POST-PAYMENT AUDITS
BCBSKS conducts periodic post-payment audits of patient records and adjudicated claims to verify congruence with BCBSKS medical and payment policies, including medical necessity and established standards of care. Post-payment audits can range from a basic encounter audit to determine if the level of care is accurately billed, to a complete audit which thoroughly examines all aspects of the medical record and medical practice. Post-payment audits are performed after the service(s) is billed to BCBSKS and payments have been received by the provider. BCBSKS cannot go back further than 15 months following the date of claim adjudication to initiate an audit. Due to additional time allowed for provider appeals, as outlined in this policy memo, refunds would be applicable after the provider appeals have been exhausted, regardless of the time frame involved. BCBSKS provides education through policy memos, medical policy, newsletters, workshops, direct correspondence, peer consultant medical opinion, and on-site visits.
If medical necessity is not supported by the medical record, BCBSKS will deny as not medically necessary. When BCBSKS requests medical records for an audit and no documentation is received within the 30-day time limit, BCBSKS will deny for no documentation. Services denied for failure to submit documentation are not eligible for provider appeal, and are a provider write-off.
Post-payment Audit Appeals:
A. First-Level Appeal
Services denied not medically necessary as a part of the post-pay audit process may be appealed in writing within 30 days of notification of the findings. Written notification of disagreement highlighting specific points for reconsideration should be provided with the appeal. The BCBSKS determination will be made within 30 days of receipt of the appeal. Submit the appeal as instructed in the letter containing the determination.
B. Second-Level Appeal
A provider may request a second and final appeal in writing within 30 days of notification of the first-level appeal determination. The second and final appeal determination will be made by a physician or clinical peer within 30 days of receipt of the appeal. Submit the appeal as instructed in the letter containing the determination.
When findings reveal issues, which are presently specified in BCBSKS policy memos, billing guidelines or newsletters relating to content of service, multiple surgery guidelines, and other billing and/or reimbursement guidelines, the terms of this appeal are not available
NON-COVERED SERVICES
Providers are not reimbursed for professional services they provide to an immediate family member (“immediate family member” means the husband or wife, children, parents, brother, sister, or legal guardian of the person who received the service) or themselves as specified in the member contract.
There are several categories of services, procedures, equipment and/or pharmaceuticals that may be considered non-covered services when designated by the member’s contract. These denials are billable to the member. (
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Psychiatric and Substance Abuse Facilities
The information in this section pertains to members with PPO (BlueChoice, BlueMedicare PPO, and BlueOptions) and Traditional coverage.
Note: All behavioral health services for HMO members should be arranged through New Directions Behavioral Health, including submission of claims.
Intensive Outpatient Program
Intensive outpatient program is defined as treatment that lasts a minimum of three hours a day for a minimum of three days per week in a structured program.
• Indicate “131” type of bill with revenue code 0905 for psychiatric services and 0906 for substance abuse services. Do not bill revenue codes 0500 or 0914.
• For FEP members, IOP admissions must be certified.
Outpatient
Outpatient behavioral billing are for treatments that do not last longer than 80 minutes per day, and are eligible for payment based on the terms of the rendering MD, PhD, or licensed masters level clinician’s agreement. No more than one outpatient visit per day will be eligible for payment.
Partial Hospitalization (PHP)
Florida Blue defines revenue code 0912 as partial hospitalization for chemical dependency and revenue code 0913 as partial hospitalization for psychiatric services.
• Indicate “131” type of bill.
Note: For BlueCard members, you must contact the home plan to identify if the member’s benefit is identified as inpatient or outpatient and bill your claim to Florida Blue accordingly.
For BlueCard members, indicate “111” or “131” type of bill depending on the member’s benefits.
• For inpatient, indicate “111” type of bill with room and board revenue code 0169, and the applicable revenue code 0912 or 0913 on the following line. The days/units must be submitted on the line that contains revenue code 0169.
• If outpatient, indicate “131” type of bill with the applicable revenue code 0912 or 0913. Do not bill revenue code 0169.
For FEP members, indicate “131” type of bill with the applicable revenue code 0912 or 0913. Do not bill revenue code 0169.
New Directions Behavioral Health defines revenue codes 0912, 0913, and 0915 for use as partial hospitalization. The primary diagnosis will determine the per diem rate.
Inpatient Hospital Requirements - DRG and Per Diem concept
Inpatient services are generally reimbursed based on one of the following:
• DRG, or
• Per Diem
Outlined below are generally accepted billing guidelines. This is intended to be illustrative and is not an all-inclusive list.
• The Admission Date field should reflect the true admission date for inpatient claims.
• The Statement Covers Period should reflect the beginning and ending service dates for the period included on the bill.
• Day of Discharge or Death is not counted as a covered day, unless admitted and discharged/deceased on the same day.
• For institutional claims with Bill Type 11X, the number of Covered Days is required and must be reported using "Value Code" 80.
Specifically, the number of Covered Days is a manual calculation of the length of stay by counting from the admit date to the day before discharge. Count all days except the day of discharge to get the patient's length of stay.
• Submit separate bills for mother and baby for obstetric and neonatal services.
• Reimbursement for newborn hearing screenings is included as part of the inpatient stay associated with a birth. It is the hospital’s responsibility to establish payment arrangements with physicians for the technical portions of this service if the necessary equipment is not available at the hospital.
• Submit one bill to Florida Blue upon member discharge, transfer or death.
• All charges related to a hospital admission, including any charges for outpatient procedures, surgical or non-surgical (including observation), incurred within 72 hours of an admission (unless otherwise specified in your contract) must be itemized on the UB-04 bill for the admission and will be included in the inpatient allowance.
• All relevant services that are part of an admission, including transfers within the hospital (e.g., from a medical surgical unit to a psychiatric unit or acute rehabilitation unit), should be included on one bill.
Exception: If separate contracts exist for a hospital’s DPU(s) and/or NPIs associated with any specialty unit or other hospital owned entity.
• Include charges for preoperative testing related to surgery on the same bill as the surgery, whether or not the testing was provided on the date of surgery. For an inpatient claim, the From Date and Admission Date will be different, as the Admission Date will be the date the patient was admitted to the hospital while the From Date reflects the date pre-operative services were performed.
• No interim or split bills.
• Bill physician/professional fees (0960-0989) on a CMS-1500 form.
• For hospitals that have a per diem contract, the revenue code that applies to the specific per diem room and board rate or medical condition should be used (e.g., maternity/OB admissions should be billed with the applicable room and board revenue code ending with a 2).
• Florida Blue can only accept claims with up to 12 diagnosis codes and up to 6 procedure codes.
• Diagnosis codes impacting the DRG assignment should be in the first through 12 diagnosis code position.
• Report only the ICD diagnoses codes corresponding to conditions that affect the treatment received and/or length of stay.
• If surgery is performed and a charge is made for the operating room, recovery room, or special procedure room, an ICD procedure code must be entered on all inpatient claims.
• POA Indicators are required for all primary and secondary diagnosis codes billed on inpatient acute care hospital claims.
• A private room is only covered if it is medically necessary or no semi-private room is available. The difference between the private and semi-private room rate is a non-covered amount and the patient's liability. For information on billing and reporting inpatient room and board refer to Coding a Facility Claim.
• Care associated with HACs, as defined by CMS, is taken into consideration when the DRG is assigned. Those coded with an “N” or a “U” indicator will be excluded from the DRG grouping.
• Beginning August 1, 2015 for claim submissions where the member is admitted to the hospital through the emergency room, non-participating BlueSelect hospitals and facilities should submit two separate bills (one for emergency services and another for inpatient services) so that Florida Blue can apply the in-network benefits to the emergency room services.
Note: The “U” indicator is subject to specific guidelines with regard to the patient status code before it is excluded from the DRG grouping process.
Services Included in the DRG or Per Diem Payment
Examples of items that should not be submitted as separate charges since they are included in the DRG or per diem payment, as applicable:
• Non-physician professional services, including all non-physician professional personnel time.
• Supplies routinely provided with a service or procedure (e.g., X-ray film, lab collection devices).
• Re-stock charges, processing fees and other direct administrative expenses. Pharmacy compounding equipment, supplies and fees (e.g., Laminar flow hoods).
• Any indirect expenses, including but not limited to housekeeping, dietary, plant and equipment maintenance, utilities and insurance.
What is Clinical trials and well child care
Clinical Trials
CMS has specific billing requirements for Clinical Trials. For clinical trials other than IDE A and B devices and Clinical Evidence Development, traditional Medicare A or B will pay primary, waiving any deductible. To ensure claims are processed correctly, it is extremely important that claims are billed according to CMS guidelines. Additional Electronic Billing requirements can be obtained in the Availity Companion Guide.
