Procedure to Place of Service Policy, Professional

Transcription

1 Procedure to Place of Service Policy, Professional REIMBURSEMENT POLICY Policy Number 2018R7108Q Annual Approval Date 3/8/2018 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT *), Centers for Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider contracts, the enrollee s benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. *(CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.) Application This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid products. This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a ) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Policy Overview UnitedHealthcare Community Plan follows Current Procedural Terminology (CPT ) code descriptions/guidelines and Healthcare Common Procedure Coding System (HCPCS) procedure code definitions/guidelines that indicate a POS in their descriptions when assigning the applicable places of service. Reimbursement Guidelines

2 This policy addresses the appropriate places of service for certain CPT and HCPCS procedure codes. Descriptions of some CPT and HCPS codes included in what places of service the code may be used. For example, it would not be appropriate to submit place of service inpatient for a code that states office or outpatient visit. UnitedHealthcare Community Plan has established a list of CPT and HCPCS codes along with their appropriate places of service. For any code that is not on the list, the place of service is not limited. Note that any procedure code reported with an appropriate place of service may also be subject to other UnitedHealthcare Community Plan reimbursement policies. State Exceptions Arizona California Delaware Florida Arizona Medicaid has a state specified procedure to place of service list. California Medicaid allows CPT code in an 81 (Independent Lab) place of service. California Medicaid allows CPT in POS 12, 55, and 81. Delaware Medicaid allows HCPCS code T1015 in 03 (school) place of service. Florida Medicaid allows CPT codes and in 12 (home) and 25 (birthing center) place of service. Florida Medicaid allows T1015 in POS 02 (Telehealth). Iowa HCPCS code T1015 is allowed in additional POS: 12, 21, 23, 31, 32, 51, 52, and 56. HCPCS code H0019 is allowed in POS 14. HCPCS code T1017 is allowed in POS 21. Kansas Kansas allows: CPT codes in 22 (outpatient hospital) place of service CPT code T2042 in POS 31 CPT codes and in a 22 (On Campus-Outpatient Hospital) and 19 (Off Campus-Outpatient Hospital) places of service. Kansas does NOT allow: CPT codes 99234, 99235, and in POS 19 (Off Campus-Outpatient Hospital) Kanas Medicaid has a state specified list of codes allowed in a telehealth place of service (02). The list of allowable codes can be found within the attachment section of this policy Louisiana Louisiana Medicaid allows codes 99000, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99344, 99348, 99350, 99354, 99355, 99339, 99340, 99363, 99364, 99374, 99375, 99461, H0007, S0260, S9475, T1015, T1025, and T1026 in a 03 (school) place of service. Maryland Maryland allows E&M codes in 03 (school) place of service to accommodate school based clinics. Massachusetts Massachusetts allows S9122 to be paid under POS 32. Michigan Michigan Medicaid denies all CPT and HCPCS procedure codes billed in POS 05, 06, 08, 09, 25, 26, 53, 54, and 60. Mississippi Mississippi CAN allows the following codes in the corresponding listed place(s) of service (POS). H0035 in POS 99 and 53

3 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and in POS 03 and and in POS 03, 12, 13, 31, and 32 S9480 in POS 03, 12, and 14 T2048 in POS 53 Nebraska Nebraska Medicaid to allow code S9480 when billed in POS 11 Nebraska Medicaid allows behavioral health provider to bill codes 99221,99222, 99223, 99238, 99239, in a POS 02. Per Nebraska Medicaid State regulations, POS 2 there are no limitations on POS 2. New Mexico New York Ohio New Mexico Medicaid allows CPT codes in 03 (school) place of service. New York allows E&M codes in 04 and 15 places of service. Ohio Medicaid allows CPT codes T2042 and T2043 in a 31 (skilled nursing facility) and 32 (Nursing Facility) place of service. OH Medicaid and MMP products allows the follow procedure to place of service code combinations: with POS 13, 31, and with POS 13, 31, 32, and with POS 13, 31 and , with POS and with POS 13, 31, and 32 H0012 with POS Pennsylvania Pennsylvania Medicaid allows HCPC code T1015 in 21 (inpatient) place of service. Tennessee Virginia Washington For Tennessee Medicaid, services that are allowed in a POS 11 (office) are also allowed in POS 03 (school). Code G0155 is allowed in POS 53. Virginia Department of Medical Assistant Services allows H0035 in a 03 place of service (POS) when submitted with an appropriate modifier or modifier combination: H0035 HA, H0035 HA UG, or H0035 HA U7. VA DMAS does not impose any POS restrictions on codes G0151, G0152, G0153 and G0495. VA DMAS allows additional POS 11, 22 and 53 when submitted with an appropriate modifier or modifier combination: H0035 HA, H0035 HA UG, H0035 HA U7 or H0035 HB Washington Medicaid allows CPT codes and in 12 (home) place of service. Wisconsin Wisconsin Medicaid allows CPT codes in 04 (homeless shelter) place of service and codes in 03 (school) place of service and in 04 (homeless shelter) place of service. Wisconsin Medicaid allows CPT code when billed in a place of service 12. Wisconsin Medicaid allows CPT code 99000, G0398, G0399 when billed in a place of service 19. For Wisconsin Medicaid certain surgical procedures may be reimbursed only when

