Following are coding guidelines for specific conditions and situations.
- Allergy Immunotherapy
- Anesthesia Services Reporting Requirements
- Bone Mineral Density Test Billing
- Care Plan Oversight Services
- Chiropractic Care
- Clinical Trial Coverage Billing
- Consultation Codes
- Diabetes Management Training
- Flu Vaccination Billing
- Hemodialysis Services Billing
- Immunization Coverage
- Infusion Codes
- Intraoperative Neurophysiologic Monitoring
- Mammography or Breast Digital Tomosynthesis (3D digital mammogram)
- Nutritional Counseling in Chronic Disease
- Prenatal and Delivery Services Billing
- Preventive Health Benefit
- Routine and Complex Office Procedures
- Smoking and Tobacco Cessation
- Telemedicine Payment Policy
- Transitional Care Management Services
- Vision Exam/Refraction Services
A physician who administers allergy immunotherapy but does not create or bill for the creation of the injected antigen, should use CPT® codes 95115 and 95117. No more than one of the administration codes may be used on any date of service. A maximum of one unit of either of these codes is allowed per date of service. Periodic random audits may be used to ensure the shots are being administered.
A physician who prepares and bills for the allergen, but who does not administer the allergen, may use codes 95144-95170 to bill for these services. These services are limited to preparation of 24 doses per two sessions. In the event that greater than 144 doses per 365 days are clinically required, pre-authorization for the additional doses will be required to ensure the higher number of units is justified due to incompatible antigens that may not be combined.
If a physician prepares the allergen on one occasion and administers it on other occasions, it would be correct to bill 95144-95170 on the day of the preparation of the allergen and 95115 or 95117 on the day of administration of the allergen. No more than one of the administration codes may be used on any date of service. A maximum of one unit of either of these codes is allowed per date of service. Periodic random audits may be used to ensure the shots are being administered.
Mixing and administering the allergen on the same day “off the board” is not considered to be appropriate; codes 95120-95134 will no longer be recognized or paid by QualChoice.
Anesthesia services are paid based on Anesthesia Relative Value Units. The customary values for reimbursement of anesthesia services are based on the sum of the components listed below.
- Base units for the primary procedure
- Total time
- Physical status
Bone mineral density (BMD) screening is covered without pre-authorization every two (2) years or longer as preventive for:
- All females over 65, regardless of risk factors or females 55-64 with a specific diagnosis known to be a major risk factor for osteoporosis. More frequent testing will deny as not medically necessary/exceeding benefit limit.
BMD testing is covered without pre-authorization every three (3) years or longer under the medical benefit for:
- Women ages 30-54 or men ages 30 and older who have a specific diagnosis known to be a major risk factors for osteoporosis. More frequent testing will deny as not medically necessary/exceeding benefit limit.
BMD testing is covered without pre-authorization every two (2) years or longer under the medical benefit for:
- Members age 30 and older being treated for osteoporosis with or without fractures. More frequent testing will deny as not medically necessary/exceeding benefit limit.
Bone density studies for all members under age 30 requires pre-authorization. BI216 Bone Mineral Density Studies
Charges by physicians for participation in care management team conferences are generally considered to be included in the other services rendered relating to that care and are not separately reimbursable. Team conferences under CPT codes 99366 – 99368 are considered to be a part of the routine care provided by physicians, other caregivers and facilities to patients confined in acute, subacute and rehabilitation facilities. CPT codes 99366 – 99368 are not covered services. Care plan oversight services under CPT codes 99374 – 99380, G0181, and G0182 are significant services rendered by a physician to oversee and coordinate the complex care requirements of some patients confined at home, enrolled in hospice or in a nursing facility. These charges may be subject to audit prior to reimbursement. G0181 and G0182 are only covered with QualChoice is the secondary payer for Medicare beneficiaries.
Some chiropractic services may be subject to prepayment review. For chiropractic coverage and limits, consult the member’s coverage document. See BI220 Chiropractic X-rays for guidance regarding chiropractic X-rays. Maintenance therapy is not covered.
