Title
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Date
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Policy Statement
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Billing Instructions
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Reimbursement Information
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All Providers
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Add-on Codes
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Revised July 2015
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ConnectiCare recognizes CMS and AMA CPT Add-on code guidelines.
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According to the CMS HCPCS Manual, an add-on code describes additional intra-service work associated with the primary procedure and must never be reported as a stand-alone code.
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Add-on codes billed with the primary procedure will be reimbursed.
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Assignment of Benefit
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Effective November 2012
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ConnectiCare, in compliance with the 5010 standard, will pay the provider or member based on what the provider submitted under the Benefits Assignment Certification Indicator on the claim.
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If the provider wants the payment to be sent to the member, the provider should enter "N" under the Benefits Assignment Certification Indicator. If the provider wants to receive the payment, the provider should enter "Y" under the Benefits Assignment Certification Indicator. If the provider does not include any designation, the payment will be made to the member.
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Assistants at Surgery and Co-surgeon Billing & Reimbursement
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Effective January 1999
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ConnectiCare will reimburse assistant surgeon, assistant-at-surgery and co-surgeon services when billed with surgical procedure codes based on CMS guidelines. Surgeons are responsible for notifying any non-participating assistant surgeon, assistant-at-surgery or co-surgeon of billing requirements.
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Allowable services billed with modifier '-80' or '-82' will be reimbursed at 20% of the primary surgeon's fee. Allowable services billed with modifier '-81'or 'AS' will be reimbursed at 10% of the primary surgeon's fee.
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Bilateral Radiology Procedures
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Effective April 1995,
revised July 2015
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ConnectiCare follows CMS guidelines for codes that are subject to bilateral procedure reimbursement, including reimbursement reduction.
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Submit the procedure code for a bilateral procedure on one service line and indicate the number of services as "2" in the count field. Alternatively, the service may be billed on 2 separate lines, one with modifier "RT" and one with "LT" when used in place of 2 units in the office location only.
When the CMS MUE limit is 1, submit bilateral radiology on one line with 1 unit and modifier 50.
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Codes not subject to reduction will be paid at 100% for each side. Codes subject to reduction will follow CMS reduction guidelines.
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Bundled Status Codes
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Effective August 1998, revised December 2004, revised September 2013, revised April 2015
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ConnectiCare follows all CMS Relative Value Unit (RVU) file recommendations for the following:
• Status Code B, for which reimbursement is considered bundled with payment for other services.
• Status Codes P and X, when covered, will be reimbursed only to ancillary providers, such as DME, home care, or pharmacy providers.
Some exceptions may apply. Refer to the RVU file for more details.
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Reimbursement for bundled status codes is considered included in the related therapeutic or diagnostic service. Example codes with status "B" include 20936, 97602, 99051.
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Clinical Documentation with Initial Claim Submission
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Revised July 2015
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Clinical documentation is not required with initial claim submission, unless otherwise specified.
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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.
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Paper claims are converted to electronic format and will be processed as an electronic claim.
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Colonoscopy Services, Incomplete
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Revised July 2015
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Colonoscopy frequency is limited to once every 12 months with exceptions.
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CPT code 45378 should be billed no more frequently than every 12 months.
If an incomplete colonoscopy is performed, submit CPT code 45378 with modifier 53 in order to allow a second one in a 12-month period.
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Reimbursement will be provided when billed according to Billing Instructions. Also see Preventive Services.
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Co-surgeons
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Revised July 2015
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Co-surgeon services are allowed in accordance with the CMS Physician RVU file.
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Physicians who perform co-surgeon services should bill the appropriate surgical procedure code with the applicable modifier-62. 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.
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Reimbursement will be provided when modifier 62 is billed in accordance with the CMS RVU file. Certain procedure codes may require clinical documentation.
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CPT, HCPCS and ICD Coding
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Effective June 1997, revised January 2005
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ConnectiCare requires the use of current CPT, HCPCS and ICD-10 coding. Deleted procedure codes will no longer be accepted after the deleted date.
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Date Spanning
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Effective April 2001
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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 revision.
Exclusion: IV therapy services.
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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 be submitted as follows:
Line 1: 99232 - DOS 2/2
Line 2: 99232 - DOS 2/3
Line 3: 99232 - DOS 2/4
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End Stage Renal Services
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Revised July 2015
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Monthly end stage renal disease services are payable on a monthly basis.
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Bill with appropriate CPT code with a date of service at the beginning or at the end of each month. CPT codes 90951-90962.
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Monthly reimbursement may be provided.
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Evoked Potential Testing
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Revised July 2015
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Evoked Potential Testing is allowed for patients who are less than 17 years old and have a diagnosis of Multiple Sclerosis or other demyelinating disease or intraoperative testing.
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CPT codes 95925, 95926, 95927, 95939 may be reimbursed when billed according to the policy.
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Services will be reimbursed according to the policy.
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Extended Electroencephalography (EEG) Services
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Revised July 2015
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Extended EEG services are not allowed in the office location.