• All claims must be billed with V700.7 (ICD9) or Z00.6 (ICD10) in the first or second diagnosis position
• Each claim submitted must include the clinical trial number
• Outpatient claims must contain an appropriate modifier
• Q1 on each line to denote routine service
• Q0 on each line billed for investigational services
• Electronic claims billed for IDE A or B devices must have an LX in REF01, loop 2300 and Clinical Trial claims must have P4 in REF01, loop 2300
• Clinical Trial Claims (other than IDE and Clinical Evidence Development) must be submitted to traditional Medicare first, then submitted to the Medicare Advantage plan with the Medicare EOB
Well-Child Care
Well-child care refers to physician-provided preventive health care services for children. The well-child benefit applies to an insured dependent child under BlueOptions, BlueChoice or Traditional products.
Well-child services include:
• The first newborn examination in the hospital by a physician other than the delivering obstetrician or anesthesiologist
• Periodic examinations to monitor the normal growth and development of a child
• Specified immunizations (see chart)
• Specified laboratory tests (see chart)
Well-child services are not subject to a calendar-year deductible and are reimbursed at the contracted percentage of the allowed amount.
Note: Florida Blue HMO (Health Options, Inc.) product, uses the USPSTF guidelines for preventive care and the recommended childhood immunization schedule published and updated annually by the Centers for Disease Control and Prevention.
Present of Admission (POA) Indicator list on UB 04
The table below outlines the payment implications for each of the different POA Indicator reporting options.
POA Indicator Options and Definitions Code Description
Y Diagnosis was present at time of inpatient admission. Florida Blue will pay the CC/MCC DRG for those selected HACs that are coded as "Y" for the POA Indicator
N Diagnosis was not present at time of inpatient admission. Florida Blue will not pay the CC/MCC DRG for those selected HACs that are coded as "N" for the POA Indicator.
U Documentation insufficient to determine if the condition was present at the time of inpatient admission. Florida Blue will not pay the CC/MCC DRG for those selected HACs that are coded as "U" for the POA Indicator.
W Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. Florida Blue will pay the CC/MCC DRG for those selected HACs that are coded as "W" for the POA Indicator.
1 Unreported/Not used. Exempt from POA reporting. This code was the equivalent to a blank on the UB-04, however; it was determined that blanks are undesirable when submitting this data via the 4010A. For 5010 reporting, the 1 is no longer valid because POAs are no longer reported in a separate string.
Present On Admission (POA) Indicator
Note: This article was updated on June 5, 2013, to reflect current Web addresses. This article was previously revised on September 11, 2007, to clarify the timeframes for reporting the POA indicators. All other information remains unchanged.
Background
Section 5001(c) of the Deficit Reduction Act of 2005 requires hospitals to begin reporting the secondary diagnoses that are present on admission (POA) of patients effective for discharges on or after October 1, 2007. By October 1, 2007, the Centers for Medicare & Medicaid Services (CMS) will have selected at least 2 high cost or high volume (or both) diagnosis codes that:
• Represent conditions (including certain hospital acquired infections) that could reasonably have been prevented through the application of evidence-based guidelines; and
• When present on a claim along with other (secondary) diagnoses, have a DRG assignment with a higher payment weight.
Then, for acute care inpatient PPS discharges on or after October 1, 2008, while the presence of these diagnosis codes on claims could allow the assignment of a higher paying DRG, when they are present at the time of discharge, but not at the time of admission, the DRG that must be assigned to the claim will be the one that does not result in the higher payment.
Beginning for discharges on or after October 1, 2007, hospitals should begin reporting the POA code for acute care inpatient PPS discharges. There is one exception, i.e., claims submitted via direct data entry (DDE) should not report the POA codes until January 1, 2008, as the DDE screens will not be able to accommodate the codes until that date.
Between October 1, 2007, and December 31, 2007, CMS will collect the information on the hospital claim, but does not intend to provide any remittance or other information to hospitals if the information is not submitted correctly for each diagnosis on the claim. Hospitals that fail to provide the POA code for discharges on or after January 1, 2008 will receive a remittance advice remark code informing them that they failed to report a valid POA code. However, beginning with discharges on or after April 1, 2008, Medicare will return claims to the hospital if the POA code is not reported and the hospital will have to supply the correct POA code and resubmit the claim. In order to be able to group these diagnoses into the proper DRG, CMS needs to capture a Present On Admission (POA) indicator for all claims involving inpatient admissions to general acute care hospitals. CR 5499, from which this article is taken, announces this requirement and provides your fiscal intermediaries (FI) and A/B MACs with the coding and editing requirements, and software modifications needed to successfully implement this indicator.
Note: Adjustments to the relative weight that occur because of this action are not budget neutral. Specifically, aggregate payments for discharges in a fiscal year could be changed as a result of these adjustments.
These POA guidelines are not intended to replace any found in the ICD-9-CM Official Guidelines for Coding and Reporting, nor are they intended to provide guidance on when a condition should be coded. Rather, you should use them in conjunction with the UB-04 Data Specifications Manual and the ICD-9-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the Present on Admission (POA) indicator for each “principal” diagnosis and “other” diagnoses codes reported on claim forms (UB-04 and 837 Institutional). Information regarding the UB-04 Data Specifications may be found at http://www.nubc.org/become.html on the Internet.
Note: Critical access hospitals, Maryland waiver hospitals, long term care hospitals, cancer hospitals, and children’s inpatient facilities are exempt from this requirement.
The following information, from the UB-04 Data Specifications Manual, is provided to help you understand how and when to code POA indicators:
1. General Reporting Requirements
• Pertain to all claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to a law or regulation mandating collection of present on admission information.
• Present on admission is defined as present at the time the order for inpatient admission occurs -- conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered as present on admission.
• POA indicator is assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for Coding and Reporting) and the external cause of injury codes.
• Issues related to inconsistent, missing, conflicting, or unclear documentation must still be resolved by the provider.
• If a condition would not be coded and reported based on UHDDS definitions and current official coding guidelines, then the POA indicator would not be reported.
• CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an “other diagnosis.”
2. Reporting Options and Definitions
• Y - Yes (present at the time of inpatient admission)
• N – No (not present at the time of inpatient admission)
• U - Unknown (documentation is insufficient to determine if condition is present at time of inpatient admission)
• W – Clinically undetermined (provider is unable to clinically determine whether condition was present at time of inpatient admission or not)
• 1 -- Unreported/Not used – Exempt from POA reporting (This code is the equivalent of a blank on the UB-04, but blanks are not desirable when submitting data via the 4010A1.
The POA data element on your electronic claims must contain the letters “POA”, followed by a single POA indicator for every diagnosis that you report. The POA indicator for the principal diagnosis should be the first indicator after “POA,” and (when applicable) the POA indicators for secondary diagnoses would follow. The last POA indicator must be followed by the letter “Z” to indicate the end of the data element (or FIs and A/B MACs will allow the letter “X” which CMS may use to identify special data processing situations in the future).
Note that on paper claims the POA is the eighth digit of the Principal Diagnosis field (FL 67), and the eighth digit of each of the secondary diagnosis fields (FL 67 A-Q); and on claims submitted electronically via 837, 4010 format, you must use segment K3 in the 2300 loop, data element K301. Below is an example of what this coding should look like on an electronic claim:
If segment K3 read as follows: “POAYNUW1YZ,” it would represent the POA indicators for a claim with 1 principal and 5 secondary diagnoses. The principal diagnosis was POA (Y), the first secondary diagnosis was not POA (N), it was unknown if the second secondary diagnosis was POA (U), it is clinically undetermined if the third secondary diagnosis was POA (W), the fourth secondary diagnosis was exempt from reporting for POA (1), and the fifth secondary diagnosis was POA (Y).
As of January 1, 2008, all direct data entry (DDE) screens will allow for the entry of POA data and POA data will also be included with any secondary claims sent by Medicare for coordination of benefits purposes. See the complete instructions in the UB-04 Data Specifications Manual for more specific instructions and examples.
Note: CMS, in consultation with the Centers for Disease Control and Prevention and other appropriate entities, may revise the list of selected diagnose from time to time, but there will always be at least two conditions selected for discharges occurring during any fiscal year. Further, this list of diagnosis codes and DRGs is not subject to judicial review.
Finally, you should keep in mind that achieving complete and accurate documentation, code assignment, and reporting of diagnoses and procedures requires a joint effort between the healthcare provider and the coder. Medical record documentation from any provider (a physician or any qualified healthcare practitioner who is legally accountable for establishing the patient’s diagnosis) involved in the patient’s care and treatment may be used to support the determination of whether a condition was present on admission or not; and the importance of consistent, complete documentation in the medical record cannot be overemphasized.
NOTE: You, your billing office, third party billing agents and anyone else involved in the transmission of this data must insure that any resequencing of diagnoses codes prior to their transmission to CMS, also includes aresequencing of the POA indicators.
UB-04 Desk Reference for Hospitals
ThesevaluesarevalidforpaperclaimsubmissionontheUB-04ClaimFormonly.