Laboratory studies are not generally necessary for the diagnosis of conditions treated by chiropractors. When laboratory studies are required, they will be ordered through a participating independent laboratory, such as LabCorp or Quest. The patient should be sent to the nearest draw station, or the specimen may be delivered or sent to the participating independent laboratory.
QualChoice covers many spine X-rays taken by chiropractors in their offices:
- CPT codes 72081 – 72084 – Total Spine Exam are not covered for chiropractic treatment.
- CPT codes 72081 – 72084 and 72120 – Scoliosis Exams are covered only if performed at an imaging center or hospital and read by a radiologist.
- CPT codes 72020, 72040, 72050, 72052, 72070, 72072, 72074, 72080, 72100, 72110, 72114 – Regional Skeletal X-rays are considered medically necessary for:
- Any age, with any of the following:
- A known congenital anomaly of the spine and no study available within the prior 12 months
- A history of a malignancy, with unexplained new symptoms (please coordinate all radiology with the PCP and/or Oncologist)
- A history of spondylolisthesis with no study within 18 months and/or new trauma
- Significant trauma (head injury, spine injury) including spinal antalgia with ambulation severely impaired (e.g., torticollis, LBS acute IVD displacement with antalgia and visually distorted posture)
- Unexplained weight loss with orthopedic chief complaints
- Known osteoporosis. If the patient is at risk but undiagnosed, a referral to the patient’s primary care physician for assessment or bone density study may be indicated. Skeletal X-ray is not acceptable as a screening tool for osteoporosis
- A palpable abnormal mass
- Substance abuse
- Prolonged corticosteroid use
- Fever of unknown origin – If the patient is febrile without known cause, the patient should be referred to the PCP for evaluation before having any manipulative treatment considered
- Suspected physical abuse
- Suspicion of an extremity or spinal fracture
- No response to treatment after two weeks of conservative care
- Age over 50, with no X-rays within the past year and with any of:
- Radiating pain
- Extremity numbness
- Extremity motor weakness or asymmetrical deep tendon reflexes
- Age over 60 with symptoms and no X-rays within the past 18 months
Please remember that ionizing radiation has a cumulative effect on the human body. Chiropractors are required to keep a record of their patients’ exposure to all X-ray studies, including CT, dental X-ray and radiation therapy. For the safety of the member, coordinate care with other providers and do not duplicate studies or perform unnecessary X-rays.
For children aged 16 years and younger, X-rays are covered only if performed at an imaging center or hospital and read by a radiologist.
The visit expectation is that 8 visits will be allowed with each episode of care. Visits beyond 8 may be subject to pre-payment or post-payment review for documentation of medical necessity.
For coverage information: BI395 Clinical Trial Coverage
QualChoice will not deny a qualified individual from participating in an approved clinical trial for treatment of cancer or another life-threatening condition, nor impose additional conditions or limitations on such participation other than those applied to other medical services. Pre-authorization is required.
To be qualified for such treatment, the individual must have a clear diagnosis of cancer or another disease or condition that directly threatens the individual’s life. Additionally, the individual’s participation in the trial must be appropriate to treat the life threatening disease or condition.
QualChoice will cover routine patient costs for qualified patients participating in an approved clinical trial. This includes the items and services that would be covered for a similar patient not participating in a trial. Note that all requirements for coverage still apply, including requirements for pre-authorization, where applicable, and for medical necessity. QualChoice will NOT cover:
- The cost of the investigational item, device, medication, or service.
- The cost of items or services used only to meet study requirements for data collection or analysis. For example, an MRI that the study protocol requires be done at a specific interval will not be covered if it would not be covered for a patient not participating in the trial.
- Service that is clearly inconsistent with widely accepted standards of care for that diagnosis.
To be approved, a clinical trial must be one of the following:
- Federally funded or approved; OR
- Conducted under an FDA investigational new drug application; OR
- A drug trial that is exempt from the requirement of an FDA investigational new drug application.
The only way QualChoice can verify that a clinical trial meets the above criteria is for the participating clinician (clinical trial investigator) to share the details of the trial. Vague claims about a clinical trial do not allow independent confirmation by QualChoice that the clinical trial meets the necessary criteria. Also, without knowing the study protocol, QualChoice cannot determine which services are standard and which services are experimental (this is particularly true of extra office visits, imaging studies and laboratory testing). QualChoice will deny coverage of any request for clinical trial participation when details of the clinical trial are withheld.