4 REIMBURSEMENT POLICY performed in an inpatient hospital, indicated by POS code 21 or an ASC (ambulatory surgery center), and indicated by POS 24. The list of surgical procedure can be found within the attachment section of this policy. Wisconsin Medicaid allows CPT code 99001when billed in a place of service 11 Wisconsin Medicaid allows CPT code 35682,35683,38746,99356,99357 when billed in a place of service 22 Questions and Answers Q: Why aren t all CPT and HCPCS codes addressed in this policy? 1 A: The intent of the Procedure to Place of Service Policy is to limit the place of service for CPT and HCPS codes to places of service that are in their description. It is not intended to be all inclusive. Q: Where do the places of service codes come from? 2 A: CMS defines places of services and assigns corresponding codes to them. Attachments: Please right-click on the icon to open the file UnitedHealthcare Community Plan Medicaid Procedure to Place of Service List UnitedHealthcare Community Plan Place of Service List A list of CPT and HCPCS codes with corresponding allowable places of service for Medicaid products. A list of place of service codes and their description. Arizona Procedure to Place of Service List A list of place of service codes and CPT codes for Arizona

5 Kansas Procedure to Place of Service List A list of place of service codes and CPT codes for Kansas Wisconsin Medicaid CPT List A list of CPT codes for Wisconsin Medicaid. Resources Individual state Medicaid regulations, manuals & fee schedules American Medical Association, Current Procedural Terminology ( CPT ) and associated publications and services Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets Centers for Medicare and Medicaid Services, Place of Service Code Set MLN/MLNMattersArticles/downloads/MM7631.pdf History 12/9/2018 Attachments Section: Arizona Procedure to Place of Service CPT List 12/2/2018 Attachments Section: UnitedHealthcare Community Plan Medicaid Procedure to Place of Service List 11/18/2018 Attachments Section: Arizona Procedure to Place of Service CPT List 11/11/2018 Massachusetts state exceptions added Nebraska state exceptions 10/07/2018 Ohio State Exceptions Attachments Section: Arizona Procedure to Place of Service CPT List 9/30/2018 Nebraska state exceptions 9/23/2018 Attachments Section: Arizona Procedure to Place of Service CPT List 9/3/2018 Attachments Section: Arizona Procedure to Place of Service CPT List 8/19/2018 Attachments Section: Arizona Procedure to Place of Service CPT List 8/3/2018 State Exceptions: Updated Virginia 7/15/2018 Attachments Section : A list of CPT codes for Wisconsin Medicaid in addition to WI state

6 exceptions. REIMBURSEMENT POLICY 7/1/2018 Attachments Section: Arizona Procedure to Place of Service List 6/24/2018 State Exceptions: Updated Virginia 6/10/2018 Attachments Section: Wisconsin Procedure to Place of Service List 6/3/2018 Attachments Section: Arizona Procedure to Place of Service List 5/20/2018 Florida State Exception Arizona Procedure to Place of Service List 3/25/2018 Wisconsin CPT list name Arizona Procedure to Place of Service List 3/8/2018 Annual Policy Version Change History Section: Entries prior to 1/1/2016 archived. 3/18/2018 Wisconsin exceptions 3/11/2018 Kansas, Michigan, Wisconsin, and Virginia exceptions 2/21/2018 Wisconsin exceptions 2/11/2018 Kansas state exceptions, in addition to POS 02 list created and attached for the state of Kansas 1/14/2018 Arizona Procedure to Place of Service List 11/12/2017 Wisconsin surgical procedure list for POS 21 and /1/2017 Tennessee exceptions 9/11/2017 Medicaid Proc to POS list 8/20/2017 California exceptions 5/20/2017 Application Section: Removed UnitedHealthcare Community Plan Medicare products as applying to this policy. Added location for UnitedHealthcare Community Plan Medicare reimbursement policies 4/2/2017 Ohio state exceptions added. 3/8/2017 Policy Approval Date Change (no new version) 2/19/2017 State Exceptions Section: Exception added for Florida, Nebraska & removed deleted codes and /1/2017 Annual Version Change Attachments Section: UnitedHealthcare Community Plan Place of Service List History Section: Entries prior to 1/1/2015 archived 11/12/2016 Attachments Section: UnitedHealthcare Community Plan Wisconsin Medicaid Surgical Procedure List added State Exceptions Section: Exception added for Wisconsin 10/2/2016 Policy List Change: UnitedHealthcare Community Plan Medicaid Procedure to Place of Service List State Exceptions Section: Exception added for New York 8/21/2016 State Exceptions Section: Exception added for Iowa and Wisconsin 7/10/2016 Attachments Section: UnitedHealthcare Community Plan Medicare Procedure to Place of Service List 7/3/2016 State Exceptions Section: Exception added for Iowa

7 5/22/2016 Policy List Change: UnitedHealthcare Community Plan Medicaid Procedure to Place of Service List State Exceptions Section: Exception added for Pennsylvania 4/17/2016 Policy List Change: UnitedHealthcare Community Plan Medicaid Procedure to Place of Service List 4/10/2016 Attachments Section: UnitedHealthcare Community Plan Medicare Procedure to Place of Service List 4/3/2016 State Exceptions Section: Added exception for Tennessee 3/6/2016 Attachments Section: UnitedHealthcare Community Plan Medicare Procedure to Place of Service List State Exceptions Section: Exception added for Pennsylvania 2/19/2016 State Exceptions Section: Updated the Arizona state exception to reference it was specific to Medicaid. 2/14/2016 State Exceptions Section: Exception for Mississippi 1/10/2016 Attachments Section: UnitedHealthcare Community Plan Medicare Procedure to Place of Service List State Exceptions Section: Added exception for California 1/1/2016 Annual Policy Version Change History Section: Entries prior to 1/1/2014 archived Policy List Change: UnitedHealthcare Community Plan Medicaid Procedure to Place of Service List and UnitedHealthcare Community Plan Place of Service List State Exceptions Section: Exception for Kansas to include POS 19 for codes and and added codes not allowable in POS 19. Exception added for New Mexico. 5/13/2012 Policy Implemented by UnitedHealthcare Community Plan Back To Top