Type of Bill Codes (Form Locator 4)
INPATIENT ONLY: First Digit
1 Type of Facility – Hospital Second Digit
1 Bill Classification – Inpatient
Third Digit
0 Non Payment/Zero Claim
1 Admit through Discharge Claim
2 Interim – First Claim
7 Replacement of Prior Claim
8 Void/Cancel of Prior Claim
OUTPATIENT ONLY:
First Digit
1 Type of Facility – Hospital Second Digit
3 Bill Classification – Outpatient
4 Bill Classification – Hospital Special Treatment Room
Third Digit
0 Nonpayment/Zero Claim
1 Admit through Discharge Claim
7 Replacement of Prior Claim
8 Void/Cancel of Prior Claim
Admission Type (Form Locator 14)
1 Emergency Admission
2 Urgent Admission
3 Elective Admission
4 Newborn Admission
5 Trauma Admission (Emergency Admission)
Condition Codes (Form Locators 18–28)
2 Condition is Employment Related
3 Patient is Covered by Insurance Not Reflected Here
05 Lien Has Been Filed
44 Outpatient Observation Only
60 Day Outlier
77 Provider accepts or is obligated/required to a contractual agreement or law to accept payment by primary payer as payment in full
A1 EPSDT
A4 Family Planning Outpatient
AA Abortion Consent (MA 3) – Rape
AB Abortion Consent (MA 3) – Incest
AD Abortion Consent (MA 3) – Danger to Life
AI Sterilization Patient Consent Form (MA 31)
X2 Medicare EOMB on File
B3 Pregnancy
X3 Hysterectomy Acknowledgment Form (MA 30)
X4 Medicare Denial on File
X5 Third Party Payment on File
X6 Restricted Recipient Referral Form
X7 Medical Documentation for Hysterectomy
Y0 Newborn Eligibility
Y3 Copay Not Collected
Y6 Third Party Denial on File
Patient Status Codes (Form Locator 17)
1 Discharge to home or self-care – Routine Discharge
2 Discharged/transferred to another hospital for inpatient care
3 Discharged/transferred to a skilled nursing facility
04 Discharged/transferred to an intermediate care facility
05 Discharged/transferred to another type of institution for inpatient care
07 Left against medical advice or discontinued care
20 Expired
30 Still a patient
Occurrence Codes (Form Locators 31–34)
1 Auto Accident
2 No Fault Accident
3 Accident/Tort Liability
4 Accident/Employment Related
5 Other Accident
6 Crime Victim
24 Date Insurance Denied
25 Date Benefits Terminated By Primary Payer
A3 Benefits Exhausted
B3 Benefits Exhausted
C3 Benefits Exhausted
DR Disaster Related Occurrence Span Codes (Form Locator 35–36)
71 Prior Stay Dates
74 Non-covered Level of Care/Leave of Absence (JCAHO RTF only)
MR Disaster Related
What is Present on Admission Indicator Reporting ?
A Present on Admission (POA) Indicator is used to identify whether a primary or secondary condition was present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered present on admission.
For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions known as, Hospital Acquired Conditions (HACs), are present at the time of admission. The case will be reimbursed as though the secondary diagnosis were not present. Critical Access Hospitals (CAHs), Long-term Care Hospitals (LTCHs), Cancer Hospitals, Children's Inpatient Facilities, Inpatient Psychiatric Hospitals, Inpatient Rehabilitation Facilities, and Veterans Administration/Department of Defense Hospitals are exempt from this payment provision.
The Florida Blue Present on Admission (POA) Indicator requirement applies to both Inpatient Prospective Payment Systems (IPPS) and Non-IPPS Hospitals. A POA indicator should be submitted with all primary and secondary diagnoses codes, regardless of whether the condition is considered a Hospital Acquired Condition (HAC) or not.
If an indicator of “Y” or “W” is submitted with a HAC condition, the major complicating condition or complicating condition (MCC/CC) is included in DRG grouping logic. HAC conditions submitted with an “N” or a “U” will be excluded from DRG grouping impacts. The “U” indicator is subject to specific guidelines with regard to the patient status code before it is excluded from the DRG grouping
process.
Per Diem agreement and allowed amount calculation
Per Diem
Per Diem is a per day negotiated rate which represents an allowance that includes all services for that day.
Per Diem agreements reimburse based on the admission date of the member.
The following terminology is used when referring to per diem contracts:
• Inliers- Inpatient cases reimbursed based on room and board per diem rates
• Outliers- Inpatient cases reimbursed as a DRG carve-out or based on catastrophic reimbursement.
Per Diem Hierarchy for a Standard Base Agreement
Each inpatient case in a per diem contract is evaluated using the following payment hierarchy:
• Implant Carve-out - Typically reimbursed in addition to inliers and outliers
• Catastrophic - Outlier
• DRG Carve-outs as case rate with additional day per diem - Outlier
• Per Diem Rates - Inlier
Once a claim meets the criteria for a step in the hierarchy table, then the reimbursement calculation method is based on that applicable step.
Calculating the Inpatient Allowed Amount
Amounts displayed for example purposes only. These examples illustrate allowed amount calculations, not the Florida Blue payment because member deductible, coinsurance, and/or copayment liability have not been applied. Determination of the allowed amount for inpatient and outpatient services is made based upon the terms of your Agreement.
Per Diem Examples
Per Diem payment rate is based on room and board revenue codes (e.g., med/surg, ICU, psychiatric) ranging from 110-219. The following examples illustrate the per diem methods for determining payment for inpatient admissions. Per Diem Examples
DRG Hierarchy and calculation of allowed amount
DRG Hierarchy for a Standard Base Agreement
Each inpatient case for a DRG contract is evaluated using the following payment hierarchy:
• Low Stay Outlier
• High Charge/High Stay Outlier
• DRG Value Inlier
Once a claim meets the criteria for a step in the hierarchy table, then the reimbursement calculation method is based on that applicable step. For example, if a case meets the qualification as a low stay case and a high charge case, it will be reimbursed based on the low stay allowance.
Note: The hierarchy for a hospital that provides tertiary services is different from the hierarchy list above.
Calculating the Inpatient Allowed Amount
Amounts displayed for example purposes only. These examples illustrate allowed amount calculations, not the Florida Blue payment because member deductible, coinsurance, and/or copayment liability have not been applied.
Determination of the allowed amount for inpatient and outpatient services is made based upon the terms of your Agreement.
DRG Examples
The following examples illustrate the various methods for determining the allowed amount for inpatient admissions.
Use the following “case” for the calculations:
• DRG = DRG 202 Bronchitis and Asthma, with complication or major complication
• Conversion Price = $3,000
• Low (Length of Stay) Trim Point = 2 days*
• High (Length of Stay) Trim Point = 12 days*
• Contracted Negotiated Low Stay Per Diem = $750
• Contracted Negotiated High Stay Per Diem = $800
• Relative Weight = 0.8446
• DRG Value = $2,534 (Conversion Price x Relative Weight)
*Trim point is a numerical value that represents the minimum (in the case of the low trim point) and the maximum (in the case of the high trim point) number of days for which payment will be made at the DRG value for hospital services. Length of Stay Examples
Billing Guide for partial hospitalization
Partial Hospitalization
• Submit partial hospitalization services with the following revenue codes:
• 0912, 0913 or 0915
o If a separate contract for the hospital and psych DPU are in effect, submit partial hospitalization services and inpatient services on separate UB-04 claim forms.
• Florida Blue considers partial hospitalization to be an outpatient service.
• Partial hospitalization for psychiatric or substance abuse admissions is calculated as follows:
o Partial Days (including beginning and ending dates) x Per Diem.
DRG
DRGs are statistically meaningful medical groupings used for the purpose of categorization and reimbursement of hospital services.
• DRGs allow for more uniform billing based upon the member’s diagnosis and procedures, age, sex, and discharge status.
• Reimbursement for DRG cases is based on discharge date.
• Exception: A newly established participating provider, under a DRG contract, will have the first year of claims reimbursed based on the admission date of the inpatient claim.
• Deaths and transfers are reimbursed based on the assigned DRG and payment hierarchy logic. There are no special reimbursement arrangements applicable to deaths and transfers.
• A list of DRGs, along with length of stay trim points and relative weights, is contained in your hospital’s Agreement.
Outlier Cases
Outlier cases are exceptions to typical inpatient DRG cases. Refer to your Agreement for which outlier method applies.
There are three types of outlier cases but not limited to:
• Low length of stay outlier - Low Length is a case in which the member stays in the hospital fewer days than the low length of stay trim point.
• High length of stay outlier - High Length is a case in which the member stays in the hospital a greater number of days than the high length of stay trim point.
• High charge outlier- High charge is a case in which total covered charges exceed the high charge threshold.
Billing Multiple Infusion Therapies - Revenue code 0640, 0641, 0644
When billing home health services to Florida Blue, revenue codes and CPT/HCPCS should be reported using the most current publications. The matrix below indicates the commonly used the revenue codes to be used in billing home health/home infusion services.
