Procedure coding used for the submission of a healthcare services claim consists of two industry standard coding systems:
When a CPT and a HCPCS code have very similar descriptions for a procedure or service, use the CPT code. If the code descriptions are not identical, select the code with the more specific description that reflects the service rendered.
Select diagnosis coding from the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM).
We abide by federal and state regulations concerning fraud, as well as our contract obligations to members and providers. To support this commitment, we have a Special Investigations Unit to prevent fraud and abuse. If you suspect fraud, call the Anti-Fraud Hotline at 800-848-0244.
We apply the following claims coding guidelines:
Because we cannot provide coding advice, we recommend that you maintain current copies of coding reference books or current versions of coding software in your office.
We only reimburse current effective procedure codes in the CPT book published by the AMA and HCPCS Codes as maintained by CMS that are effective at the time of service in the year the service was rendered.
If you submit a claim with a deleted code, it will be processed as a denial and the line item will indicate the corresponding denial code. Then you will need to correct the claim to reflect the appropriate code effective for the date of service on the claim and resubmit the claim as described in “Rebilling” below. Denied claims will be considered a physician or provider write-off until the corrected claim is processed.
We use the following definitions established by the AMA and found in the current CPT codebook:
We adopted a policy addressing the use of new and established patient evaluation and management codes. We rely on the physician or other qualified healthcare practitioner to use the code that most accurately reflects the service rendered. We may perform random audits to ensure services are billed appropriately per provider's documentation. As part of the audit process, we may request medical records supporting use of these codes.
After-hours services (codes 99050 through 99060) are provided in the physician or provider’s office outside posted office hours, on Sundays, or on holidays. We don’t reimburse these codes unless provider contract terms specifically include and allow reimbursement. These codes are Medicare Status B codes and are included in the allowance of another service(s).
We use American Society of Anesthesiologists (ASA) codes (codes 00100-01999) to establish anesthesia base units. Use only ASA codes when billing anesthesia. Please note the following:
We limit reimbursement of blood draws (36415) to one per provider, per patient, per day regardless of the number of specimens drawn. We’ll deny CPT code 36416 as a Medicare Status B code.
Codes and Proprietary Lab Panels
Surgical pathology (88300-88309)
and technical components:
Review the current National Physician Fee Schedule
maintained by CMS to identify those laboratory/pathology codes that have a
professional and/or technical components as defined by the “PC/TC” indicator
flag in the Fee Schedule
All hospital outpatient facility services billed with revenue codes 0760 – 0769 (outpatient treatment/observation room) are processed subject to the hospital outpatient facility medical benefit cost shares. You must bill hospital outpatient facility surgical services with revenue codes 0360, 0361, 0369, 0490-0499, or 0750 and the appropriate surgical CPT procedure code in order to be subject to the hospital outpatient facility surgical benefit cost shares.
Outpatient facility diagnostic services will apply to the diagnostic services benefit when not impacted by a pricing mechanism that packages or bundles based on a procedure.
All other outpatient facility service (except diagnostic) will apply toward the applicable services benefit (i.e. surgical services, rehab, ER, etc.), when not impacted by a pricing mechanism that packages or bundles based on a procedure.
A locum tenens physician does not need to be credentialed because he/she is considered a temporary provider; however, if a locum tenens physician provides services for more than 90 days, he/she must be credentialed. A locum tenens physician bills under the name of the absent, contracted physician appending modifier Q6 to all services rendered.
We'll reimburse one global obstetric birthing procedure (routine prenatal obstetric care, delivery, and postpartum care) for the first
birth, whether vaginal or cesarean delivery and one delivery-only procedure for the second and subsequent births, whether vaginal or cesarean
delivery. Note that the level of reimbursement is subject to our payment policy on multiple procedures.
Bill the delivery of each baby on a separate line on the claim. Each subsequent birth after the initial birth should be billed with modifier 59-Distinct Procedural Service in order to prevent an edit indicating a duplicate service.
an additional diagnosis code to indicate the outcome of the delivery was for multiple
births for the second and subsequent births after the initial birth.
Chiropractic and osteopathic manipulation are a form of manual treatments applied to eliminate or alleviate somatic dysfunction and related disorders. Please note the following:
Evaluation and management services provided the date before or on the date of a major surgical procedure will be considered part of the global surgery reimbursement and are not eligible for separate reimbursement. If the visit resulted in the initial decision to perform surgery separate reimbursement will be allowed for the evaluation and management service when appended with Modifier 57.
