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Medicare - Billing & Claims Payment Policy

Overview of Policy

Title	Effective Date	Policy Statement	Billing Instructions	Reimbursement Information
All Providers
Wellness Visits	January 1, 2011	Annual wellness visits are allowed once per year. An additional Gynecological preventive exam is allowed once per year for females.	Bill either G0438 or G0439, or 99381- 99397.	G0438 or G0439 will be denied as mutually exclusive if billed with 99381-99397 by the same provider group for the same date of service on the same patient.
Professional Fee Schedule Changes	January 1, 2010	ConnectiCare will update the professional fee schedule within 3 months of the release by the Centers for Medicare and Medicaid Services (CMS). Until an update is complete, the current rates will remain in effect. ConnectiCare will not retroactively process claims paid prior to the implementation of changes to CMS rates.
Medicare Status Codes	January 2009	Medicare claims will be processed in accordance with CMS Relative Value Unit (RVU) file status code recommendations. Status N codes are not covered unless otherwise specified under the benefit plan. Refer to Connecticut Medicare Part B Update November 2001 pages 8-12 at http://www.connecticutmedicare.com/.../050990.pdf
Diagnosis and Procedure Coding	January 2009	Current diagnosis and procedure codes are required. Deleted codes will be denied.
Date Spanning	April 2001	When multiple, like services are billed for more than one date of service, ConnectiCare requires that the services be billed on separate lines, based on the date of service. Claims not submitted in this manner will be denied and returned for correction. Exclusion: IV therapy services.	Bill each date of service on a separate line. The number of units on each line should equal one (1). For example, if CPT 99232 (subsequent hospital care per day) is billed for dates of service (DOS) 2/2 - 2/4 then the claim should reflect: Line 1: 99232 - DOS 2/2 Line 2: 99232 - DOS 2/3 Line 3: 99232 - DOS 2/4
In-Office Laboratory and Radiology	January 2009	ConnectiCare will apply in office laboratory and radiology procedure restrictions for all contracted providers.	List of in office laboratory and radiology service restrictions.
Modifiers	January 2009	ConnectiCare follows CMS guidelines for CPT and HCPCS modifiers.
Multiple Procedure Reduction	January 2009	ConnectiCare follows CMS guidelines for codes that are subject to multiple procedure reduction as indicated in the Physician Relative Value Unit file at www.cms.gov. See Medicare Status Codes discussed earlier in this section.	The reimbursement schedule is applied based on the provider contract with ConnectiCare. Unless otherwise specified in the contract, CMS multiple procedure reimbursement will apply.
Nutritional Counseling	January 2000	ConnectiCare will cover nutritional counseling according to the applicable benefit plan.	Bill with CPT codes 97802, 97803, 97804, 99078 or 0942.
Preventive Examinations	January 2009	ConnectiCare covers preventive examinations. CPT Preventive Examination codes and should be billed. Welcome to Medicare preventive examinations will be covered once per lifetime.	Refer to current CPT for Preventive Examination codes and guidelines.
Routine Vision Examination	January 2009	ConnectiCare will cover routine eye examinations according to the applicable benefit plan.		Reimbursement will be made according to applicable fee schedules when covered. Note: In accordance with CMS, refraction is not a covered service.
Unlisted Codes	January 2001	ConnectiCare will provide reimbursement to contracted providers for covered services billed with unlisted CPT or HCPCS procedure codes in accordance with CMS rules. Unlisted codes billed by PFFS providers will be processed according to Original Medicare. ConnectiCare requires completion of the Claim Submission for Unlisted Procedure or Service Code Special Report form. Note: Some exceptions may apply.	Providers will be reimbursed for covered services according to their contracts for unlisted codes.
Bilateral Procedures	January 2009	Professional claims should be submitted using the five-digit CPT code describing the procedure, followed by the bilateral Modifier ’-50’, or with modifier RT on one line and modifier LT on the subsequent line with the applicable CPT or HCPCS code. Facility claims must be submitted with modifier RT on one line and modifier LT on the subsequent line with the applicable CPT or HCPCS code.	Bilateral services may be submitted for codes identified by Medicare in the Physician RVU file.	Reimbursement will be made based on traditional Medicare unless otherwise specified in your contract.
Global Periods	January 2009	ConnectiCare will process claims according to CMS global rules. Physicians should not require members to have a separate encounter solely for the purpose of being able to bill for an office visit separate from a diagnostic or therapeutic procedure.
Venipuncture	December 2007	ConnectiCare follows CMS coding policy for billing of venipuncture CPT code 36415. This code should be used for all routine venipuncture for specimen collection. ConnectiCare will audit provider claims submitted with CPT 36410, and may request a refund if found to be billed inappropriately.	• Bill all routine venipuncture for specimen handling with CPT 36415. • Use CPT 36410 only when the venipuncture must be performed by a physician.

If you have any questions, please call Provider Services at 674-5850 or 1-800-828-3407.

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Headlines

Medicare - Billing & Claims Payment Policy

Overview of Policy