• Multiple infusion therapies apply to patients who require multiple concurrent infusion treatments including, but not limited to, multiple antibiotics, hydration and chemotherapy.
• Reimbursement for multiple medications may be allowed with payment reductions, as noted per payment policy.
• The only exception to this is aerosolized AIDS drug therapy. It is the only therapy that must be billed in conjunction with another mode of home IV therapy administration. It is also the only drug therapy that, while provided as part of a multiple-therapy treatment, can be billed as a separate service.
• Use procedure code S9061 to report aerosolized AIDS drug therapy.
NOTE: Some groups and other Blue Plans may have specific coding and/or billing requirements for home infusion. Call the appropriate Blue Plan with any questions prior to filing the claim.
Revenue Codes Used
• General Classification Home IV Therapy
o 0640
o Non-routine nursing, central line 0641
o Site Care, central line 0642
o Start/Change, peripheral line 0643
o Routine Nursing, peripheral line 0644
• Drugs
o 0250-0252
o 0630-0636
BILLING Guideline for home health - 0571, 0572 revenue codes
Home Health/Home Infusion Agencies
Florida Blue defines home health care services as those services rendered to an individual in the home by health care professionals (e.g., nurses, therapists) or paraprofessionals (e.g., home health aides, physical therapy assistants) to achieve and sustain an optimum state of health and independence for that individual. For purposes of coverage, home health care is provided on a per visit basis, generally for no more than two hours at a time.
Revenue Codes Used
• Home Health Aide
o 0571
o 0572 - hourly
• If the agency does not bill on a calendar month basis, it prepares two bills. The first covers the period ending December 31 of the old year; the second, the period beginning January 1 of the New Year.
• All services must be itemized by date of service. Enter the appropriate revenue code and date for each service rendered.
• Physical therapy, speech therapy and occupational therapy services should be billed by the visit, not by the modality or hour, unless approved by Care Coordination.
• Reimbursement for visits provided by a health care professional of differing specialties is limited to one per day for each specialty, unless documented as medically necessary.
• Some plans, including BlueCard may require medical documentation for unlisted codes, such as 99600.
• Utilization of specific codes is strongly recommended to facilitate easier claims processing.
Home Health Billing Requirements for Non-Contracted Medicare Advantage
• Effective for home health episodes beginning on or after October 1, 2013, Original Medicare will no longer accept institutional claims submitted with Type of Bill 033X. After October 1, 2013 home health will need to bill with Type of Bill 032X.
• Bill type "322-329"
• Health Insurance Prospective Payment System (HIPPS) code
• Treatment Authorization Code
• Core-Based Statistical Area (CBSA) must be included with value amount field for a value code 61
Billing for Infusion Services for Providers NOT participating in the CareCentrix Network:
Classified drugs must be submitted with valid CPT/HCPCS codes, HCPCS quantity, NDC Code, and NDC Quantity.
• Do not bill more than seven consecutive days on any claim line.
• Bill only primary drugs and S per diem codes related to infusion when professional nursing services are provided.
• Do not bill codes that are considered inclusive in the S per diem code.
• Corrected claims; if billing for additional dates of service or additional items, not included on the original claim, a corrected claim is required.
• Effective for home health episodes beginning on or after October 1, 2013, Original Medicare will no longer accept institutional claims submitted with Type of Bill 033X. After October 1, 2013 home health will need to bill with Type of Bill 032X.
• Home health providers with several provider numbers should submit the provider number of the agency that provided the care. This will ensure claims are reimbursed correctly.
• Submit both revenue and CPT/HCPCS Codes. Claims submitted without both revenue and CPT/HCPCS codes or with invalid codes will be rejected at the claim or line level.
• Bill according to CPT/HCPCS definitions to determine appropriate coding, inclusive supply and item sizing. Claim lines must be split unevenly when units exceed 9999 to prevent duplicate denials.
• Do not bill more than 15 lines or 31-days of services on the same claim. If billing for services over a span of dates, bill once for that span (after span is complete) to include all services for the dates of service on one claim. Overlapping or repeating span dates causes duplicate denials.
• The home health agency should not submit a bill/claim for an inclusive period beginning in one calendar year and extending into the next calendar year.
• A separate line item should be submitted for each per diem for each date of service. To report units per diem, one unit should be billed for each line.
Some groups and other Blue Plans may have specific coding and/or billing requirements for home infusion. Call the appropriate Blue Plan with any questions prior to filing the claim.
Home Health Agency Billing Guidelines
Blue Cross recognizes the need to maintain consistency of billing requirements for both Blue Cross and Medicare wherever possible. Therefore, we require home health agencies to file claims using the UB- 04 claim form (see instructions in the Claims Submission section of this manual) in accordance with Medicare guidelines with the following exceptions:
1. The revenues codes accepted by Blue Cross and which may be entered in UB-04 field 42 are limited, and revenue code descriptions for field 43 have been modified. These modifications are necessary due to member contract/certificate variations.
Revenue codes 551 and 559 and their respective descriptions have been changed to identify services provided by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN). This change is necessary because reimbursement rates are different for RNs and LPNs.
Revenue code 261, IV Therapy Pump, requires a modifier in order for the correct type of service to be assigned (see page 76 and 77 for detailed information). The revenue codes with descriptions accepted by Blue Cross from participating home health agencies listed in this manual. The appropriate HCPCS or Procedure code must be included in field 44 of the UB-04 when billing revenue codes with double asterisks (**), shown under the column heading “Code Reqd.” This is necessary for proper pricing and payment of the service. (Please refer to your Blue Cross Home Health Agency Member Provider Agreement and Reimbursement Appendix for information on reimbursement).
2. Accumulative billing of services will be accepted by utilizing a “From” and “Through” date with the total units of service for a specific revenue code or HCPCS code. However, some member contracts/ certificates and/or groups require that the individual date of service be shown for each day on which services where provided. When this situation applies, you will be notified when you authorize services and also via the written confirmation of the authorization.
Authorization is required for all home health care. Blue Cross requires 48 hours advance notice of all home health care to be provided. The authorization will include the service and/or code to be provided and in some cases, the quantity/units of services authorized. The services that we will generally approve are included in this manual and include the range of HCPCS/Procedure codes that should be billed with the revenue code. To obtain authorization, please call Provider Services at 1-800-523-6435.
Home Health Agency Revenue Codes Accepted by Blue Cross and Blue Shield of Louisiana Visit charge is defined as a consecutive period of time up to two hours during which home health care is rendered. Hourly charges exceeding two hours require additional authorization from Blue Cross.
Hourly charges for home health aides and private duty nursing (in shifts of at least eight continuous hours) must be billed using the revenue codes appropriate to the level of professional training.
Florida Blue defines home health care services as those services rendered to an individual in the home by health care professionals (e.g., nurses, therapists) or paraprofessionals (e.g., home health aides, physical therapy assistants) to achieve and sustain an optimum state of health and independence for that individual. For purposes of coverage, home health care is provided on a per visit basis, generally for no more than two hours at a time.
Revenue Codes Used
• Home Health Aide
o 0571
o 0572 - hourly
• If the agency does not bill on a calendar month basis, it prepares two bills. The first covers the period ending December 31 of the old year; the second, the period beginning January 1 of the New Year.
• All services must be itemized by date of service. Enter the appropriate revenue code and date for each service rendered.
• Physical therapy, speech therapy and occupational therapy services should be billed by the visit, not by the modality or hour, unless approved by Care Coordination.
• Reimbursement for visits provided by a health care professional of differing specialties is limited to one per day for each specialty, unless documented as medically necessary.
• Some plans, including BlueCard may require medical documentation for unlisted codes, such as 99600.
• Utilization of specific codes is strongly recommended to facilitate easier claims processing.
Home Health Billing Requirements for Non-Contracted Medicare Advantage
• Effective for home health episodes beginning on or after October 1, 2013, Original Medicare will no longer accept institutional claims submitted with Type of Bill 033X. After October 1, 2013 home health will need to bill with Type of Bill 032X.
• Bill type "322-329"
• Health Insurance Prospective Payment System (HIPPS) code
• Treatment Authorization Code
• Core-Based Statistical Area (CBSA) must be included with value amount field for a value code 61
Billing for Infusion Services for Providers NOT participating in the CareCentrix Network:
Classified drugs must be submitted with valid CPT/HCPCS codes, HCPCS quantity, NDC Code, and NDC Quantity.
• Do not bill more than seven consecutive days on any claim line.
• Bill only primary drugs and S per diem codes related to infusion when professional nursing services are provided.
• Do not bill codes that are considered inclusive in the S per diem code.
• Corrected claims; if billing for additional dates of service or additional items, not included on the original claim, a corrected claim is required.
• Effective for home health episodes beginning on or after October 1, 2013, Original Medicare will no longer accept institutional claims submitted with Type of Bill 033X. After October 1, 2013 home health will need to bill with Type of Bill 032X.
• Home health providers with several provider numbers should submit the provider number of the agency that provided the care. This will ensure claims are reimbursed correctly.
