuberculosis test o Hematocrit and hemoglobin tests o Lead toxicity screening o Cholesterol test o Pap smear, for sexually active members o Sexually transmitted disease screening, for sexually active members o Urinalysis Providers should follow periodicity guidelines established by the American Academy of Pediatrics and the Centers for Disease Control and Prevention. If a provider performs EPSDT services in conjunction with a sick visit, all services are subject to UniCare s preventive medicine and sick visits on same day policy.

131 Reimbursement Policy: Early and Periodic Screening, Diagnostic and Treatment Page 131 of 160 Claims requirements Provider claims for EPSDT services should include all of the following items: EPSDT special program indicator EPSDT referral indicator codes (aka referral condition codes), if applicable Appropriate diagnosis code(s) Appropriate HCPCS code identifying the completed EPSDT service (list in addition to code for appropriate E&M service) Appropriate E&M codes for new or established members Appropriate procedure code for the component services Modifier EP (only with developmental screening/testing) History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of medical necessity, generally accepted standards of medical practice and review of medical literature and government approval status, in addition to the following: CMS State Medicaid State contract American Academy of Pediatrics Centers for Disease Control and Prevention Definitions General Reimbursement Policy Definitions Related policies Modifier 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Modifier usage Preventive medicine and sick visits on the same day Vaccines for children program Related materials None

132 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Vaccines for Children Program Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Prevention ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare Health Plan of West Virginia, Inc. WEB-UWV UniCare allows reimbursement for vaccinations provided by the vaccines for children (VFC) program for eligible members under the age of 19, unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Medicaid providers who immunize children shall participate in the VFC program and comply with all of the reporting requirements and procedures for provider participants. Reimbursement is based on the fee schedule or contracted/negotiated rate of the vaccine administration up to maximum fee limits set by the Centers for Disease Control and Prevention (CDC) and Modifier SL. UniCare does

133 Reimbursement Policy: Vaccines for Children Page 133 of 160 not reimburse providers for the vaccine serum as it is provided free-ofcharge through the VFC program. Although providers shall only be reimbursed for the administration of the vaccine, serum code(s) must be included on the claim to meet regulatory and HEDIS reporting requirements that members are receiving the proper immunization(s). Claims submitted without applicable serum, administration and modifier codes may be rejected and/or denied. Reimbursement of office visits Vaccine administrations are separately reimbursable expenses from wellchild exams or office visits. When the vaccine administration is the only service performed, UniCare does not allow reimbursement for a minimal office visit (i.e., an office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician where the presenting problem(s) are usually minimal and typically five minutes are spent performing or supervising these services). Non-VFC members/vaccines For members not eligible or for vaccines not provided under the VFC program, UniCare reimburses providers for the administration and serum based on the fee schedule or contracted/negotiated rate. Reimbursement during state supply shortages During documented supply shortages within applicable state VFC programs, UniCare will reimburse providers for serum(s) based on the fee schedule or contracted/negotiated rate and applicable modifier. The health plan shall develop internal processes and procedures to track state VFC program and CDC information to monitor vaccine shortages. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Centers for Disease Control and Prevention Social Security Act, Section 1928: Program for Distribution of Pediatric Vaccines State VFC Program Definitions General Reimbursement Policy Definitions Related policies Modifier usage

134 Related materials None West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc. Reimbursement Policy: Vaccines for Children Page 134 of 160

135 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Prosthetic and Orthotic Devices Reimbursement Policy Section: Prosthetics and Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Orthotics ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of prosthetic and orthotic devices when provided as part of a physician s services or ordered by a physician and used in accepted medical practice unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate for the prosthetic or orthotic device dispensed. The design, materials, measurements, fabrications, testing, fitting and training in the use of the device are included in the reimbursement of the UniCare Health Plan of West Virginia, Inc. WEB-UWV