Consultation Codes (99241-99255) are codes used by physicians to report services specifically requested by another physician. These codes are not eligible for reimbursement. Physicians should use the corresponding Evaluation and Management codes instead of the consultation codes.
Diabetic education counseling visits are generally covered for an approved comprehensive diabetic education program. Further diabetic education sessions will be covered if medically necessary according to QualChoice criteria. Diabetic education is not covered unless administered by a licensed provider certified by the American Diabetes Association or the American Association of Diabetes Educators. Educational services are covered on a limited basis for diagnoses other than diabetes; see BI342 Nutritional Counseling in Chronic Disease.
Dietary counseling and diabetic education will be covered for diabetics under the following criteria:
- Diabetic education is covered for one course.
- Dietary group counseling is not covered.
Dietary counseling for other diagnoses is only covered when specifically permitted by the Summary Plan Description or Evidence of Coverage. When permitted by the plan, coverage is available as discussed in BI342 Diabetic Educational Services. Codes permitted are:
- 97804 is not covered
Flu Immunizations are a covered benefit for both adults and children. Standard flu shots may be obtained from a network pharmacy at no member cost share subject to the limitations of medical policy BI010 Flu Immunizations. Reimbursement limitations of up to $25.00 apply to flu immunizations provided by non-participating physicians or pharmacies.
Standard flu immunizations (trivalent, quadrivalent, with or without preservatives, intradermal or intramuscular) administered by a network provider are covered in full. Non-standard immunizations (antibiotic-free or recombinant-DNA derived preparations), require pre-authorization and are only indicated with a history of anaphylaxis (severe allergic reaction).
Per recommendations from the Center for Disease Control (CDC), the intranasal flu vaccination is no longer covered.
- All home health services require pre-authorization.
- For QualChoice Medicare Advantage plans, bill according to Medicare rules.
- 99512 Home visit for hemodialysis
- Bill CPT code 90999 with type of bill 72 and condition code 74.
- Condition code 74 must be billed to indicate the dialysis was in the patient’s home.
- Payment for 90999 with condition code 74 is manually priced.
Dialysis performed in a facility
- For QualChoice Medicare Advantage plans, bill according to Medicare rules.
- Bill for dialysis services in accordance with individual participation agreement.
- 90999 billed to QualChoice secondarily will be paid according to the coordination of benefits.
Immunizations recommended for routine administration to children and adults by the Center for Disease Control of the US Department of Health, or similarly authoritative body, will be covered. Coverage includes payment both for the cost of the immunization materials and for the administration fee. Immunizations not covered as routine and which are intended primarily for travel, or required for work, school, or camp, are not covered.
Reference to the member’s coverage documents and benefit summary is necessary to determine specific preventive health benefit coverage. The Enrollee should be aware of special benefits, limits, and/or restrictions on preventive treatments, in particular whether the service is covered when obtained out of network. For coverage on flu immunizations, please refer to BI010 Flu Immunizations.
QualChoice covers infusions of medications in participating physicians’ offices, participating infusion centers and participating hospital outpatient departments. Policy BI006 Infusion Codes restates rules that are present in the national standard coding books about what services are included in the infusion charges.
The professional component of intraoperative neurophysiological monitoring (IOM) may be considered reimbursable as a separate service by QualChoice only when a licensed physician trained in clinical neurophysiology (e.g., neurologist, physiatrist), who is not a member of the surgical team performs the monitoring while onsite or in the operating room throughout the pertinent portions of the procedure. Services that provide remote IOM (95941) are not covered because they simultaneously monitor multiple patients in multiple locations. For those procedures in which the risk of neurologic injury warrants IOM, remote IOM does not meet the standard of care. In these situations, an onsite physician (who is dedicated to monitoring a specific patient in the operating room without distractions from other patients) is considered medically necessary. Anything less than that cannot be clinically justified and therefore does not meet medical necessity and coverage criteria.