• Submit both revenue and CPT/HCPCS Codes. Claims submitted without both revenue and CPT/HCPCS codes or with invalid codes will be rejected at the claim or line level.
• Bill according to CPT/HCPCS definitions to determine appropriate coding, inclusive supply and item sizing. Claim lines must be split unevenly when units exceed 9999 to prevent duplicate denials.
• Do not bill more than 15 lines or 31-days of services on the same claim. If billing for services over a span of dates, bill once for that span (after span is complete) to include all services for the dates of service on one claim. Overlapping or repeating span dates causes duplicate denials.
• The home health agency should not submit a bill/claim for an inclusive period beginning in one calendar year and extending into the next calendar year.
• A separate line item should be submitted for each per diem for each date of service. To report units per diem, one unit should be billed for each line.
Some groups and other Blue Plans may have specific coding and/or billing requirements for home infusion. Call the appropriate Blue Plan with any questions prior to filing the claim.
Home Health Agency Billing Guidelines
Blue Cross recognizes the need to maintain consistency of billing requirements for both Blue Cross and Medicare wherever possible. Therefore, we require home health agencies to file claims using the UB- 04 claim form (see instructions in the Claims Submission section of this manual) in accordance with Medicare guidelines with the following exceptions:
1. The revenues codes accepted by Blue Cross and which may be entered in UB-04 field 42 are limited, and revenue code descriptions for field 43 have been modified. These modifications are necessary due to member contract/certificate variations.
Revenue codes 551 and 559 and their respective descriptions have been changed to identify services provided by a Registered Nurse (RN) or a Licensed Practical Nurse (LPN). This change is necessary because reimbursement rates are different for RNs and LPNs.
Revenue code 261, IV Therapy Pump, requires a modifier in order for the correct type of service to be assigned (see page 76 and 77 for detailed information). The revenue codes with descriptions accepted by Blue Cross from participating home health agencies listed in this manual. The appropriate HCPCS or Procedure code must be included in field 44 of the UB-04 when billing revenue codes with double asterisks (**), shown under the column heading “Code Reqd.” This is necessary for proper pricing and payment of the service. (Please refer to your Blue Cross Home Health Agency Member Provider Agreement and Reimbursement Appendix for information on reimbursement).
2. Accumulative billing of services will be accepted by utilizing a “From” and “Through” date with the total units of service for a specific revenue code or HCPCS code. However, some member contracts/ certificates and/or groups require that the individual date of service be shown for each day on which services where provided. When this situation applies, you will be notified when you authorize services and also via the written confirmation of the authorization.
Authorization is required for all home health care. Blue Cross requires 48 hours advance notice of all home health care to be provided. The authorization will include the service and/or code to be provided and in some cases, the quantity/units of services authorized. The services that we will generally approve are included in this manual and include the range of HCPCS/Procedure codes that should be billed with the revenue code. To obtain authorization, please call Provider Services at 1-800-523-6435.
Home Health Agency Revenue Codes Accepted by Blue Cross and Blue Shield of Louisiana Visit charge is defined as a consecutive period of time up to two hours during which home health care is rendered. Hourly charges exceeding two hours require additional authorization from Blue Cross.
Hourly charges for home health aides and private duty nursing (in shifts of at least eight continuous hours) must be billed using the revenue codes appropriate to the level of professional training.
Billing Guidelines for Dialysis center
Dialysis Centers
Outlined below are generally accepted billing guidelines. This is intended to be illustrative and is not an all-inclusive list.
• Indicate “72X” type of bill. The third digit is based on the type of claim (interim, corrected, etc.).
• Hospital inpatient dialysis departments should bill with their hospital provider number and will be paid under the hospital agreement.
• Bill one claim per calendar month except when training is provided or when hemodialysis is performed in the same month as peritoneal dialysis.
• Do not submit claims that cross over from one month to the other. For example, service dates in January should be on one claim and service dates in February should be on another claim.
• Bill a line item date of service for each revenue code billed on the claim form.
• Revenue codes should be listed in ascending numeric order by date of service and line item billed.
• Bill a separate line item for each dialysis session performed.
• Separately billable drugs, including EPO should be line item billed. Include the line item date of service for the administration. Reimbursement will be calculated based on the units reported on the line.
• The units reported on the line for each date dialysis (codes 821, 831, 841 and 851) was performed should not exceed one.
• Height and weight should be reported for all ESRD patients.
• A8 – Weight in kilograms
• A9 – Height in centimeters
• Report modifiers, occurrence codes, and condition codes.
• Bill must include revenue codes and CPT codes for each line of service. For example, when billing hemodialysis submit revenue code 0821 with CPT code 90999.
• The training rate includes the composite rate. Therefore, the composite rate should not be billed separately for days when training was provided.
• Do not bill for hemodialysis and peritoneal dialysis composite rates on the same claim. In this situation, you must bill a claim for each type of dialysis provided within the same calendar month. Dates of service must not overlap.
Non-contracted Medicare Advantage
The following fields are required on all Medicare Advantage claims:
• A patient’s height and weight – entered in the value amount fields for value codes A8 and A9
• CBSA – must be included in the value amount field for value code 61
Therapy and Acupuncture CPT code list
Therapeutic Procedures
Physician or therapist required to have direct (one-on-one) patient contact. The therapeutic procedures, for one or more areas, each 15 minutes interval is as follows:
• 97110 Therapeutic exercises to develop strength and endurance, range of motion and flexibility
• 97112 Neuromuscular reeducation of movement, balance, coordination, kinesthetic senses, posture, and/or proprioception for sitting and/or standing activities
• 97113 Aquatic therapy with therapeutic exercises
• 97116 Gait training (includes stair climbing)
• 97124 Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
• 97140 Manual therapy techniques, one or more regions, each 15 minutes
• 97150 Therapeutic procedure(s), group (2 or more individuals)
• 97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
• 97535 Self-care/home management training (e.g., ADL), each 15 minutes
Tests and Measurements (Requires direct on-on-one patient contact)
• 97750 Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes
• Orthotic Management and Prosthetic Management
• 97760 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes
• 97762 Checkout for orthotic/prosthetic use, established patient, each 15 minutes
Acupuncture
• 97810 Without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
• 97811 Without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)
• 97813 With electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
• 97814 With electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)
Florida Blue reserves the right to change the contents of the listing in accordance with revisions to industry standards, AMA/CPT guidelines, and with normal annual fee schedule coding updates.
Chiropractic Modalities
• Physical Medicine and Rehabilitation
• CPT Code Description
The application of a modality that does not require direct (one-on-one) patient contact by the provider is as follows:
• 64550 Application of surface (transcutaneous) neuro stimulator
• 97012 Traction, mechanical
• 97014 Electrical stimulation (unattended)
• 97016 Vasopneumatic devices
• 97018 Paraffin bath
• 97022 Whirlpool
• 97024 Diathermy (e.g., microwave)
• 97028 Ultraviolet
Constant Attendance Modalities
The application of a modality that requires direct (one-on-one) patient contact by the provider is as follows:
97032 Electrical stimulation (manual)
97033 Iontophoresis
97034 Contrast baths
97035 Ultrasound
97036 Hubbard tank
Acupuncture CPT CODES 97810, 97811, 97813, 97814
Procedure code and Description
• 97810: Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
• 97811: Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles
• 97813: Acupuncture, one or more needles, with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
• 97814: Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles
Acupuncture: A chiropractic provider may not provide acupuncture services until certified by the Florida Board of Chiropractic Medicine. Acupuncture is reported based on 15 minute increments of personal (face-to-face) contact with the patient, not the duration of acupuncture needle(s) placement. If no electrical stimulation is used during a 15 minute increment, use 97810 or 97811. If electrical stimulation of any needle is used during a 15 minute increment, use 97813 or 97814. Only one code may be reported for each 15 minute increment. Use either 97810 or 97813 for the initial 15 minute increment. Only one initial code is reported per day.
The FEP does not include benefits for acupuncture when performed by a chiropractor.
Covered Services for Medicare Advantage Members:
According to the Centers for Medicare & Medicaid Services (CMS) Internet-only manual, Publication 100-02 Medicare Benefit Policy Manual, chapter 15, section 30.5, chiropractors’ services extend only to treatment by means of manual manipulation of the spine to correct a subluxation. All other services furnished or ordered by chiropractors are not covered. Chiropractors are not limited to any specific procedures and may render services as they feel necessary, but according to CMS guidelines; the benefit will only cover manual spinal manipulation, which includes procedure codes: 98940, 98941, and 98942.
The following procedure code ranges will deny for chiropractors as non-covered services:
• 00100 through 98929
• 98943 through 99607
• A0021 through V5364
Guideline from BCBS
Acupuncture and an initial evaluation (for a new patient) is covered when rendered by a licensed doctor of acupuncture (D. Ac.) or physician (State of Rhode Island-licensed MD or DO)* only. Acupuncture assistants are not recognized for separate reimbursement and are therefore considered inclusive of the acupuncture reimbursement.