136 Reimbursement Policy: Prosthetic and Orthotic Devices Page 136 of 160 device and are not separately reimbursable expenses. Reimbursement is allowed for repair of prosthetic and orthotic devices: When necessary to make the device serviceable. When the device is no longer covered under the supplier s or manufacturer s warranty. Up to the estimated expense of replacement of the device. Reimbursement is allowed for replacement of prosthetic and orthotic devices due to: Change in the patient s condition. Substantial change in patient s growth and/or weight. Permanent and/or accidental damage. Irreparable wear in consideration of the reasonable useful lifetime of the device of not less than five years based on when the equipment is delivered to the member. Nonreimbursable UniCare does not allow reimbursement for prosthetics and orthotics under the following conditions: Provision of a device that exceeds the benefit limit unless authorized through medical necessity Enhancements or upgrades of a device (i.e., deluxe or luxury) for the convenience of the member or caregiver The aesthetic appearance of a device for the preference of the member or caregiver A device considered experimental or investigational Repair or replacement of a device as a result of abuse or neglect Repair or replacement of a device during the warranty period Over-the-counter orthotic devices (e.g., items available without a prescription and not custom fitted for the member) Dental prosthetics are considered for reimbursement through delegated agreements between UniCare and contracted dental vendors In instances of theft, a police report is required for consideration of replacements. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid

137 Reimbursement Policy: Prosthetic and Orthotic Devices Page 137 of 160 Definitions State contract Prosthetic Device: An artificial structural and functional replacement of: o A limb/appendage or internal organ o All or part of the function of a permanently inoperative or malfunctioning internal body organ Orthotic Device: A brace with rigid metal or plastic stays applied to the body: o For support or immobilization of a body part o To correct or prevent deformity o To assist or restore function General Reimbursement Policy Definitions Related policies Reimbursement of items under warranty Related materials None

138 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Portable/Mobile/Handheld Radiology Services UniCare Health Plan of West Virginia, Inc. WEB-UWV Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Radiology ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for portable/mobile radiology services when furnished in a residence used as the patient s home if ordered by a physician and performed by qualified portable radiology suppliers unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Portable/mobile radiology studies should not be performed for routine purposes or for reasons of convenience. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate for the radiological service, and transportation and set-up components with

139 Reimbursement Policy: Portable/Mobile/Handheld Radiology Services Page 139 of 160 the use of applicable modifiers. Note: Portable radiology suppliers must be licensed or registered to perform services as required by applicable state laws. Transportation and setup UniCare allows reimbursement for transportation and setup of portable radiology equipment when transported to the member s residence. Transportation costs are payable when the portable X-ray equipment used was actually transported to the location where the X- ray was taken. Reimbursement for the set-up cost of portable radiology equipment is not separately reimbursable. Reimbursement for transportation is based on a single payment for each particular location regardless of the number of members receiving radiological services. For services provided to more than one member, the transportation cost is divided by the total number of members receiving services at that location. If more than one member receives portable radiology services, providers must bill with one of the following applicable modifiers: Modifier UN two members served Modifier UP three members served Modifier UQ four members served Modifier UR five members served Modifier US six or more members served o Total payment for the service is divided by six regardless of the number of members served. No modifier is required when only one member is served Nonreimbursable UniCare does not allow reimbursement for transportation costs of equipment stored for use as needed at any location qualifying as a member s residence. If the diagnostic X-rays are not covered, payment will not be made for the transportation and set-up fee. Handheld radiology The use of handheld radiology instruments is allowed. Reimbursement will be part of the physician s professional service, and no additional charge will be paid. The technical components for handheld radiology are not separately reimbursable. History UniCare review approved and effective 03/01/15 References and This policy has been developed through consideration of the

140 Reimbursement Policy: Portable/Mobile/Handheld Radiology Services Page 140 of 160 research materials following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Modifier usage Related materials None

141 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Abortion (Termination of Pregnancy) Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Surgery ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claims submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. UniCare allows reimbursement of induced abortions unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Policy Induced abortions are allowed only when the voluntary and informed consent has been obtained of the woman upon whom the abortion is to be performed and the provider performing the procedure certifies: The pregnancy is the result of an act of rape or incest. The woman suffers from a physical disorder, injury or illness, UniCare Health Plan of West Virginia, Inc. WEB-UWV

