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Reimbursement Policies

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Reimbursement Policy Document
After Hours and Weekend Care Download (PDF)
Allergy Testing and Immunotherapy Download (PDF)
Ambulatory Surgical Groupers Download (PDF)
Anesthesia Billing Download (PDF)
Assistant-at-Surgery – Modifiers 80/81/82 and AS Download (PDF)
Bilateral/Multiple Surgical Procedures Download (PDF)
Co-Surgeon/Team Surgeon-Modifiers 62/66 Download (PDF)
Coding Edit Rules Download (PDF)
Computer Assisted Surgical Navigation Download (PDF)
COVID-19 Billing Guidelines Download (PDF)
COVID-19 Testing Download (PDF)
COVID-19 Vaccine and Monoclonal Antibody Infusions Policy Download (PDF)
Daily Maximum Units Download (PDF)
Discarded Drugs/Biologicals – Modifier JW Download (PDF)
Discontinued procedures/Reduced Services – Modifiers 52/53/73/74 Download (PDF)
DME In-Office/Non-Facility Download (PDF)
DME Rental vs. Purchase Download (PDF)
Drug Alcohol Testing Download (PDF)
Emergency Department Facility E&M Coding Download (PDF)
Evaluation and Management (E&M) Services Download (PDF)
Hospital Readmissions Download (PDF)
In-Office Laboratory Effective Through 7/31/2020 Download (PDF)
Intraoperative Neurophysiology Monitoring Services (IONM) Download (PDF)
Laboratory/Venipuncture Codes Download (PDF)
Mid-Level Practitioners Download (PDF)
Modifier Reference policy Download (PDF)
Modifier Reference Policy – Effective 9/1/2021 Download (PDF)
Modifier SU – Procedure Performed in Physician’s Office Download (PDF)
Modifiers PN & PO for Clinic Visit Services (G0463) Download (PDF)
Multiple Diagnostic Radiology Download (PDF)
Multiple Procedure Reduction Cardiology/Opthamology Download (PDF)
Multiple Surgical Procedures Download (PDF)
National Drug Code (NDC) Requirements Download (PDF)
Never Events/Adverse Events – Modifiers PA/PB/PC Download (PDF)
No Cost/Reduced Cost Drugs, Implants & Devices Download (PDF)
Non-Participating Provider Advance Member Notification Form Download (PDF)
Observation Stay Download (PDF)
Operating Microscope/Microsurgery (64727/69990) Download (PDF)
Preventive Medicine and Screening Download (PDF)
Preventive Services Download (PDF)
Preventive Services List – Effective 10/01/2021 Download (PDF)
Prolonged Services Download (PDF)
Revenue Codes Requiring Detailed Coding Download (PDF)
Revenue Codes Requiring Detailed Coding (Updated Effective 1/1/2021) Download (PDF)
Robotic Surgery Download (PDF)
Split Surgical Care – Modifiers 54/55/56 Download (PDF)
Telehealth – Supplemental Telehealth Guidelines Download (PDF)
Telehealth/Virtual Care Services - Effective 6/01/2022 Download (PDF)
Unlisted Codes Download (PDF)
Use of Non-Participating Provider Advance Member Notification Policy Download (PDF)

 

Overview of Billing and Claims Policy

ConnectiCare has policies in place that reflect billing or claims payment processes unique to our health plans. Current billing and claims payment policies apply to all our products, unless otherwise noted. ConnectiCare will inform you of new policies or changes in policies through updates to the Provider Manual and/or provider news. If a billing or claims payment policy for a particular service is not addressed in this outline, follow procedures that are considered standard throughout the health care industry. Most of ConnectiCare’s billing and claims payment policies are standard in the health insurance industry, and you should follow industry standard procedures for issues that are not specifically addressed in the Provider Manual.
 

We also evaluate medical billing information to detect coding patterns such as unbundling, integral procedures, and mutually exclusive procedures. ConnectiCare reserves the right to audit physician documentation in order to verify coding and billing accuracy.
 

ConnectiCare's claims system will process claims based on Centers for Medicare & Medicaid Services (CMS) and National Correct Coding Initiative (NCCI) edits. ConnectiCare follows coding edits that are based on industry sources, including, but not limited to, CPT guidelines from the American Medical Association, specialty organizations, and CMS. In coding scenarios where there appears to be conflicts between sources, we will apply the edits we determine are appropriate. ConnectiCare uses industry-standard claims editing software products when making decisions about appropriate claim editing practices. Upon request, we will provide an explanation of how ConnectiCare handles specific coding issues.

 

Title

Date

Policy Statement

Billing Instructions

Reimbursement Information

All Providers

       

Add-on Codes

Revised July 2015

ConnectiCare recognizes CMS and AMA CPT Add-on code guidelines.

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.