An initial evaluation (99201-99205) is allowed only for new patients. According to CPT guidelines, a new patient is one who has not received any professional services from the physician within the past three years.
The following services are not covered:
** **cupuncture with electrical stimulation;
** **djunctive therapies, such as but not limited to moxibustion, herbs, oriental massage, etc.;
** **cupuncture when used as an anesthetic during a surgical procedure;
** Precious metal needles (e.g., gold, silver, etc.);
** **cupuncture in lieu of anesthesia;
** **ny other service not specifically listed as a covered service.
*Acupuncture services may be rendered by a physician (MD or DO) when the following Rhode Island Department of Health criteria has been met:
2.2 Any physician licensed in Rhode Island under the provisions of Chapter 5-37 who seeks to practice medical acupuncture as a therapy shall comply with the following:
2.2.1 Meet the requirements for licensure as a doctor of acupuncture set forth in the Rules and Regulations for Licensing Doctors of Acupuncture and Acupuncture Assistants promulgated by the Department of Health; or 2.2.2 Successfully complete a course offered to physicians that meets the requirements set forth in these regulations and includes no less than the following:
a) a minimum of three hundred (300) hours of formal instruction;
b) a supervised clinical practicum incorporated into the formal instruction required in subsection 2.2.2(a) (above).
Acupuncture is a covered benefit for those groups who have purchased the acupuncture rider or who have an acupuncture benefit. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable acupuncture benefits/coverage. Rhode Island-mandated benefits do not apply to Plan 65, FEHBP, and Medicare Advantage plans. Selffunded groups may or may not choose to follow state mandate(s).
Acupuncture is the practice of piercing the skin with needles at specific body sites to induce anesthesia, to relieve pain, to treat various nonpainful disorders, and to alleviate withdrawal symptoms of opioid dependence. Acupuncture has also been used or proposed for a large variety of indications.
Acupuncture is a traditional form of Chinese medical treatment that has been practiced for over 2000 years. It involves piercing the skin with needles at specific body sites. The placement of needles into the skin is dictated by the location of meridians. These meridians, or channels, are thought to mark patterns of energy, called Qi (Chi), that flow through the human body. According to traditional Chinese philosophy, illness occurs when the energy flow is blocked or unbalanced, and acupuncture is a way to influence chi and restore balance. Another tenet of this philosophy is that all disorders are associated with specific points on the body, on or below the skin surface.
Several physiologic explanations of acupuncture’s mechanism of action have been proposed including an analgesic effect from release of endorphins or hormones (eg, cortisol, oxytocin), a biomechanical effect, and/or an electromagnetic effect.
There are 361 classical acupuncture points located along 14 meridians, and different points are stimulated depending on the condition treated. In addition to traditional Chinese acupuncture, there are a number of modern styles of acupuncture, including Korean and Japanese acupuncture. Modern acupuncture techniques can involve stimulation of additional non-meridian acupuncture points. Acupuncture is sometimes used along with manual pressure, heat (moxibustion), or electrical stimulation (electroacupuncture). Acupuncture treatment can vary by style and by practitioner, and is generally personalized to the patient. Thus, patients with the same condition may receive stimulation of different acupuncture points.
Scientific study of acupuncture is challenging due to the multifactorial nature of the intervention, variability in practice, and individualization of treatment. There has been much discussion in the literature on the ideal control condition for studying acupuncture. Ideally, the control condition should be able to help distinguish between specific effects of the treatment and nonspecific placebo effects related to factors such as patient expectations and beliefs and the patient-provider therapeutic relationships. A complicating factor in selection of a control treatment is that it is not clear whether all 4 components (ie, the acupuncture needles, the target location defined by traditional Chinese medicine, the depth of insertion, and the stimulation of the inserted needle) are necessary for efficacy.
CODING Commercial Products
Local providers in the Acupuncture Specialty (053) are able to file only the codes found in this policy.
Providers should not file an E & M service on the same date of service as the acupuncture service unless it meets the definition for use of Modifier -25. The acupuncture codes and services 97810, 97811 include preservice, intra-service and post-service evaluation and management for the typical following factors of history, evaluation, management and chart documentation done as part of the overall daily treatment.
The following CPT codes are covered under the acupuncture rider only:
97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-onone contact with the patient
97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)
Evaluation and Management codes are only used for separately identifiable procedures.
99201 Office or other outpatient visit for the evaluation and management of a new patient
99202 Office or other outpatient visit for the evaluation and management of a new patient
99203 Office or other outpatient visit for the evaluation and management of a new patient
99204 Office or other outpatient visit for the evaluation and management of a new patient
99205 Office or other outpatient visit for the evaluation and management of a new patient
99211 Office or other outpatient visit for the evaluation and management of an established patient
99212 Office or other outpatient visit for the evaluation and management of an established patient
99213 Office or other outpatient visit for the evaluation and management of an established patient
99214 Office or other outpatient visit for the evaluation and management of an established patient
99215 Office or other outpatient visit for the evaluation and management of an established patient
The following CPT codes are contract exclusions (non-covered):
97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s).
• 97810: Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
• 97811: Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles
• 97813: Acupuncture, one or more needles, with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
• 97814: Each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needles
Acupuncture: A chiropractic provider may not provide acupuncture services until certified by the Florida Board of Chiropractic Medicine. Acupuncture is reported based on 15 minute increments of personal (face-to-face) contact with the patient, not the duration of acupuncture needle(s) placement. If no electrical stimulation is used during a 15 minute increment, use 97810 or 97811. If electrical stimulation of any needle is used during a 15 minute increment, use 97813 or 97814. Only one code may be reported for each 15 minute increment. Use either 97810 or 97813 for the initial 15 minute increment. Only one initial code is reported per day.
The FEP does not include benefits for acupuncture when performed by a chiropractor.
Covered Services for Medicare Advantage Members:
According to the Centers for Medicare & Medicaid Services (CMS) Internet-only manual, Publication 100-02 Medicare Benefit Policy Manual, chapter 15, section 30.5, chiropractors’ services extend only to treatment by means of manual manipulation of the spine to correct a subluxation. All other services furnished or ordered by chiropractors are not covered. Chiropractors are not limited to any specific procedures and may render services as they feel necessary, but according to CMS guidelines; the benefit will only cover manual spinal manipulation, which includes procedure codes: 98940, 98941, and 98942.
The following procedure code ranges will deny for chiropractors as non-covered services:
• 00100 through 98929
• 98943 through 99607
• A0021 through V5364
Questions and Answers
1 Q: Acupuncture is not covered by Medicare, but can members still have the treatment?
A: Some Medicare Advantage members have a supplemental benefit package with coverage for acupuncture.
2 Q: Does CMS have new limited coverage for acupuncture?
A: A new NCD 30.3.3 Acupuncture for Chronic Lower Back Pain (cLBP) has coverage only for chronic lower back pain, effective January 21,2020. All other acupuncture remains non-covered.
3 Q: Is auricular peripheral nerve simulation covered?
A: The service for auricular peripheral nerve simulation (CPT code 64999) will be denied as non-covered. This service is not a covered Medicare benefit because acupuncture does not meet the definition of reasonable and necessary under Section 1862(a) (1) of the Act. ANSiStim, E-Pulse, Neurostim system/NSS, P-Stim, and NSS-2
Bridge, other current or future devices when used for the procedure electro-acupuncture or auricular peripheral nerve stimulation, would also be considered a non-covered service. Any ear or auricular electrical devices (e.g., DyAnsys®) are also non-covered by Medicare as electrical acupuncture.
2021 Medicare Product Acupuncture Benefit Changes
Beginning January 1, 2021, two separate benefits, with separate accumulations, will apply to acupuncture services provided to subscribers enrolled with a Medicare Advantage or Platinum Blue (Medicare Cost) plan.
Medicare Eligible Benefit
The Centers for Medicare & Medicaid (CMS) announced that acupuncture for low back pain is a covered benefit beginning in January 2020. Twenty acupuncture (20) visits are covered within a rolling 12-month period. Acupuncture services will only be allowed if billed for diagnosis codes listed in NCD 30.3.3. Providers must accurately point the correct diagnosis to each claim line for dates of service in 2021 to apply the appropriate benefit. Acupuncture services pointed to pain diagnoses other than those in NCD 30.3.3 will process under the Supplemental Benefit described below.
Supplemental Benefit
Blue Cross and Blue Shield of Minnesota (Blue Cross) will offer a supplemental benefit for acupuncture services for physical pain diagnoses other than low back pain. Acupuncture services for diagnoses unrelated to physical pain will not be covered. Providers must accurately point the correct diagnosis to each claim line for dates of service in 2021 to apply the appropriate benefit. This benefit is limited to 20 visits per calendar year.