142 Reimbursement Policy: Abortion Page 142 of 160 including a life-endangering physical condition caused by or arising from the pregnancy itself that would, as certified by a physician, place the woman in danger of death unless an abortion is performed. Consent form does not have to be submitted for claim payment; however, it is required to be in the patient s chart. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate when the state-approved certification of medical necessity abortion form is properly executed. An informed consent is not needed for the treatment of incomplete, missed or septic abortions. These procedures are not considered induced or elective abortions and are allowed under the criteria of medical necessity. History UniCare review approved and effective 03/01/15 References and research materials Definitions This policy has been developed through consideration of the following: CMS State Medicaid State contract Code of Federal Regulations (CFR) Subpart E- Abortions Abortion, Induced: One resulting from measures taken to intentionally end a pregnancy, using medications (medical abortion) or instrumentation (surgery) Abortion, Incomplete: Part of the product of conception has been retained in the uterus Abortion, Missed: A dead, nonviable fetus and other products of conception are retained in the uterus for two or more months Abortion, Septic: There is an infection of the product of conception and the endometrial lining of the uterus usually resulting from attempted interference during early pregnancy Abortion Spontaneous/Miscarriage: Occurs when a natural cause ends a pregnancy prior to 20 weeks Abortion, Threatened: The appearance of signs and symptoms of possible loss of embryo Stillborn: Occurs when a natural cause ends a pregnancy after 20 weeks Termination of Pregnancy: Synonym for abortion General Reimbursement Policy Definitions Related policies None Related materials None

143 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Global Surgical Package for Professional Providers Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Surgery ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for the global surgical package unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. UniCare follows CMS global surgery values. The global surgery package may be furnished in any setting and reimbursement applies to both major and minor surgical procedures as defined by their postoperative periods of 90, 10 or 0 days. UniCare Health Plan of West Virginia, Inc. WEB-UWV

144 Reimbursement Policy: Global Surgical Package for Professional Providers Page 144 of 160 Included in the global surgical package Reimbursement for the following components is included within the global surgical package: Preoperative services rendered after the decision is made to operate, beginning with the day before major procedures and the day of surgery for minor procedures Intraoperative services that are normally a usual and necessary part of a surgical procedure Treatment for all additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room and that are not categorized as a hospital-acquired condition or present on admission Postsurgical pain management by the surgeon Visits during the postoperative periods that are related to recovery from the surgery Miscellaneous surgical services and supplies used during the surgery Unlisted surgical procedures included in global package Reimbursement for an unlisted surgical procedure is based on the review of the unlisted code on an individual claim basis. Claims submitted with unlisted codes must contain any of the following information and/or documentation describing the procedure or service performed for consideration during review: A written description Office notes An operative report Add-on surgical procedures included in global surgical package The global surgical period for an add-on surgical procedure will be based on the primary surgical code. Separately reimbursable from global surgical package The following services are not included in the payment amount for the global surgery. The services listed below are separately reimbursable expenses: The initial consultation or evaluation by the surgeon to determine the need for a major surgical procedure Visits during the postoperative period of surgery that are unrelated to the diagnosis of the surgery, unless the visits occur due to complications of the surgery

145 Reimbursement Policy: Global Surgical Package for Professional Providers Page 145 of 160 Treatment for an underlying condition or an added course of treatment which is not part of the normal recovery from surgery Diagnostic tests and procedures Clearly distinct surgical procedures during the postoperative period that are not re-operations or treatment for complications Treatment for postoperative complications which require a return trip to the operating room If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately Immunosuppressive therapy for an organ transplant Critical care services unrelated to the surgery where a seriously injured or burned member is critically ill and requires constant attendance of the physician Providers must use applicable HIPAA-compliant modifiers for any services provided during the post-operative period. These modifiers are appended to the corresponding CPT/HCPCS code in conjunction with an appropriate diagnosis code for reimbursement consideration. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Code Editing Guidelines Definitions General Reimbursement Policy Definitions Related policies Claims requiring additional documentation Duplicate or subsequent services on the same date of service Modifier 24: Unrelated evaluation and management service by the same physician during the postoperative period Modifier 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Modifier 57: Decision for surgery Modifier 78: Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period Modifier usage Other provider preventable conditions Split-care surgical modifiers