The technical components of these services are considered to be included in the facility fee, just as the technical components of intraoperative radiological testing are. Intraoperative somatosensory evoked potentials (SSEPs) with or without motor evoked potentials (MEPs) may be appropriate for:
- Spinal surgeries at levels C1-L2, where there is documentation of significant risk of injury to the spinal cord, such as correction of scoliosis, removal of spinal tumors, or surgery as a result of traumatic injury to the spinal cord;
- Intracranial surgical procedures, such as surgery for intracranial AV malformations, cerebral aneurysms, or surgery as a result of traumatic brain injury;
- Vascular surgeries that put the central nervous system at risk, such as surgery of the aortic arch or carotids where there is risk of cerebral ischemia, or distal aortic procedures where there is risk of spinal cord ischemia.
Intraoperative electroencephalography (EEG) is considered medically necessary for monitoring cerebral function during carotid artery surgery or intracranial vascular surgical procedures. Intraoperative visual evoked potentials (VEPs) are considered medically necessary for any surgical procedure performed on or near the optic nerve, cortex, or chiasm. Intraoperative brainstem auditory evoked potentials (BAEPs) are considered medically necessary for any surgical procedure performed on or near the auditory nerve, inner ear, or brainstem.
Intraoperative electromyography (EMG) may be appropriate for monitoring the facial nerve during any of the following intracranial surgeries:
- Decompression of the facial nerve
- Surgery for acoustic neuroma, congenital auricular lesions, or cranial based lesions
- Excision of facial neuromas
- Vestibular neurectomy for Meniere’s disease
- Mammography Screen women age 40 years and older, with or without clinical breast examination, every 1 to 2 years. G0202, 77067 or 77063 covered as preventive annually (every 12 months) for women at least 40 years old. If billed otherwise, will be denied as non-covered, exceeding benefit limit; member responsibility.
- Diagnostic mammography or breast digital tomosynthesis (CPT 77065, 77066, 77061, 77062, G0204 or G0206) is only covered under the medical benefit when billed with any of the following diagnosis codes: 011 - C50.929 (Malignant neoplasm of breast), C79.81(Secondary malignant neoplasm of breast), D05.00 - D05.92 (Carcinoma in situ of breast), D24.1 - D24.9 (Benign neoplasm of breast), D48.60 - D48.62 (Neoplasm of uncertain behavior of breast), N60.01 - N65.1(Disorders of breast)
Breast ultrasounds (CPT Code 76641 and 76642);
- The use of ultrasound for routine breast cancer screening is considered experimental and investigational, and is not covered.
- Breast ultrasound is covered under preventive benefit when it is performed as an adjunct to screening mammography for dense breast tissue or masses found on mammogram.
Automated Whole Breast ultrasounds (AWBUS) are considered experimental and investigational and therefore are not covered.
Many QualChoice plans exclude coverage for any nutritional counseling services. For plans that cover nutritional counseling, QualChoice covers a limited number of units of nutritional counseling for members who have certain chronic diseases, such as phenylketonuria (PKU), other single gene inborn errors of metabolism, chronic renal failure, celiac disease, and chronic malabsorption. Nutritional counseling does not require pre-authorization for specified diagnoses (see BI342 Nutritional Counseling in Chronic Disease) but requires pre-authorization for any other diagnoses.
Nutritional counseling for diabetics is covered under global diabetic education programs, for member’s eligible for such programs. Nutritional counseling for diabetics is considered as part of standard diabetic education, and is not separately covered.
Nutritional counseling for purposes of weight loss is not covered, except for members in plans that have specific weight loss benefits. Nutritional counseling is not covered for purposes of encouraging healthy eating habits or general education about nutrition.
In general, a woman will expect to receive prenatal care, delivery care and postpartum care from the same physician or group. In this case, standard global billing will apply.
- 59400 – Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care.
- 59510 – Routine obstetric care including antepartum care, cesarean delivery, and postpartum care.
For a variety of reasons, some women receive obstetrical care from more than one physician. There are CPT codes for “antepartum care only”, “delivery only” and “postpartum care only.” The purpose of this policy is to document the appropriate use of these codes for QualChoice members.
