Member

Switch to:

Coding edits, effective Aug. 29

06/21/2017

The following coding edits will go into effect Aug. 29, 2017, for both commercial and Medicare Advantage plans, unless otherwise noted:

  • 24-Hour EEG Monitoring: We recognize NGS Medicare LCD L33399 for commercial and Medicare claims. CPT codes 95950, 95951, 95953 or 95956 (24-Hour EEG Monitoring) will be reimbursed when billed with a requisite diagnosis in accordance with the LCD criteria.

  • Ambulance Transport and Mileage: We follow Centers for Medicare & Medicaid Services (CMS) policy that states mileage codes must be billed for the same date of service as ambulance services (A0380, A0390, A0425, A0435 or A0436) and/or transport codes (A0225, A0426-A0434, S9960 or S9961).

  • Anatomical Modifiers: Procedure codes that involve a specific body site require an applicable anatomical modifier, which are:
    • E1-E4 (Eyelids)
    • FA-F9 (Fingers)
    • TA-T9 (Toes)
    • LC (Left circumflex, coronary artery)
    • LD (Left anterior descending coronary artery)
    • LM (Left main coronary artery)
    • RC (Right coronary artery)
    • RI (Ramus intermedius)
    • LT (Left side)
    • RT (Right side)
    • 50 (Bilateral side)

  • Consultation Services: Consultation services have specific reporting and documentation criteria to be able to be reported based on America Medical Association (AMA) and AMA CPT Assistant guidelines.

    If a provider of the same primary specialty and same group tax ID has billed any other Evaluation and Management service in any place of service in the previous 12 months, outpatient/office consultation services 99241-99245 will be denied and may be reconsidered upon submission of the clinical documentation.

    Alternatively, an office visit 99201-99215 may be submitted on a corrected claim. An exception is made to this policy for consultations performed for the purpose of pre-operative evaluations (ICD-10 codes Z01.810, Z01.811, Z01.818).

  • Duplicate Drug Claims: We will not reimburse more than one professional provider for the same drug code and unit count billed on a different claim by any other professional provider for the same member and date of service.

    This edit will only go into effect on Aug. 29 for commercial plans. An existing edit is already in place for Medicare Advantage plans.

  • Emergency Ambulance Destination Modifiers: We recognize the CMS policy for emergency (ground) ambulance services (A0427, A0429 or A0433) are payable only for the destination of hospital (Modifier H), site of transfer (Modifier I), or intermediate stop at physician’s office on way to hospital (Modifier X).