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Bill CPT codes 95812, 95813, 95816, 95819, 95822, and 95827 with a diagnosis code that supports the use of extended EEG testing. Not allowed for separate reimbursement when performed in the office setting.
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Services will be reimbursed according to the policy.
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Facility Location Only Services
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Effective July 2015
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ConnectiCare recognizes CMS facility location only services.
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Procedure codes restricted to facility location, as indicated by CMS, are not payable in the office location unless documentation supports the level of coding.
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Gastric Bypass Rider
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Effective August 2012
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CPT code 43999 billed with ICD-10 codes E66.01 & Z46.51 will not require prior authorization if the member has the Gastric Bypass Rider. If the member does not have the Gastric Bypass Rider, the claims will deny as not covered.
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Global Surgical Billing
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Effective August 1998
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ConnectiCare recognizes CMS (Centers for Medicare & Medicaid Services) global surgical periods. 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.
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HCPCS codes
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Revised July 2015
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Unless otherwise specified, CPT codes should be billed when there is a corresponding HCPCS code.
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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. Exceptions may apply, such as Drug Testing.
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When a more appropriate code is required, a service may be denied so the provider may submit a more appropriate code.
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Incidental Arthroscopic Procedures
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Revised July 2015
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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.
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Please refer to NCCI edits to determine when the use of modifier 59 is acceptable.
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"Incident to" Services
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Revised July 2015
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"Incident to" services, as identified by CMS, may only be billed for the office location.
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"Incident to" services will be payable in the office location, unless otherwise indicated.
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Injection Codes
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Revised June 2016
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ConnectiCare recognizes CMS guidelines including code status values. Certain codes are identified on the Physician RVU file as status "T" for Injections. Example CPT codes with a status "T" are: 36591, 36592, 36598, 94760, 94761.
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Submit all services rendered during a single encounter on one claim.
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ConnectiCare will not reimburse services with "T" status if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are not payable and the reimbursement is considered bundled into the physician services for which payment is made.
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Inpatient Only Codes
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Effective July 2015
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ConnectiCare recognizes CMS inpatient only services.
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Procedure codes restricted to inpatient only, as indicated by CMS, are not payable as outpatient unless documentation supports the level of coding.
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Maternity Billing Procedures
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Effective May 1994
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ConnectiCare requires the use of global delivery codes when the same physician or same physician group provides care throughout the pregnancy and delivery. These codes include one postpartum visit.
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• Bill antepartum care as part of the global delivery codes 59400 and 59510. Either 59425 or 59426 may be used if the physician or group did not provide care throughout the pregnancy and delivery.
• Modifier 22 can be billed in conjunction with any delivery service for high-risk patients who require 16 or more antepartum visits, or in the case of a multiple gestation pregnancy.
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Mid-level Practitioners
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Effective November 1999, revised January 2005
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ConnectiCare recognizes licensed, mid-level practitioners as a separate provider type when working under the supervision of a participating physician. Mid-level practitioners are reimbursed at 85% of the allowable amount, regardless of the location where services are provided. This is consistent with CMS policy. Mid-levels are reimbursed at 100% for only certain procedures noted to the right.
Note: Mid-level practitioners who join an IPA/PHO that already participates with ConnectiCare must obtain their own separate contract with ConnectiCare.
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Use assigned individual mid-level NPI#. It is not necessary to use modifier -81 or AS unless assisting with surgery in an inpatient location.
Also see Assistant at Surgery Billing & Reimbursement .
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CPT codes are reimbursed at 85% of fee schedule except the following codes, which are reimbursed at 100% of fee schedule: 90281-90399; 90460-90474; 90476-90749; 91010-91299; 92511-92533; 92551; 92567; 93000-93352; 94010-95079; 96360-96361; 96365-96379; 96910; 96912; 99000; J codes; Laboratory in-office rules.
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Moderate Sedation
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Effective January 2006
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ConnectiCare follows:
• AMA CPT coding guidelines
• CMS NCCI Manual (edits and policies),
• CMS Medicare Claims Processing Manual (Publication 100-04, Chapter 12, Section 50) for moderate (conscious) sedation.
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• Moderate sedation codes are CPT 99143-99145 and 99148-99150.
• CPT codes 99148-99150 require documentation supporting the need for the second physician to administer moderate sedation. These codes are not to be reported when performed in a non-facility setting (e.g., physician office).
• Moderate sedation does not include 00100-01999.
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• Moderate sedation codes will be reimbursed in accordance with AMA CPT guidelines and applicable CMS references.
• Moderate sedation codes will not be reimbursed when the medication administration record indicates the services were rendered by individuals other than the billing provider.
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Multiple Identical Services
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Revised July 2015
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Multiple claims for the same procedure code may be payable when submitted on one claim.
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When billing multiples of the same code, submit on one line, on one claim and indicate the number of units in the units field.
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When submitted on the same claim and when multiples of the same code are allowed, services will be reimbursed.
When submitted on separate claims, multiples of the same service will be denied as duplicates.
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NCCI Edits (National Correct Coding)
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Revised July 2015
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ConnectiCare recognizes CMS NCCI policy, including CMS MUE (Medically Unlikely Edits) for Professional and Facility claims.
