Payment Policy Updates

  • Here are the latest updates to our payment policies. You’ll need to log in to see the policy updates.

    January 3, 2019

    Medicare Indicator “Status B” Services Reimbursement (effective 01/04/2019 with dates of service on and after)
    The existing policy has been modified to allow code 96040-Medical genetics and genetic counseling services, each 30-minute face to face with patient/family to now be reimbursed for genetic counseling rendered by a trained genetic counselor only (per CPT coding guidelines) effective with dates of service 01/04/2019 and after. As stated in the coding guidelines in the AMA’s CPT Codebook, this code will be payable for trained genetic counselors only. Physicians should continue to bill E&M codes as per CPT coding guidelines for any genetic counseling. All other submissions of this code by providers other than “trained genetic counselors” will continue to be denied as a Medicare Status B code.

    Modifier 51 – Multiple Procedures (NEW POLICY – effective 01/01/2019)
    This policy was created in response to provider inquiries. The policy identifies the criteria used to determine which procedure codes are subject to “multiple procedure reductions” based on the Center for Medicare and Medicaid Services (CMS) National Physician Fee Schedule. The policy also identifies which codes are “not” subject to multiple procedure reductions in reimbursement.

    Drugs Administered in a Physician Office (NEW POLICY – effective 04/14/2019 with process dates on and after)
    Effective with process dates of 04/14/2019 and after, a number of claim edits will be applied to drugs that are administered in the Physician office and submitted under a member’s medical benefits. This policy identifies the sourcing that will be used for the edits and supplies a link to the FDA site where providers can search for their drugs and view the approved criteria as published in the drug package insert and approved by the FDA. The specific drugs and criteria that will be implemented by a claim edit will be incorporated into either a Medical or Pharmacy policy.

    Consultation Code Services
    Effective with dates of service 01/01/2019 and after, Interprofessional Telephone/Internet Consultation codes (99446-99449) are no longer Medicare Status B codes but reimbursable codes. For dates of service prior to 01/01/2019, these codes will continue to be denied as Medicare Status B codes.

    Multiple Diagnostic Ophthalmology Services Reduction
    Corrected the percentage of the reduction taken on multiple Ophthalmology codes billed on same date of service to reflect the actual percentage being applied in the claims processing pricing application.

    Drug Assay Services
    Code 0020U was terminated by CPT effective 10/01/2018 and the policy was updated to reflect the code termination.

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