For significant, separately identifiable and documented E/M services billed on the same day as a surgical procedure, use modifier 25 on the evaluation and management service to indicate the service was a distinct and unrelated procedural service from the surgical procedure. Documentation in the member’s medical record must support that the evaluation and management services was truly distinct, unrelated, and separate from the surgical procedure performed.
Screening PAP smear:
Cervical/vaginal cancer screening, pelvic and clinical breast exams:
Prostate cancer screening with digital rectal exam:
We have payment policies that define how to use Modifiers -80, -81, -82 and -AS to indicate when surgical assistance is provided to a primary surgeon. Bill all surgical assistance services under the name of the performing provider or the person who assisted the primary surgeon. Bill the charges for the primary surgeon and the assisting surgeon on separate claims
Modifier -80, Assistant Surgeon. This modifier indicates that the assisting surgeon is actively assisting a primary surgeon. Add Modifier -80 to the surgical procedure to identify surgical assistant services when appropriate. Only one physician may assist another physician in performing a procedure. If an assistant surgeon assists a primary surgeon and is present for the entire operation, then the assisting physician reports the same surgical procedure as the primary surgeon with Modifier -80 appended. Modifier 80 and modifier AS can't be billed on the same claim by the same provider.
Modifier -81, Minimum Assistant Surgeon. This modifier is used when the surgical assistant does not participate in the entire surgical procedure. Add Modifier -81 to the surgical procedure to identify minimum surgical assistant services when appropriate. There are times when a primary operating physician may plan to perform a surgical procedure alone, but during the operation, circumstances may require surgical assistance for a relatively short time. In this instance, the second surgeon provides minimal assistance, for which he/she reports the same surgical procedure as the operating surgeon with Modifier -81 appended. Modifier 81 and modifier AS can't be billed on the same claim by the same provider.
Modifier -82, Assistant Surgeon (when qualified resident surgeon is not available). The prerequisite for adding Modifier -82 to the surgical procedure is the unavailability of a qualified resident surgeon. In certain programs (e.g., teaching hospital), the physician acting as the assistant surgeon is usually a qualified resident surgeon. However, there may be times (e.g., during rotation change) when a qualified resident surgeon is not available and another surgeon assists in the operation. In this instance, the services of the nonresident-assistant surgeon should be reported with Modifier -82 appended to the appropriate code to show that another surgeon assisted the operating surgeon instead of a qualified resident surgeon. Modifier 82 and modifier AS can't be billed on the same claim by the same provider.
Modifier -AS. Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery. This modifier is used when a “non-physician” provider assists the primary surgeon. Use this modifier when a physician assistant, nurse practitioner, or clinical nurse specialist provides surgical assistance. Add the HCPCS modifier -AS to the same surgical procedure code as the primary surgeon. Modifier AS and modifiers 80, 81, or 82 can't be billed on the same claim by the same provider.
Telehealth services are described as medical information exchanged from one site to another via electronic modes of communication between a practitioner and patient in a manner other than an in office face-to-face encounter. Such services can be delivered via:
Audio and Video Real-Time Interactive or Synchronous Technology
Audio only/Telephone Assessment and Management
An Originating Site is where the patient is physically located during a telehealth encounter,
whether being physically hosted in a Clinic while interacting with a Distant
Site provider or by themselves in their home or private residence. We recognize HCPCS Code Q3014-Telehealth
originating site facility fee (without any modifier) as the code designated
to indicate the originating facility fee. This code cannot be billed by the
“distant site” provider
We recognize the following appropriate modifiers appended to a telehealth service:
Audio/video services only
Audio only services
Store and forward services
To identify where the patient receiving telehealth services is physically located, one of the following Place of Service (POS) codes is required:
We require documentation to be permanently stored in the member's record to support any encounter conducted as an audio/video office visit, an audio only telephone assessment or an online/internet communication/text, and that it be made available for review in the event of an audit. Documentation in the members record should include the following:
We do not reimburse for professional services or supplies that are usually provided free because of the relationship to the patient.
As a reminder, physicians, providers or suppliers who are our members are not reimbursed by us for professional services for any of the following when services are
An ARNP or nurse practitioner provides services to members via one of the following methods:
A Physician Assistant provides services to members via one of the following methods:
Some procedures in the CPT codebook are performed in addition to a primary service code. These services are notated as an add-on code by the symbol “ + “ in the CPT codebook and are listed in Appendix D of the CPT Codebook. Add-on codes are always performed in conjunction with a primary code/procedure. Instructions identifying the correct primary code are listed after the add-on code in the CPT codebook.
