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Claims payment policies updated as of Jan. 31, 2017

03/09/2017

We have made a number of updates to our claims payment policies that went into effect with claims processed on and after Jan. 31, 2017. The updates apply to commercial and Medicare Advantage plans, unless otherwise specified.

The updates are:

Topoc Instructions for claims payment submission
ICD-10 ICD-10 diagnoses codes are required to be reported in accordance with guidelines set by the Centers for Medicare & Medicaid Services (CMS) and National Government Services (NGS) Medicare and noted in the ICD-10 manual.
  • Bill with the code to the highest specificity.
  • Manifestation or secondary diagnoses codes cannot be the only code on a claim.
  • Encounter diagnoses codes for chemo or immunotherapy administration procedures must be reported with a primary diagnosis for which treatment is needed.
Drugs and Biologicals The following drug and biological code edits will apply:
  • J0881, J0885 or J0888 will not be payable when billed with modifier EC, and the diagnosis associated to the claim line is not approved for ESA treatment.
  • J9041 will be limited to 32 combined units per date of service by any provider when billed and the diagnosis is mantle cell lymphoma or multiple myeloma.
  • J0178 is payable with a diagnosis of diabetic macular edema when diabetic retinopathy or diabetic macular edema and diabetes mellitus with ophthalmic manifestations is also present.
  • J0897 is payable when billed with a diagnosis for a Food and Drug Administration-approved indication or an off-labeled indication.
  • J0897 will be limited to 60 combined units per date of service by any provider when the diagnosis is not adults and skeletally mature adolescents with giant cell tumor of bone, hypercalcemia of malignancy refractory to bisphosphonate therapy or prevention of skeletal-related events in patients with bone metastases from solid tumors.
  • J0881, J0885 or J0888 will be required to be billed with modifier EA, EB or EC as applicable.
  • Medicare Advantage only: J9310 will be limited to 10 combined units per date of service by any provider when A9542 (Indium In-111 ibritumomab tiuxetan, diagnostic) or A9543 (Yttrium Y-90 ibritumomab tiuxetan, therapeutic) has not been billed for the same date of service, and the diagnosis is not chronic lymphocytic leukemia, minimal change disease, or systemic lupus erythematosus.
  • Medicare Advantage only: J9310 will be limited to eight times in a patient's lifetime when billed by any provider and the diagnosis is acute lymphocytic leukemia, benign mucous membrane pemphigoid, Burkitt's lymphoma, chronic graft-versus-host disease, multicentric Castleman's disease, pemphigus foliaceus or pemphigus vulgaris.
Cardiology 93260-93261, 93282-93284, 93289, 93292 or 93295 (Automatic implantable cardiac defibrillator [AICD] monitoring) will be allowed when billed up to once per three months when the diagnosis is ICD-10 code Z95.810 (Presence of automatic [implantable] cardiac defibrillator).
Chirporactic
  • Medicare Advantage only: Chiropractic manipulation (98940-98942) will be payable when billed with modifier AT.
  • Medicare Advantage only: Chiropractic manipulation (98940-98942) will be payable only when billed with a primary diagnosis of subluxation and a secondary diagnosis for the symptoms associated with the diagnosis of subluxation is not present.
Immunization Services
  • Medicare Advantage only: G0008, G0009, G0010 will be required to be billed with the appropriate, corresponding vaccine code.
  • Medicare Advantage only: Immunization administration (90460-90461, 90471-90474) will be required when billed with a vaccine/toxoid code (90476-90749, J3530, Q2033-Q2039, or S0195 (if code is allowed).
Ophthalmology Fundus photography (92250) will be allowed when billed up to two units within one year, except when specific diagnoses are present.
Physician Services
  • Hospital discharge services (99238-99239) will be payable once per member for the same date of service.
  • Transitional care management (TCM) services (99495-99496) will be payable once per member for the same date of service.
  • Evaluation and management services not indicated as being for a significantly separately identifiable unrelated reason will not be payable when billed with cardiovascular services.
  • Services billed for locations 19 (outpatient hospital - off campus), 22 (outpatient hospital - on campus) or 23 (emergency room - hospital) billed by any provider on the same date where the member is inpatient the day before and the day after, will not be reimbursed.
Professional Component One professional component may be reimbursed per code for the same service when billed by different providers. Multiple interpretations of the same service are not payable.
Surgery
  • Knee arthroscopy lavage and/or debridement procedures will be payable with a diagnosis other than osteoarthritis of the knee.
  • Procedures billed without modifier 54, 55 or 56 when another provider has billed the same procedure with modifier 54, 55 or 56 will not be paid separately.