• First procedure (count as 1st & 2nd procedures) reimbursed at 150% of allowable fee

• Second procedure and subsequent procedures reimbursed at 50% of allowable fee

Some procedure codes are not separately reimbursable; reimbursement is considered bundled with the primary procedure code. These codes are identified by CMS as “bundled” services and may not be “gap-filled” by other reimbursement methods.

Bill with appropriate modifier to identify it as a separate procedure when the catheter is used for a separate reason (e.g., chemotherapy, hemodialysis)

Clinical documentation is not required with initial claim submission, unless otherwise specified. When submitting clinical documentation for the purpose of ensuring the claim will be reviewed prior to payment, please contact Provider Services to request that the documentation be reviewed prior to payment.

Bill with appropriate CPT code no more frequently than every 12 months, unless done in the inpatient setting or associated with the following diagnoses: 555.1; 555.2; 555.9; 556-556.9; 569.3; 578.9; 560.2; 560.89; 997.4.

Physicians who perform co-surgeon services should bill the appropriate surgical procedure code with the applicable modifier. Each surgeon should report the co-surgery only once using the same procedure code. If additional procedures, including add-on procedures, are performed during the same surgical session, separate codes may be reported without the modifier 62.

Bill with appropriate CPT code no more frequently than every 56 days.

Bill with appropriate CPT code with a date of service at the beginning or at the end of each month.

Bill with appropriate CPT code. Allowed for patients who are less than 17 years and have a diagnosis of Multiple Sclerosis or other demyelinating disease or intraoperative testing.

Bill with a diagnosis code that supports the use of extended EEG testing. Not allowed separate reimbursement when performed in the office setting.

Whenever possible, please convert all HCPCS codes to the applicable CPT code prior to submitting to ConnectiCare. While ConnectiCare recognizes some HCPCS codes, they are not always consistent with those recognized by Medicare.

When more than 1 procedure is performed through the same arthroscopic portal (incision), the most clinically intensive procedure will be allowed. Other services performed through the same portal will be denied as incidental in accordance with NCCI edits, and will be upheld upon appeal. Please refer to NCCI edits to determine when the use of modifier 59 is acceptable.

“Incident to” services, as identified by CMS, may only be billed for the office location.

Certain CPT procedure codes may be billed more than once on the same date of service by the same provider, for the same member. These services should be billed on one service line for the total number of units, with the total charge.

Bill one E&M code to represent total services per member, per day. (Exceptions: critical care  CPT codes 99291-99292, 99295-99298, add-on codes 99354-99359, attendance at delivery 99436 and E&M codes billed with modifier -25)

Bill on one service line for the total number of units with the total charge.

• First procedure pays 100% of allowable

• Second procedure pays 50% of allowable fee

• Third and subsequent procedures pay 25% of allowable fee

Radiology codes identified in current year CMS RVU file will be subject to reduction based on CMS guidelines.

Bill all of the most specific diagnoses to support the EMG code.

Bill the most specific diagnoses to support the nerve conduction testing codes.

Do not bill as a new patient visit if the patient has seen the physician or a physician from the same group practice within the past 3 years.

Bill with appropriate HCPCS codes. An 8% reduction will be applied based on CMS guidelines.

Bill with the primary procedure code, in accordance with CPT guidelines.

These services must be billed with diagnosis codes that support the use of these procedures based on the American Academy of Dermatology’s treatment guidelines.

Bill codes with the appropriate modifier (’TC’ or ’26’).

Not separately reimbursed when billed with an E&M service.

Not separately reimbursed when billed with E&M services or an interventional service in a facility

There are procedures that are identified in CPT as "separate procedures" that are never allowed when billed with a related service. These procedures should only be billed when performed alone, as a separate procedure.

When a series of identical services, such as chemotherapy, are required over multiple days, the claim should be submitted with the chemotherapy procedure code on separate lines for each individual date of service. Date spans are not acceptable and will be denied for the provider to resubmit.

Services are not allowed more frequently than every 6 months, unless done in the inpatient setting or associated with the following diagnoses: 154.1; 154.2; 555.1; 555.2; 555.9; 556-556.9; 569.49; 569.3.

Removal or destruction of skin tags is not a covered benefit.

ConnectiCare requires that services that are provided by the same provider, for the same member, on the same  date of service be billed together on one claim, including electronically submitted claims. Split billed services may result in incorrect reimbursement.

Bill the appropriate modifier -54 (surgical care only), -55 (post-operative care only) and -56 (pre-operative care only) when performing split surgical care.

This service is allowed in-office for PCPs only.

Bill applicable follow-up or limited study codes when performing subsequent echocardiography studies for the same diagnosis code, within 180 days of the initial study.