Add-on codes billed with the primary procedure will be reimbursed.

Assignment of Benefit

Effective November 2012

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.

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.

 

Bundled Status Codes

Effective August 1998, revised December 2004, revised September 2013, revised April 2015

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.

 

Reimbursement for bundled status codes is considered included in the related therapeutic or diagnostic service. Example codes with status "B" include 20936, 97602, 99051.

Clinical Documentation with Initial Claim Submission

Revised July 2015

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.

Paper claims are converted to electronic format and will be processed as an electronic claim.

Colonoscopy Services, Incomplete

Revised July 2015

Colonoscopy frequency is limited to once every 12 months with exceptions.

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.

Reimbursement will be provided when billed according to Billing Instructions. Also see Preventive Services.

CPT, HCPCS and ICD Coding

Effective June 1997, revised January 2005

ConnectiCare requires the use of current CPT, HCPCS and ICD-10 coding. Deleted procedure codes will no longer be accepted after the deleted date.

   

Date Spanning

Effective 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 revision.

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 be submitted as follows:

Line 1: 99232 - DOS 2/2
Line 2: 99232 - DOS 2/3
Line 3: 99232 - DOS 2/4

 

End Stage Renal Services

Revised July 2015

Monthly end stage renal disease services are payable on a monthly basis.

Bill with appropriate CPT code with a date of service at the beginning or at the end of each month. CPT codes 90951-90962.

Monthly reimbursement may be provided.

Evoked Potential Testing

Revised July 2015

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.

CPT codes 95925, 95926, 95927, 95939 may be reimbursed when billed according to the policy.

Services will be reimbursed according to the policy.

Extended Electroencephalography (EEG) Services

Revised July 2015

Extended EEG services are not allowed in the office location.

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.

Services will be reimbursed according to the policy.

Facility Location Only Services

Effective July 2015

ConnectiCare recognizes CMS facility location only services.

 

Procedure codes restricted to facility location, as indicated by CMS, are not payable in the office location unless documentation supports the level of coding.

Gastric Bypass Rider

Effective August 2012

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.

   

Global Surgical Billing

Effective August 1998

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.

   

HCPCS Codes

Revised July 2015

Unless otherwise specified, CPT codes should be billed when there is a corresponding HCPCS code.

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.

When a more appropriate code is required, a service may be denied so the provider may submit a more appropriate code.

Incidental Arthroscopic Procedures

Revised July 2015

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

Revised July 2015

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

 

"Incident to" services will be payable in the office location, unless otherwise indicated.

Injection Codes

Revised June 2016

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.

Submit all services rendered during a single encounter on one claim.

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.

Inpatient Only Codes

Effective July 2015

ConnectiCare recognizes CMS inpatient only services.

 

Procedure codes restricted to inpatient only, as indicated by CMS, are not payable as outpatient unless documentation supports the level of coding.

Maternity Billing Procedures

Effective May 1994

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.

• 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.

 

Moderate Sedation

Effective January 2006

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.

• 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.

• 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.

Multiple Identical Services

Revised July 2015

Multiple claims for the same procedure code may be payable when submitted on one claim.

When billing multiples of the same code, submit on one line, on one claim and indicate the number of units in the units field.

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.

NCCI Edits (National Correct Coding)

Revised July 2015

ConnectiCare recognizes CMS NCCI policy, including CMS MUE (Medically Unlikely Edits) for Professional and Facility claims.

Refer to National Correct Coding Initiative Edits

 

Needle Electromyography (EMG) Services

Revised July 2015

 

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

 

Nerve Conduction Services

Revised July 2015

 

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."

 

Non-Licensed Personnel

Effective January 1999

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).

   

Nutritional Counseling

Effective January 2000

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.

Bill with CPT codes 97802, 97803, 97804, 99078 or 0942.

Reimbursement will be made according to applicable fee schedules.

Osteopathic Manipulative Treatment (OMT)

Effective April 1995

Any DO may provide treatment for Osteopathic Manipulative Treatment (OMT) codes 98925-98929.

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.

 

Photochemotherapy (PUVA), Actinotherapy

   

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.

 

Professional Component Procedures

 

Professional interpretation is included in Evaluation and Management services.

 

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

Removal of Skin Lesions

Effective February 2002

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.

Refer to the most current CPT and ICD-10 manuals for applicable billing codes.

 

Rhythm Electrocardiography

Revised July 2015

 

 

CPT 93042 is not separately reimbursed when billed with E&M services or an interventional service in a facility.

Separate Procedure Codes

Revised July 2015

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.

Do not report procedure codes designated as "Separate Procedure" when also billing another procedure code for the same date of service.

Codes with Separate Procedure designation will be denied.

Serial Visits (Identical Services Provided Over a Defined Time Span on Different Dates of Service)

Effective July 2015

 

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.