If a physician sees a pregnant woman one to three times for prenatal care, the physician codes those visits using the appropriate level of office visit (CPT Codes 99201-99215) for each visit. If a physician sees a woman more than three but less than seven times for prenatal care, the physician should use CPT Code 59425, Antepartum care only; 4-6 visits.
The inclusive dates of service should include all visits from the diagnosis of the pregnancy to the termination of care. The number of units to be billed is one (1). If a physician provides seven or more prenatal visits, the physician should use CPT code 59426, Antepartum care only; 7 or more visits. The inclusive dates of service should include all visits from the diagnosis of the pregnancy to the termination of care. The number of units to be billed is one (1).
For vaginal delivery without complications, the physician who does not provide antenatal care should use one of the following codes:
- 59409 Vaginal delivery only (with or without episiotomy and/or forceps)
- 59410 Vaginal delivery only (with or without episiotomy and/or forceps) including postpartum care
For cesarean delivery without complications, the physician not providing antenatal care should use one of the following codes:
- 59514 Cesarean delivery only
- 59515 Cesarean delivery only; including postpartum care
If the physician who provided prenatal services and intended to perform the delivery (“primary obstetrician” – who may be a family physician) is not the primary physician responsible for the delivery of the patient, because a consultant comes in to do a complicated vaginal delivery or a cesarean delivery, then the primary obstetrician cannot use either the delivery codes or the global maternity care codes to describe his or her services.
- 59430 Postpartum care only (Separate procedure)
- If a physician does not handle the delivery but does provide postpartum care, the physician should use code 59430. This includes hospital and office visits, but it does not include any lab services provided at the postpartum visit.
- If the primary obstetrician provides postpartum care along with a consultant, then only one of the physicians may use code 59430. The other physician should code services rendered in the same manner as any other concurrent care services by utilizing the subsequent hospital care codes (99231-99238) and office visit codes (99211-99215). Only one physician will be paid if the diagnosis codes indicate routine postpartum care, however, so care should be taken not to duplicate services.
Vaginal Birth After Cesarean
CPT includes a set of special codes for patients who have had a previous cesarean delivery and now present with the expectation of a vaginal delivery. If the patient has a successful vaginal delivery after a previous cesarean delivery, use the appropriate code from among the following:
- 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery.
- 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps).
- 59614 including postpartum care.
If the attempt is unsuccessful and results in another cesarean delivery, use the appropriate code from among the following:
- 59618 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery.
- 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery.
- 59622 including postpartum care.
All of the other rules applying to the billing of prenatal and postpartum care apply as outlined above.
The CPT provides that a number of obstetrical complications are not intended to be included in the global prenatal or global obstetrical charges. Additional services provided because of such complications may be billed in addition to the global fees. Modifier 25 should be used for E&M codes and the -59 modifier for surgical codes to indicate that these are above and beyond what is required for routing prenatal care.
Complicated labor management (pre-term, post-term, induced, augmented or complicated by bleeding, PROM, blood pressure problems, cardiac problems, arrest of labor, fetal distress, etc.) is not considered part of routine obstetrical care and extra time spent in the management of a complicated labor may be billed using prolonged service codes (CPT codes 99356-99357).
Admissions during pregnancy that do not result in delivery are not routine and require additional time and resources. Physicians may code these situations with hospital evaluation and management codes. If the pregnancy was high-risk or had medical or surgical complications, the physician should consider using visit codes (office or hospital) for postpartum care in provided in excess of routine postpartum care.
More than one Insurance Carrier
According to Arkansas State Law, the carrier whose coverage is in effect at the time of delivery is responsible to pay the global fee that includes prenatal care. See BI161 Pregnancy Coverage Issues. At times, the change in carrier will also require a change in provider. In this instance, providers should bill the prenatal and delivery charges as noted above.
QualChoice preventive health benefits are intended for the early detection and/or treatment of diseases by screening for their presence in an individual who has neither symptoms nor findings suggestive of those diseases.
Many services are NOT covered as part of the preventive health screening benefit because they are not recommended by the United States Preventive Services Task Force (USPSTF) for this use. These tests may be covered under the standard medical benefit, in accordance with standard medical benefit rules, when they are used to investigate abnormal findings in the history or physical examination or to make or confirm a diagnosis or to gather follow-up information after treatment of a medical condition.