If an add-on code is billed without an appropriate primary code or
billed by itself without a primary code, the add-on code will be denied
reimbursement. In addition, if the
appropriate primary code is denied reimbursement, the add-on code will also be
Add-on codes are exempt from multiple procedure reductions so modifier 51-Multiple
Procedures should not be appended to these codes. No modifiers appended to an add-on code will
bypass a denial of an add-on code.
Healthcare professionals may render procedures and services for which there is no specific CPT or HCPCS code available. Providers may use unlisted codes, unspecified codes, or miscellaneous codes, which usually end in XXX99. These codes don’t have specific language that describes the service. These codes should only be used as a last resort if there is not a more specific CPT or HCPCS code available.
If an unlisted code is submitted, we require that you submit supporting detailed documentation with claims to describe the service(s) rendered, identifying what was performed as part of the service. Critical documentation should include:
Failure to provide such detailed information will result in a delay or denial of the claim being processed.
All unlisted, non-specific, and miscellaneous CPT and HCPCS codes submitted on a claim, along with the supporting documentation described above, will be subject to clinical review at claims submission. Premera does not review unlisted, non-specific or miscellaneous CPT and HCPCS codes prior to service delivery; this subset of codes is not subject to prior authorization. During the review of each submitted unlisted, non-specific, or miscellaneous code, Premera will determine how that code will be priced (e.g. such as but not limited to basing on a comparable code, a comparable code with modifier 22 added, or on a percentage of charge) as part of the processing of the entire claim.
In the National Physician Fee Schedule (NPFS), as maintained by CMS, procedure codes that are identified with a Status Indicator code of B are not eligible for reimbursement, whether billed alone or with another service, and will be denied. To obtain a complete list of Status B codes, visit the CMS website and select the most current NPFS release.
We restrict the use of these prolonged service codes in maternity care. We don’t provide reimbursement separately when prolonged service codes are billed to indicate the management of labor, which is considered a component of the delivery care.
Prolonged services for both outpatient and inpatient care billed for labor management include the following codes:
Global surgery or global surgical package is a period that starts either with the day of or the day before the surgical procedure. It ends some timeframe after the surgical procedure based on whether the procedure is classified as minor or major surgery.
We use the global surgery indicator flag as established in the current version of the National Physician Fee Schedule (NPFS), maintained by CMS, to determine whether a procedure code does/doesn’t have a specified global surgery period (e.g., simple/minor procedures, minor surgical procedures, major surgical procedures, maternity codes, global periods do not apply, carrier/plan determined or add-on codes).
Services considered “included” in the global
surgical package include but are not limited to such items as related preoperative
visits, intraoperative services, follow up E&M related visits, supplies for
postoperative complications/treatments and miscellaneous medical/surgical
Robotic surgery and computer-assisted navigation services are add-on techniques used to perform the main surgical procedure. As such, when these add-on codes are billed , the robotic surgical system code, the computer-assisted navigation codes and their related supplies and equipment will be considered bundled/included as part of the primary surgical procedure. They aren’t separately reimbursable, whether billed separately or in conjunction with a primary procedure.
Robotic surgical system services and computer-assisted navigation for musculoskeletal surgical services are billed using the following HCPCS or CPT codes:
When administering drugs from a single use vial or package only, any leftover portion of the drug that wasn't administered to a patient can be submitted for reimbursement. Include both the administered portion of the drug as well as the discarded or wasted portion
of the single use drug vial or package.
Submit two lines with the same HCPCS or CPT code and the same NDC number, one line with the modifier JW to represent the non-administered/wasted portion and the other line without the modifier to represent the administered portion. Units on each line
should represent the portions administered and the portion non-administered or wasted.
Modifiers are required on any piece of DME that is rental only, purchase only or rental to purchase/outright purchase. Add one of the following modifiers to reflect whether the equipment is either a purchase, a replacement, or a rented piece of equipment:
Units of service must also match the type of DME rental to be correctly reimbursed:
All related diagnostic and non-diagnostic services (preadmission testing) provided by an admitting hospital on the date of an inpatient admission or within 3 calendar days preceding the date of an inpatient admission including the 72-hour period that immediately
precedes the time of admission are considered to be part of/incidental to the inpatient admission hospital claim. These services aren't separately billable or reimbursable. Related services rendered within the 3-calendar day window must be billed on the same claim as the inpatient admission.
Any services rendered within the 3-calendar day window or immediate 72-hour period prior to the admission that are not related to a planned inpatient admission must be identified on the UB-04 claim form as being unrelated by using Condition Code 51-Attestation of Unrelated Outpatient Non-diagnostic Services in Field Locator 18-28.
