Here are claims edits that will go into effect Feb. 27, 2018:
| Policy | Description | What plans are affected? |
|---|---|---|
| Canalith repositioning procedure | Canalith repositioning procedure CPT code 95992 will be reimbursed only when billed with benign paroxysmal vertigo diagnoses as indicated on the NGS Medicare LCD L33631. | Commercial and Medicare Advantage |
| Cosyntropin (J0833, J0834) |
J0833 or J0834 are payable when billed with a diagnosis code supported by an FDA-approved indication or an approved off-label indication. Source: FDA package insert |
Commercial and Medicare Advantage |
| Iontophoresis | Iontophoresis procedure CPT code 97033 will be reimbursed only when billed with diagnoses for primary focal hyperhidrosis as indicated on the NGS Medicare LCD L33631. | Commercial and Medicare Advantage |
| Iron Sucrose (J1756) | J1756 is payable when billed with a diagnosis code supported by an FDA-approved indication or an approved off-labeled indication. Source: FDA package insert J1756 is payable when billed with a diagnosis of chronic kidney disease and a diagnosis of anemia in chronic kidney disease. Source: ICD-10 Manual J1756 is limited to 200 combined units per date of service by any provider when the diagnosis on the claim is iron deficiency anemia associated with chronic heart failure, iron deficiency anemia due to malabsorption disorders, or iron deficiency anemia of pregnancy. Source: Thomson Micromedix Drugdex |
Commercial and Medicare Advantage |
| Place of Service Coding for Physician Services | Professional claims for services performed in a facility place of service are to be submitted with the appropriate place-of-service code. If a professional claim is billed with a non-facility place of service, and a facility claim is received for the same procedure, the professional claim will be denied and should be resubmitted with the appropriate facility place of service code. |
Commercial only |
| Anesthesia for Pain Management Injections | Anesthesia and moderate sedation services (00300, 00400, 00600, 01935-01936, 01991-01992, 99152-99153, 99156-99157) when billed with pain management services, are payable only when billed and a surgical procedure (CPT 10021-69990) has been billed by any provider for a patient age 18 or older. Source: The American Society of |
Commercial only |
| Nerve Conduction Studies (NCS) and Electromyography (EMG) for Radiculopathy | Nerve conduction study (CPT 95905) is payable only when billed with a needle electromyography (95860-95864) if the only diagnosis on the claim is radiculopathy. Nerve conduction study (CPT 95907-95913) is payable only when billed with a needle electromyography (95885, 95886) if the only diagnosis on the claim is radiculopathy. Needle electromyography (95860-95864) is payable only when billed with a nerve conduction study (95905) if the only diagnosis on the claim is radiculopathy. Source: American Association of |
Commercial only |
| Omalizumab (J2357) | J2357 is limited to 75 combined units per date of service by any provider when the diagnosis is moderate to severe persistent asthma. Source: FDA package insert |
Medicare Advantage only |