146 Related materials None West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc. Reimbursement Policy: Global Surgical Package for Professional Providers Page 146 of 160 Unlisted and miscellaneous codes (aka dump codes)

147 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Hysterectomy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Surgery ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of nonelective and medically necessary hysterectomy procedures for covered members unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate and completion of a valid consent/acknowledgement of hysterectomy form. UniCare considers reimbursement for a hysterectomy only when the following criteria are met: UniCare Health Plan of West Virginia, Inc. WEB-UWV

148 Reimbursement Policy: Hysterectomy Page 148 of 160 The hysterectomy is medically necessary to treat an illness or injury. The member has given informed consent. The member or authorized representative is fully aware that the hysterectomy will render the member permanently incapable of reproducing, and has orally and in writing expressed this understanding. The member or authorized representative has signed and dated an applicable state-approved consent/acknowledgement of hysterectomy form. The form is required regardless of the member s diagnosis or age. Note: The consent/acknowledgement of hysterectomy form with the physician s certification is required if the individual was already sterile before the hysterectomy or if the individual required a hysterectomy because of a life threatening emergency situation in which the physician determined that prior consent/acknowledgement was not possible. The member s informed consent/acknowledgement of hysterectomy is not required. A valid consent/acknowledgement of hysterectomy form has to be properly executed and include all required signatures: Member, except as noted Person obtaining the member s consent The physician performing the hysterectomy Consent form does not have to be submitted for claims processing, but it is required to be in the member s medical record. If a hysterectomy is performed in conjunction with a delivery, then multiple surgery guidelines apply (refer to the UniCare multiple and bilateral surgery policy). Nonreimbursable UniCare does not allow reimbursement of a hysterectomy in the following circumstances: The hysterectomy is performed for the sole purpose of rendering the member permanently incapable of reproduction. There is more than one reason for the hysterectomy, but the primary reason is to render the member permanently incapable of reproduction. The hysterectomy is performed for the purpose of cancer prophylaxis. History UniCare review approved and effective 03/01/15

149 Reimbursement Policy: Hysterectomy Page 149 of 160 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract American College of Obstetricians and Gynecologists (ACOG) Code of Federal Regulations (CFR) Subpart F- Sterilizations Definitions General Reimbursement Policy Definitions Related policies Related materials Multiple and bilateral surgery: Professional and facility reimbursement Hysterectomy acknowledgment form and acknowledgment of receipt of hysterectomy information Instructions for completing the hysterectomy acknowledgment form

150 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Maternity Services Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Surgery ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare does not allow reimbursement for global obstetrical codes unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Antepartum care, deliveries and postpartum care are reimbursed as individual services. Providers should use the appropriate evaluation and management codes for antepartum and postpartum care. History UniCare review approved and effective 03/01/15 UniCare Health Plan of West Virginia, Inc. WEB-UWV

151 Reimbursement Policy: Maternity Services Page 151 of 160 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Current procedural terminology 2014 Definitions General Reimbursement Policy Definitions Related policies Claims requiring additional documentation Modifier 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Modifier 59: Distinct procedural service Multiple delivery services Prenatal ultrasound medical policy Related materials None

152 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Sterilization Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Surgery ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of sterilization procedures performed for the purpose of rendering a member permanently incapable of reproducing, unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on the applicable fee schedule or contracted/negotiated rate and completion of a state-approved consent form properly executed per state requirements. UniCare considers reimbursement of sterilization procedures based on the following guidelines: UniCare Health Plan of West Virginia, Inc. WEB-UWV

153 Reimbursement Policy: Sterilization Page 153 of 160 The member has given informed consent by voluntarily signing the applicable consent form: o Not less than 30 and not more than 180 calendar days prior to the procedure (if more than 180 calendar days prior to the procedure a new consent form will be required) o In the case of premature delivery or emergency abdominal surgery, not less than 72 hours prior to the procedure At the time the voluntary informed consent is obtained, the member must be: At least 21 years of age Legally and mentally competent Not institutionalized (e.g., mental hospital or correctional facility) Consent for sterilization cannot be obtained while the patient to be sterilized is: In labor or childbirth Is under the influence of alcohol or other agents affecting awareness Seeking to obtain or obtaining an abortion A valid consent form has to be properly executed and include all required signatures: Member or member s authorized representative Interpreter, if applicable Person obtaining the member's consent Physician performing the sterilization procedure Consent form does not have to be submitted for claims processing, but it is required to be in the member s chart. If a sterilization procedure is performed in conjunction with a delivery, then multiple surgery guidelines apply (refer to UniCare s multiple and bilateral surgery policy). History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract American College of Obstetricians and Gynecologists Code of Federal Regulations Subpart F- Sterilizations