Any services rendered on the date of an unplanned inpatient admission as part of an emergency room visit that led to the unplanned inpatient admission should be included on the inpatient admission claim. Such an unplanned emergency inpatient admission should be identified using Admission Type Code 1-Emergency in Field Locator 14 of the UB-04 claim form.
Emergency room visits that occur within 3-calendar days or the immediate 72 hours prior to an inpatient admission that are diagnostically related to the inpatient admission will be considered part of the inpatient admission. These visits are denied separate reimbursement.
Services which are excluded from preadmission
The following hospitals, units and services
are exempt from this policy criteria:
When a member receives inpatient or outpatient care in a preferred/in-network hospital, all services associated with that hospital care performed by the following specialty categories will be covered
at the preferred/in-network level of benefits based on the allowable charge:
Take-home drugs supplied and billed by a hospital or facility and billed with revenue code 0253-Take Home Drugs are paid under the hospital ancillary benefit and not under the pharmacy benefit.
The use of modifiers is an important component to coding and billing for services. A modifier is a two-digit character (numeric, alpha numeric, or alpha) designed to provide additional information needed to process a claim or increase or decrease reimbursement.
Modifiers allow a provider to identify that a special circumstance has altered a service, but that the basic procedure code description has not changed. Appropriately document the patient’s medical record or chart to support the use of any modifier.
In certain circumstances, multiple modifiers may be necessary to completely describe a service. Our payment system recognizes multiple modifiers to allow you to bill up to four separate modifiers per claim line.
When more than 4 modifiers are needed for a service, modifier 99-Multiple Modifiers should be used to reflect this situation. Make sure that documentation in the member’s medical record supports all the modifiers submitted.
We process the following modifiers when appended to an appropriate code(s). Where applicable, the provider's fee schedule allowed amount will be adjusted per any percentage noted. Please note this doesn't represent all of the available modifiers but a list of commonly used modifiers:
*Outpatient and ambulatory surgery center use only
For any provider administered or supplied drug or vaccine submitted on an electronic or paper claim, a National Drug Code (NDC) number, an NDC units/basis of measure, and NDC units is required to be submitted along with an appropriate HCPCS or CPT code on the same claim line. The appropriate NDC number can be found on the drug label or outer packaging and should be 11 digits in length. Failure to supply an NDC number may result in a denial of the claim line.
An NDC code number is an 11-digit number in a 5-4-2 digit format that is assigned to each medication approved by the Food and Drug Administration. The three segments in the number, NNNNN-NNNN-NN, indicate the following:
How to submit an NDC number on a claim
Some general guidelines to help in the submission of an NDC drug code include:
1) Electronic Claim Guidelines (ANSI 837P)
2) Paper Claim Guidelines (CMS-1500)
The CMS-1500 claim form allows for the submission of one NDC code per HCPCS/CPT drug code line submitted. The HCPCS/CPT drug code is submitted on the lower portion (unshaded portion) of the claim line and the NDC code is billed on the upper portion (shaded portion) of the same line (see example below).
In the shaded portion/upper portion of the line, item field 24 on the CMS-1500, enter the following:
Facility Claims - Outpatient Facility Claims Only
1) Electronic Claim Guidelines (ANSI 8371)
2) Paper Claim Guidelines (UB-04/CMS-1450)
On the UB-04/CMS-1450 claim form, each drug administered in the hospital/facility setting is required to be submitted on an individual line with an appropriate Revenue Code (Field 42). Each drug code line must include the NDC drug code (Field 43, left justified), the applicable CPT or HCPCS code (Field 44), date of service (Field 45), CPT/HCPCS code units (Field 46) and a charge for the drug supplied/administered (Field 47).
UB-04/CMS-1450 Claim Example:
Field 42 - REVENUE CODE - insert the appropriate code
Field 43: DESCRIPTION - Insert the NDC code along with the following information:
If billing for a compound drug, eachspecific drug in the compound must be billed on a separate line with the appropriate HCPCS/CPT drug code, the corresponding Product ID Qualifier, the NDC number, unit/basis of measurement and NDC units.
Failure to include an NDC# in the format described above along with the billed drug CPT or HCPCS code will result in a denial of reimbursement of the claim.
Reimbursement for discarded/non-administered drugs applies only to single-use vials. Multi-use vials are not subject to payment for discarded amount of the drug. Append modifier JW to the discarded drug line only.
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