QualChoice covers preventive health services as detailed in the member’s health benefit plan coverage document. Reference to the member’s coverage documents and benefit summary is necessary to determine specific preventive health benefit coverage. The Enrollee should be aware of special benefits, limits, and/or restrictions on preventive treatments, in particular whether the service is obtained out of network.
QualChoice follows the A and B recommendations of the US Preventive Services Task Force (USPSTF) of the Agency for Healthcare Research and Quality and the recommendations of the Bright Futures program supported by the Maternal and Child Health Bureau of the Health Resources and Services Administration and other legal mandates in determining what tests and examinations are covered as preventive or screening services. However, if there are multiple equivalent testing options available to fulfill a USPSTF A or B recommendation (such as for colorectal cancer screening), less cost-effective options may not be covered. For detailed information, see BI062 Preventive Health Benefit.
Immunizations are covered based on the recommendations of the Advisory Committee on Immunization Practices (ACIP) as outlined in BI022 Immunization Coverage. The procedure list found in policy BI062 Preventive Health Benefit details the screening tests that are considered part of the preventive benefit.
QualChoice-administered plans may require different cost shares for different types of procedures, in addition to the cost share for the office visit. It is important for physicians to be able to distinguish (and help members to distinguish) which procedures will be covered under the copayment as opposed to those that will require additional payment from the member. To facilitate that, services classified as “routine” or “complex” are listed in BI222 Routine & Complex Office Procedures. These rules do not override any coverage exclusions, limitations, restrictions, pre-authorization requirements or other rules that specify when a code will or will not be determined to be a covered service.
QualChoice offers a smoking and tobacco cessation program, “Kick The Nic!,” that allows the member two attempts to quit smoking or tobacco use per year. Nicotine replacement therapy is not covered. All other drugs the provider may choose to use in combination with varenicline (Chantix) must be on the QualChoice formulary and the assigned copayment will apply to those prescriptions.
Smoking and tobacco cessation services are not offered in all products. Refer to the member’s Evidence of Coverage (EOC), Certificate of Coverage (COC), Summary Plan Description, or Benefit Summary for coverage.
Telemedicine is the use of telecommunication for the delivery of healthcare when distance separates the provider and the patient. The patient’s location during the telemedicine service visit is designated the Originating Site. Telemedicine includes consultation, diagnostic, monitoring, and therapeutic services delivered via a two-way, synchronous, HIPAA compliant audio and video telecommunication system. Telemedicine can also include store and forward (asynchronous) evaluations (such as teleretinal screening exams). The ability to practice telemedicine depends on having adequate technology, training and Arkansas licensure.
Effective January 1, 2019, QualChoice will cover transitional care management services. Transitional care management services may be required for patients who are discharged from a facility stay. These services help facilitate the transition back to their usual living situation and decrease the likelihood of readmissions. These services are covered under CPT codes 99495 and 99496. Code 99495 will be reimbursed if billed within 14 calendar days of the facility discharge. Code 99496 will be reimbursed if billed within 7 calendar days of the facility discharge.
When a refraction is conducted by an optometrist or an ophthalmologist to determine the need for and proper prescription of corrective lenses/glasses, it is covered under a member’s vision services coverage. When a refraction is done as part of an ophthalmologist examination because of diagnosed eye disease other than the need for corrective lenses, it is covered under the medical benefit. Refraction performed under other circumstances is not covered.
CPT code 92015 (determination of refractive state) is payable with a diagnosis code of encounter for examination of eyes and vision (Z01.00, Z01.01) or with a diagnosis reflecting a need for a refraction (e.g.: myopia, hyperopia, etc.: H52.00-H52.4, H52.6-H52.7, and H54.7) under the vision benefits.
CPT code 92015 is not covered if:
- There is no coverage for vision services;
- The claim exceeds dollar limitations on coverage for vision services; or
- The exam exceeds frequency limitations on coverage for vision services.
When CPT code 92015 (refraction) is billed as part of an ophthalmological special examination, it is covered under the medical benefit. It is not covered for other uses.