154 Reimbursement Policy: Sterilization Page 154 of 160 Definitions Sterilization is the process of making a person permanently unable to reproduce. General Reimbursement Policy Definitions Related policies Multiple and bilateral surgery reimbursement Related materials None

155 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Transportation Services: Ambulance and Nonemergent Transport Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Transportation ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for transport to and from covered services or other services mandated by contract, unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Reimbursement is based on the guidelines in this policy. Due to the complex nature of transportation services, we recommend that providers also review state guidelines for coverage requirements. Nonemergent transport services Nonemergency medical transport (NEMT) entails the transport of a UniCare Health Plan of West Virginia, Inc. WEB-UWV

156 Reimbursement Policy: Transportation Services: Ambulance and Nonemergent Transport Page 156 of 160 member by nonmedically skilled personnel (laypersons) to receive covered services. There are several types of medical transports: ambulette/medi-van, wheelchair van, invalid coach, taxicab, mini-bus and public transportation (e.g., bus and/or subway). Reimbursement for medical transport services is based on receipt of a claim or an invoice from contracted transportation vendors or other suppliers detailing: The nonemergency medical transport base rate per trip, where a trip is defined by the origin and destination modifiers Mileage Parking and/or toll fees Ambulance services Reimbursement for ambulance services is based on: The ambulance base rate per trip in accordance with the medically necessary level of care provided to the member, where a trip is defined by the origin and destination modifiers. The fee schedule or contracted/negotiated rate for services and items separately reimbursable from the ambulance base rate. If ambulance transport is medically necessary for inpatient-toinpatient transfer between hospital-based facilities, reimbursement is included in the inpatient stay. Included in the ambulance base rate Services reimbursed as part of the ambulance base rate: Ambulance equipment and supplies: o Disposable/first aid supplies o Reusable devices/equipment o Oxygen o Intravenous drugs Ambulance personnel services Separately reimbursable from the ambulance base rate Services that are not part of the ambulance base rate are separately reimbursable expenses: Mileage Additional appropriately licensed medical personnel as medically necessary for member s health status Unusual waiting time (i.e., in excess of 30 minutes) Disposable/first aid supplies in greater than normal use

157 Reimbursement Policy: Transportation Services: Ambulance and Nonemergent Transport Page 157 of 160 Transportation modifiers Claims for transportation services must be billed with the following origin and destination modifiers. Claims for transportation services submitted without origin and destination modifiers will be denied. Modifier D: Diagnostic or therapeutic site/free standing facility other than P or H Modifier E: Residential, domiciliary, custodial facility (e.g., nursing home, not a skilled nursing facility) Modifier G: Hospital-based dialysis facility (hospital or hospitalassociated) Modifier H: Hospital (inpatient or outpatient) Modifier I: Site of transfer (e.g., airport or helicopter pad) between types of ambulance Modifier J: Nonhospital-based dialysis Modifier N: Skilled nursing facility, including swingbed Modifier P: Physician s office, including HMO nonhospital facility, clinic, etc. Modifier R: Private residence Modifier S: Scene of accident or acute event Modifier X: Intermediate stop at the physician s office en route to hospital (includes HMO nonhospital facility, clinic, etc.) o Modifier X can only be used as a destination code in the second position of a modifier. In addition to the origin and destination modifiers, the following modifiers are to be used when appropriate: Modifier GM: Indicates multiple members on one trip Modifier QL: Indicates the member died after the ambulance was called Modifier QM: Indicates the provider arranged for the transportation services Modifier QN: Indicates the provider furnished the transportation services Modifier TK: Indicates multiple carry trips Modifier TQ: Indicates life support transport by a volunteer ambulance provider Modifiers for transportation of portable/mobile radiology equipment