Reimbursement Allowance
The reimbursement for Medicare eligible acupuncture for Medicare Advantage plans will be as follows:
• Professional claim: the contracted Medicare fee schedule allowance
• Facility claim: contracted Medicare allowance
The reimbursement for non-Medicare eligible acupuncture for Medicare Advantage plans will be as follows:
• Professional claim: the contracted Medicare fee schedule allowance
• Facility claim: 35% of billed charges based on the provider billing the usual and customary charge
The reimbursement for Medicare eligible acupuncture for Platinum Blue (Medicare Cost) plans will be as follows:
• Professional claim: the contracted Medicare fee schedule allowance
• Facility claim: Medicare is primary, Blue Cross will coordinate based on Medicare processing
The reimbursement for non-Medicare eligible acupuncture for Platinum Blue (Medicare Cost) plans will be as follows:
• Professional claim: the contracted commercial fee schedule allowance
• Facility claim: 100% of billed charges based on the provider billing the usual and customary charge Eligible providers
Must be under supervision of a licensed Physician; Independent Acupuncturists are not covered. Physicians as defined in 1861(r)(1) of the Social Security Act (the Act) may furnish acupuncture in accordance with applicable state requirements.
Physician assistants (PAs), nurse practitioners (NPs)/clinical nurse specialists (CNSs) (as identified in 1861(aa)(5) of the Act), and auxiliary personnel may furnish acupuncture if they meet all applicable state requirements and have:
• a masters or doctoral level degree in acupuncture or Oriental Medicine from a school accredited by the Accreditation Commission on Acupuncture and Oriental Medicine (ACAOM); and,
• a current, full, active, and unrestricted license to practice acupuncture in a State, Territory, or Commonwealth (i.e. Puerto Rico) of the United States, or District of Columbia.
• Auxiliary personnel furnishing acupuncture must be under the appropriate level of supervision of a physician, PA, or NP/CNS required by our regulations at 42 CFR §§ 410.26 and 410.27.
Guideline from BCBS
Acupuncture and an initial evaluation (for a new patient) is covered when rendered by a licensed doctor of acupuncture (D. Ac.) or physician (State of Rhode Island-licensed MD or DO)* only. Acupuncture assistants are not recognized for separate reimbursement and are therefore considered inclusive of the acupuncture reimbursement.
An initial evaluation (99201-99205) is allowed only for new patients. According to CPT guidelines, a new patient is one who has not received any professional services from the physician within the past three years.
The following services are not covered:
** **cupuncture with electrical stimulation;
** **djunctive therapies, such as but not limited to moxibustion, herbs, oriental massage, etc.;
** **cupuncture when used as an anesthetic during a surgical procedure;
** Precious metal needles (e.g., gold, silver, etc.);
** **cupuncture in lieu of anesthesia;
** **ny other service not specifically listed as a covered service.
*Acupuncture services may be rendered by a physician (MD or DO) when the following Rhode Island Department of Health criteria has been met:
2.2 Any physician licensed in Rhode Island under the provisions of Chapter 5-37 who seeks to practice medical acupuncture as a therapy shall comply with the following:
2.2.1 Meet the requirements for licensure as a doctor of acupuncture set forth in the Rules and Regulations for Licensing Doctors of Acupuncture and Acupuncture Assistants promulgated by the Department of Health; or 2.2.2 Successfully complete a course offered to physicians that meets the requirements set forth in these regulations and includes no less than the following:
a) a minimum of three hundred (300) hours of formal instruction;
b) a supervised clinical practicum incorporated into the formal instruction required in subsection 2.2.2(a) (above).
Acupuncture is a covered benefit for those groups who have purchased the acupuncture rider or who have an acupuncture benefit. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable acupuncture benefits/coverage. Rhode Island-mandated benefits do not apply to Plan 65, FEHBP, and Medicare Advantage plans. Selffunded groups may or may not choose to follow state mandate(s).
Acupuncture is the practice of piercing the skin with needles at specific body sites to induce anesthesia, to relieve pain, to treat various nonpainful disorders, and to alleviate withdrawal symptoms of opioid dependence. Acupuncture has also been used or proposed for a large variety of indications.
Acupuncture is a traditional form of Chinese medical treatment that has been practiced for over 2000 years. It involves piercing the skin with needles at specific body sites. The placement of needles into the skin is dictated by the location of meridians. These meridians, or channels, are thought to mark patterns of energy, called Qi (Chi), that flow through the human body. According to traditional Chinese philosophy, illness occurs when the energy flow is blocked or unbalanced, and acupuncture is a way to influence chi and restore balance. Another tenet of this philosophy is that all disorders are associated with specific points on the body, on or below the skin surface.
Several physiologic explanations of acupuncture’s mechanism of action have been proposed including an analgesic effect from release of endorphins or hormones (eg, cortisol, oxytocin), a biomechanical effect, and/or an electromagnetic effect.
There are 361 classical acupuncture points located along 14 meridians, and different points are stimulated depending on the condition treated. In addition to traditional Chinese acupuncture, there are a number of modern styles of acupuncture, including Korean and Japanese acupuncture. Modern acupuncture techniques can involve stimulation of additional non-meridian acupuncture points. Acupuncture is sometimes used along with manual pressure, heat (moxibustion), or electrical stimulation (electroacupuncture). Acupuncture treatment can vary by style and by practitioner, and is generally personalized to the patient. Thus, patients with the same condition may receive stimulation of different acupuncture points.
Scientific study of acupuncture is challenging due to the multifactorial nature of the intervention, variability in practice, and individualization of treatment. There has been much discussion in the literature on the ideal control condition for studying acupuncture. Ideally, the control condition should be able to help distinguish between specific effects of the treatment and nonspecific placebo effects related to factors such as patient expectations and beliefs and the patient-provider therapeutic relationships. A complicating factor in selection of a control treatment is that it is not clear whether all 4 components (ie, the acupuncture needles, the target location defined by traditional Chinese medicine, the depth of insertion, and the stimulation of the inserted needle) are necessary for efficacy.
CODING Commercial Products
Local providers in the Acupuncture Specialty (053) are able to file only the codes found in this policy.
Providers should not file an E & M service on the same date of service as the acupuncture service unless it meets the definition for use of Modifier -25. The acupuncture codes and services 97810, 97811 include preservice, intra-service and post-service evaluation and management for the typical following factors of history, evaluation, management and chart documentation done as part of the overall daily treatment.
The following CPT codes are covered under the acupuncture rider only:
97810 Acupuncture, 1 or more needles; without electrical stimulation, initial 15 minutes of personal one-onone contact with the patient
97811 Acupuncture, 1 or more needles; without electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)
Evaluation and Management codes are only used for separately identifiable procedures.
99201 Office or other outpatient visit for the evaluation and management of a new patient
99202 Office or other outpatient visit for the evaluation and management of a new patient
99203 Office or other outpatient visit for the evaluation and management of a new patient
99204 Office or other outpatient visit for the evaluation and management of a new patient
99205 Office or other outpatient visit for the evaluation and management of a new patient
99211 Office or other outpatient visit for the evaluation and management of an established patient
99212 Office or other outpatient visit for the evaluation and management of an established patient
99213 Office or other outpatient visit for the evaluation and management of an established patient
99214 Office or other outpatient visit for the evaluation and management of an established patient
99215 Office or other outpatient visit for the evaluation and management of an established patient
The following CPT codes are contract exclusions (non-covered):
97813 Acupuncture, 1 or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient
97814 Acupuncture, 1 or more needles; with electrical stimulation, each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s).
CPT Code Description Fee
97810 Acupuncture $25.50
97811 Acupuncture, additional 15 minutes $18.93
97813 Acupuncture with electrical stimulation $27.27
97814 Acupuncture with electrical stimulation, additional 15 minutes $21.46
BCBS insurance id starts with VMB, VMA, XJQ, XJX and VME
How will our office recognize an Exchange member?
Our member identification (ID) cards will not change. However, there will be new alpha prefixes on ID cards for Exchange members:
VMB = Individual HMO
VMA = Individual PPO
XJQ = Small Group HMO
XJX = Small Group
VME/VMD = Individual HMO and PPO off-Exchange
How do I verify member benefits?
You may verify eligibility and benefits for Florida Blue members on the Exchange as you do today for any other Florida Blue member. Providers and/or their designees (billing services, clearinghouses, etc.) should use clinical, financial and administrative electronic self-service capabilities including those accessed through Availity®1. These capabilities include but are not limited to:
• Submitting administrative inquiries electronically through Availity using Authorizations and Referrals Review and Inquiry, Eligibility and Benefits, CareCalc®, the Claim Reconciliation Tool and Claims Status.
• When using certain Availity transactions (Authorizations and Referrals Review and Inquiry, Eligibility and Benefits Inquiry), providers should use the automated transaction capability and obtain a transaction ID through Availity. Providers will not receive eligibility and benefits information from Florida Blue without a transaction ID. This transaction ID will also provide fast-path priority service if you should need to call the Florida Blue Provider Contact Center for assistance. You may call the Provider Contact Center at (800) 727-2227.