Applicable cost share will be correctly applied for individual dates of service.

Services Associated with Preauthorized Services

Effective January 1, 2009

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.

   

Sigmoidoscopy

Revised July 2015

CPT codes 45330-45339 are not allowed more frequently than every 6 months, unless done in the inpatient setting.

   

Split Billing

Revised July 2015

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.

   

Unbundled Codes

Effective September 2013

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.

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.

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.

 

If you have any questions, please call Provider Services at 1-860-674-5850 or 1-800-828-3407.

 

PPM/04.21

Reimbursement Policy

Document
Allergy Testing and Immunotherapy Download (PDF)

Anesthesia Billing

Download (PDF)
Coding Edit Rules Download (PDF)
Computer Assisted Surgical Navigation Download (PDF)
COVID-19 Billing Guidelines Download (PDF)
COVID-19 Testing Download (PDF)
COVID-19 Vaccine and Monoclonal Antibody Infusions Policy Download (PDF)

Daily Maximum Units

Download (PDF)
DME In-Office/Non-Facility
Download (PDF)
DME Rental vs. Purchase Download (PDF)
Emergency Department Facility E&M Coding Download (PDF)

Evaluation and Management (E&M) Services

Download (PDF)
Hospital Readmissions Download (PDF)

In-Office Lab Policy – Effective through 7/31/2020

Download (PDF)
Intraoperative Neurophysiology Monitoring Services (IONM) Download (PDF)

Laboratory/ Venipuncture Codes- Effective 8/01/2020

Download (PDF)

Multiple Procedure Reduction Cardiology/Opthamology

Download (PDF)

National Drug Code (NDC) Requirements

Download (PDF)

No Cost/Reduced Cost Drugs, Implants & Devices

Download (PDF)

Observation Stay

Download (PDF)

Operating Microscope/Microsurgery (64727/69990)

Download (PDF)

Preventive Services – Effective 1/01/2021

Download (PDF)

Prolonged Services – Effective 1/01/2021

Download (PDF)
Robotic Surgery Download (PDF)
Telehealth – Supplemental Telehealth Guidelines Download (PDF)
Telehealth/Virtual Care Services-effective 6/01/2022 Download (PDF)

Unlisted Codes

Download (PDF)

Introduction to billing and claims payment policy

ConnectiCare will process Medicare claims according to Medicare payment rules and specialty society guidelines, unless specified otherwise in a provider contract. If a billing or claims payment policy for a particular service is not addressed in this section, follow procedures that are considered standard rules of the Centers for Medicare & Medicaid Services (CMS). This information is available at the CMS website.

ConnectiCare applies the CMS National Correct Coding Initiative (NCCI) edits for claims editing. Certain inpatient evaluation and management procedures are identified in the NCCI manual as not being separately reimbursable, even if a modifier such as modifier 25 is added to the procedure code. NCCI edits apply to claims from all providers in the same specialty and group. There are no exceptions to these edits based on sub-specialty or different diagnoses. Please refer to the CMS NCCI manual regarding reporting of Evaluation and Management Services as needed.

 

Medicare PPM/11.12

Overview of policy

 

Title Effective date Policy statement Billing instructions Reimbursement information
All providers        
Bilateral Procedures January 2009

Professional claims sho.uld 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.
 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

 
Diagnosis and Procedure Coding January 2009 Current diagnosis and procedure codes are required. Deleted codes will be denied.    

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 the Physician Relative Value Files located under "Medicare" at www.cms.gov.

 

 

Modifiers

January 2009

ConnectiCare follows CMS guidelines for CPT and HCPCS modifiers.

 

 

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.

 

Radiology Services with an Evaluation and Management (E&M) visit

June 2012

Radiology copayment applies if radiology services are provided during an Evaluation and Management (E&M) visit. Please go to Provider Connections and check the member's benefits for the appropriate copayment amount.    

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.

If you have any questions, please call Provider Services at 1-860-674-5850 or 1-800-828-3407.

Medicare PPM/4.19

Administrative procedures

Claim Edits

ConnectiCare evaluates medical billing information and coding for accuracy and appropriateness. This practice is designed to detect coding patterns such as unbundling, integral procedures, and mutually exclusive procedures.

In addition, ConnectiCare’s claims payment system will adjudicate claims based on CMS (Centers for Medicare & Medicaid Services) and NCCI (National Correct Coding Initiative) edits. ConnectiCare considers coding edits that are based on industry sources, including but not limited to CPT guidelines from the American Medical Association, specialty organizations, and CMS. In coding scenarios where there are conflicts between sources, ConnectiCare will apply edits that ConnectiCare determines are most appropriate.

For questions about why a particular claim was denied based on a coding edit, refer to your remittance, or, call Provider Services at 1-877-224-8230.

 

Medicare PPM/2.10

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