158 Reimbursement Policy: Transportation Services: Ambulance and Nonemergent Transport Page 158 of 160 Nonreimbursable UniCare does not allow reimbursement of the following for any ambulance or medical transport service provided: A member who is not available (i.e., no-show) Additional rates for night, weekend and/or holiday calls Mileage in transit to pick up or drop off the member (i.e., unloaded mileage) Mileage for additional passengers Mileage for extra attendant for additional passengers Mileage when the transport service has been denied or is not covered Transport for a member s or caregiver s convenience Transport available free of charge For ambulance services only: o For reasons other than medical care o Where another means of transportation (e.g., medi-van, public transportation) could be used without endangering the member s health o For separate reimbursement for services/items included in the base ambulance rate o For a higher level of care when a lower level is more appropriate (e.g., advanced life support [ALS] service when basic life support [BLS] is appropriate) o For both basic and advanced life support when ALS services are provided o For services provided by the emergency medical technician (EMT) in addition to ALS or BLS base rates o For services provided on the ambulance by hospital staff o Additional ground and/or air ambulance providers that respond but do not transport the member o Transport from the member s home to a facility other than a hospital, skilled nursing facility, dialysis facility or nursing home o Transport from a facility other than a hospital, skilled nursing facility, dialysis facility or nursing home to the member s home o Transport of persons other than the member and a medically required attendant who do not require medical attention

159 Reimbursement Policy: Transportation Services: Ambulance and Nonemergent Transport Page 159 of 160 o Transport for a member pronounced dead prior to the ground and/or air ambulance being contacted o Mileage beyond the nearest appropriate facility (i.e., excessive mileage) For medical transport services only: o Transportation vendor/supplier lodging or meals o Vehicle maintenance or gas History UniCare review approved and effective 03/01/15 References and research materials Definitions This policy has been developed through consideration of the following: CMS State Medicaid State contract Optum Learning: Understanding Modifiers, 2014 edition Ambulance Services Ambulance services entail the medically necessary transport of a member by medically skilled personnel to the nearest appropriate facility equipped to provide care for the member s injury and/or illness. Services are initially delineated as basic life support (BLS) or advanced life support (ALS) levels of care, and then further delineated as emergency or nonemergency: o BLS consists of noninvasive services provided by personnel trained as emergency medical technicians (EMTs) (basic) in conjunction with applicable state laws. o ALS consists of invasive services provided by personnel trained as EMTs (intermediate or paramedic) in conjunction with applicable state laws. o Emergency ambulance transportation is an urgent service in which the member experiences a sudden, unexpected onset of acute illness or injury requiring immediate medical or surgical care which the member secures immediately after the onset, (or as soon thereafter as practical) and, if not immediately treated, could result in death or permanent impairment to the member s health o Nonemergency ambulance transportation is a scheduled or unscheduled service in which the member requires attention by EMT-trained personnel while in transit. Ambulance types There are two types of ambulance transports: o Ground ambulance an equipped and staffed land or water vehicle designed to transport a member in the supine position o Air ambulance an equipped and staffed aircraft necessary to

160 Reimbursement Policy: Transportation Services: Ambulance and Nonemergent Transport Page 160 of 160 rapidly transport a member to the nearest appropriate facility that could not otherwise be accomplished or be accessed by a ground ambulance without endangering the member s health. Air ambulances are either rotary-wing (helicopter) or fixedwing (commercial or private aircraft) Medical transport services Medical transport services, also referred to as nonemergency medical transport, entails the transport of a member by nonmedically skilled personnel (i.e., laypersons) to receive covered services. There are several types of medical transports: ambulette/medi-van, wheelchair van, invalid coach, taxicab, minibus and public transportation (i.e., bus and/or subway). Transportation modifiers: Single alpha characters with distinct definitions that are paired together to form a two-character modifier; the first character indicates the origination of the member, and the second character indicates the destination of the member. General Reimbursement Policy Definitions Related policies Portable/mobile radiology services Related materials None