What if a member does not have an ID card or I can’t find eligibility and benefits information in Availity?
If you cannot find member information in Availity, call the Provider Contact Center at (800) 727-2227 for enrollment status or have the member call the number on the back of their ID card. As a reminder, if the member does not have an ID card and does not know their member ID number, you can check eligibility and benefits in Availity by using the member’s name and date of birth.
Will providers who already use electronic transactions have to do anything differently?
No. Providers should continue to follow the same processes in place today.
What is the coverage effective date for members enrolled on the Exchange?
For members who enroll on the Exchange between Oct.1, 2013 – Dec. 23, 2013, the coverage effective date is Jan. 1, 2014.
Exchange open enrollment continues from Dec. 23, 2013 – Mar. 31, 2014. Applications received prior to the 15th day of the month are effective the first day of the following month. For example, if an application is received on Mar. 10, 2014, the coverage effective date is Apr. 1, 2014.
Our member identification (ID) cards will not change. However, there will be new alpha prefixes on ID cards for Exchange members:
VMB = Individual HMO
VMA = Individual PPO
XJQ = Small Group HMO
XJX = Small Group
VME/VMD = Individual HMO and PPO off-Exchange
How do I verify member benefits?
You may verify eligibility and benefits for Florida Blue members on the Exchange as you do today for any other Florida Blue member. Providers and/or their designees (billing services, clearinghouses, etc.) should use clinical, financial and administrative electronic self-service capabilities including those accessed through Availity®1. These capabilities include but are not limited to:
• Submitting administrative inquiries electronically through Availity using Authorizations and Referrals Review and Inquiry, Eligibility and Benefits, CareCalc®, the Claim Reconciliation Tool and Claims Status.
• When using certain Availity transactions (Authorizations and Referrals Review and Inquiry, Eligibility and Benefits Inquiry), providers should use the automated transaction capability and obtain a transaction ID through Availity. Providers will not receive eligibility and benefits information from Florida Blue without a transaction ID. This transaction ID will also provide fast-path priority service if you should need to call the Florida Blue Provider Contact Center for assistance. You may call the Provider Contact Center at (800) 727-2227.
What if a member does not have an ID card or I can’t find eligibility and benefits information in Availity?
If you cannot find member information in Availity, call the Provider Contact Center at (800) 727-2227 for enrollment status or have the member call the number on the back of their ID card. As a reminder, if the member does not have an ID card and does not know their member ID number, you can check eligibility and benefits in Availity by using the member’s name and date of birth.
Will providers who already use electronic transactions have to do anything differently?
No. Providers should continue to follow the same processes in place today.
What is the coverage effective date for members enrolled on the Exchange?
For members who enroll on the Exchange between Oct.1, 2013 – Dec. 23, 2013, the coverage effective date is Jan. 1, 2014.
Exchange open enrollment continues from Dec. 23, 2013 – Mar. 31, 2014. Applications received prior to the 15th day of the month are effective the first day of the following month. For example, if an application is received on Mar. 10, 2014, the coverage effective date is Apr. 1, 2014.
review of blue cross Medicare HMO details.
Blue Cross insurance (Medicare HMO)
The Blue Cross is a consumer health advocate with the public interest as its driving force. Their plans have been providing families with the highest quality of health insurance services for 70 years. The Blue Cross Blue Shield Association only offers its members the highest quality, most innovative & customer focused, health insurance plans available. As we step further into the 21st century, medical breakthroughs are going to require changes in policies and coverage, and Blue Cross Blue Shield will be there for its customers, every step of the way.
Blue Cross offers a single Medicare + Choice HMO plan, the Blue Cross Senior Secure plan. The benefits of this plan include low or no, monthly premiums, low copayments for doctor office visits, and coverage for vision, dental and routine podiatry care. This plan, however, is only available in select geographic locals.
For more information regarding the many available plans to choose from, consult the chart below.
For more information regarding Blue Cross, visit the company website at www.BlueCross.com.
The Blue Cross is a consumer health advocate with the public interest as its driving force. Their plans have been providing families with the highest quality of health insurance services for 70 years. The Blue Cross Blue Shield Association only offers its members the highest quality, most innovative & customer focused, health insurance plans available. As we step further into the 21st century, medical breakthroughs are going to require changes in policies and coverage, and Blue Cross Blue Shield will be there for its customers, every step of the way.
Blue Cross offers a single Medicare + Choice HMO plan, the Blue Cross Senior Secure plan. The benefits of this plan include low or no, monthly premiums, low copayments for doctor office visits, and coverage for vision, dental and routine podiatry care. This plan, however, is only available in select geographic locals.
For more information regarding the many available plans to choose from, consult the chart below.
Benefits | Blue Cross Senior Secure |
Doctor and Hospital Choice | You must go to network doctors, specialists and hospitals |
Monthly Premium | $0-$30 |
Inpatient Hospital Care | Member pays $160/$165 per day until the $2,100 annual out-of-pocket maximum has been reached |
Skilled Nursing Facility | 100% up to 100 days per benefit period |
Doctor Office Visits | $5/$10 Primary Care; $10/$15 Specialist |
Prescription Drugs (on Senior Secure Approved List) | For each prescription or refill, $8 for generic drugs up to a 30-day supply; $20 for mail order generic drugs up to a 90-day supply |
Routine Physical Exams | After a $5/$10 copay, pays 100% of expenses |
For more information regarding Blue Cross, visit the company website at www.BlueCross.com.
BILLING Iontophoresis CPT 97033 - Update from BCBS
Iontophoresis
BCBS POLICY
Iontophoresis may be considered medically necessary to administer local anesthesia prior to a venipuncture or dematologic procedure.
Iontophoresis of fentanyl may be considered medically necessary for the short-term (i.e., less than 24 hours) management of acute postoperative pain in adult patients requiring opioid analgesia during hospitalization.
Iontophoresis as a transdermal drug delivery technique for other medical indications is considered investigational.
POLICY GUIDELINES
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Code Number Description
CPT - 97033 Application of a modality to one or more areas; iontophoresis, each 15 minutes
ICD- 99.27 Iontophoresis - Not reimbursed code
POLICY HISTORY
8/2001: Approved Medical Policy Advisory Committee (MPAC)
2/14/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, ICD-9 diagnosis code 780.8 added non-covered table
7/2003: Reviewed by MPAC, no changes, FEP coverage updated, Sources updated
11/19/2004: Code Reference section reviewed, CPT code 97033 description revised and "Note: Some providers may code iontophoresis using CPT code 97039, unlisted modality. This is inappropriate." deleted, non-covered table deleted, ICD-9 diagnosis code 780.8 deleted non-covered codes
10/17/2006: Policy reviewed, updated to match BCBSA policy
10/25/2006: Code Reference section updated. ICD-9 Diagnosis Codes 726.32, 726.71, 728.71 deleted from policy
10/01/2007: Policy reviewed. Added iontophoresis of fentanyl may be considered medically necessary for the short-term (i.e., less than 24 hours) management of acute postoperative pain in adult patients requiring opioid analgesia during hospitalization
11/15/2007: Policy revisions approved by MPAC
10/7/2008: Policy reviewed, no changes
BCBS POLICY
Iontophoresis may be considered medically necessary to administer local anesthesia prior to a venipuncture or dematologic procedure.
Iontophoresis of fentanyl may be considered medically necessary for the short-term (i.e., less than 24 hours) management of acute postoperative pain in adult patients requiring opioid analgesia during hospitalization.
Iontophoresis as a transdermal drug delivery technique for other medical indications is considered investigational.
POLICY GUIDELINES
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Code Number Description
CPT - 97033 Application of a modality to one or more areas; iontophoresis, each 15 minutes
ICD- 99.27 Iontophoresis - Not reimbursed code
POLICY HISTORY
8/2001: Approved Medical Policy Advisory Committee (MPAC)
2/14/2002: Investigational definition added
5/1/2002: Type of Service and Place of Service deleted
5/29/2002: Code Reference section updated, ICD-9 diagnosis code 780.8 added non-covered table
7/2003: Reviewed by MPAC, no changes, FEP coverage updated, Sources updated
11/19/2004: Code Reference section reviewed, CPT code 97033 description revised and "Note: Some providers may code iontophoresis using CPT code 97039, unlisted modality. This is inappropriate." deleted, non-covered table deleted, ICD-9 diagnosis code 780.8 deleted non-covered codes
10/17/2006: Policy reviewed, updated to match BCBSA policy
10/25/2006: Code Reference section updated. ICD-9 Diagnosis Codes 726.32, 726.71, 728.71 deleted from policy
10/01/2007: Policy reviewed. Added iontophoresis of fentanyl may be considered medically necessary for the short-term (i.e., less than 24 hours) management of acute postoperative pain in adult patients requiring opioid analgesia during hospitalization
11/15/2007: Policy revisions approved by MPAC
10/7/2008: Policy reviewed, no changes
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