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Refer to National Correct Coding Initiative Edits
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Needle Electromyography (EMG) Services
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Revised July 2015
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Bill all of the most specific diagnoses to support the EMG code.
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Nerve Conduction Services
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Revised July 2015
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Bill the most specific diagnoses to support the nerve conduction testing codes. The number of units may be limited based on CPT manual appendix J: "Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves."
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New vs. Established Patient Visits (Inpatient or Outpatient)
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Revised July 2015
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ConnectiCare recognizes CMS guidelines for new vs. established patient visits.
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Bill an established patient visit if the patient has had a service rendered by the same physician or a physician of the same specialty from the same group practice within the past 3 years. Note: Different subspecialty does not qualify for a new patient visit.
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Non-licensed Personnel
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Effective January 1999
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ConnectiCare will not reimburse for services provided by non-licensed health care personnel (e.g., home health aides, physical therapy assistants, nannies, certified surgical or nursing assistants).
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Nutritional Counseling
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Effective January 2000
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ConnectiCare covers nutritional counseling, rendered by participating providers in the office or outpatient facility. Coverage is limited to two visits per member, per calendar year and must be for illnesses requiring therapeutic dietary monitoring (e.g., diabetes, heart disease, hypertension, obesity). In some cases, an additional visit may be authorized.
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Bill with CPT codes 97802, 97803, 97804, 99078 or 0942.
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Reimbursement will be made according to applicable fee schedules.
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Operating Microscope
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Bill with the primary procedure code, in accordance with AMA CPT guidelines.
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Osteopathic Manipulative Treatment (OMT)
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Effective April 1995
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Any DO may provide treatment for Osteopathic Manipulative Treatment (OMT) codes 98925-98929.
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The DO may charge for a consultation in addition to the fees for OMT, in accordance with CPT guidelines for separate Evaluation and Management services.
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Photochemotherapy (PUVA), Actinotherapy
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CPT codes 96910-96913 must be billed with diagnosis codes that support the use of these procedures based on the American Academy of Dermatology's treatment guidelines.
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Professional Component Procedures
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Professional interpretation is included in Evaluation and Management services.
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Not separately reimbursed when billed with an E&M service.
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Removal of Skin Lesions
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Effective February 2002
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The cosmetic removal of benign lesions (including hypertrophic/keloid scars), or the removal of skin tags is not covered and may not be pre-authorized. All other procedures for removal of skin lesions are covered benefits.
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Refer to the most current CPT and ICD-10 manuals for applicable billing codes.
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Rhythm Electrocardiography
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Revised July 2015
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CPT 93042 is not separately reimbursed when billed with E&M services or an interventional service in a facility.
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Separate Procedure Codes
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Revised July 2015
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Procedure codes designated as "separate procedure" in the AMA CPT manual should not be reported in addition to the code for the total procedure or the service of which it is considered an integral component. Appeals for these codes will be upheld.
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Do not report procedure codes designated as "Separate Procedure" when also billing another procedure code for the same date of service.
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Codes with Separate Procedure designation will be denied.
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Serial Visits (Identical Services Provided Over a Defined Time Span on Different Dates of Service)
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Effective July 2015
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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 a corrected claim in the correct billing format.
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Applicable cost share will be correctly applied for individual dates of service.
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Services Associated with Preauthorized Services
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Effective January 1, 2009
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Services associated with procedures that require preauthorization will be denied when no authorization has been obtained or has been denied. Upon appeal, if the procedure requiring authorization is authorized retroactively, the related services may be reimbursed.
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Sigmoidoscopy
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Revised July 2015
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CPT codes 45330-45339 are not allowed more frequently than every 6 months, unless done in the inpatient setting.
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Split Billing
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Revised July 2015
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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.
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Split Surgical Care
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Revised July 2015
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ConnectiCare recognizes CMS Split surgical care billing guidelines.
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Bill the appropriate modifier -54 (surgical care only), -55 (post-operative care only) and -56 (pre-operative care only) when performing split surgical care.
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Services may be reduced, see Modifier Policy.
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Unbundled Codes
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Effective September 2013
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ConnectiCare recognizes AMA, CPT, CMS and Specialty organizations (eg. AAOS, ACOG) guidelines. Services are to be reported with the most appropriate code available. Comprehensive codes that represent a group of services that also have individual codes are to be billed with the comprehensive code.
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Submit all services rendered during a single encounter on one claim.
Submit the code that best represents all of the services rendered when there is an appropriate comprehensive code.
If services that would otherwise be part of a comprehensive code are performed during separate encounters or body sites, apply the appropriate modifier such as: E1 - E4, FA, F1 - F9, TA, T1 - T9, LT, RT, LC, LD, RC, -58, -78, -79 and -94.
The medical record must include supporting documentation for the use of each modifier and may be subject to auditing.
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ConnectiCare will reimburse services billed with the most appropriate code. Services billed in an unbundled method will be denied. The provider will need to submit a corrected claim with the more appropriate bundled or comprehensive code that represents the group of services.
See also "Bundled Status Codes" in this section.
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