Maximum Frequency Per Day Policy Annual Approval Date

Transcription

1 REIMBURSEMENT POLICY CMS-1500 Policy Number 2017R0060I Maximum Frequency Per Day Policy Annual Approval Date 7/12/2017 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 at you are reimbursed based on e code or codes at correctly describe e heal care services provided. UnitedHealcare reimbursement policies may use Current Procedural Terminology (CPT *), Centers for Medicare and Medicaid Services (CMS) or oer coding guidelines. References to CPT or oer sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all heal care services billed on CMS 1500 forms and, when specified, to ose billed on UB04 forms. Coding meodology, industry-standard reimbursement logic, regulatory requirements, benefits design and oer factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealcare s reimbursement policy for e services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealcare may use reasonable discretion in interpreting and applying is policy to heal care services provided in a particular case. Furer, e policy does not address all issues related to reimbursement for heal care services provided to UnitedHealcare enrollees. Oer factors affecting reimbursement may supplement, modify or, in some cases, supersede is policy. These factors may include, but are not limited to: legislative mandates, e physician or oer provider contracts, e enrollee s benefit coverage documents and/or oer reimbursement, medical or drug policies. Finally, is policy may not be implemented exactly e same way on e different electronic claims processing systems used by UnitedHealcare due to programming or oer constraints; however, UnitedHealcare strives to minimize ese variations. UnitedHealcare may modify is reimbursement policy at any time by publishing a new version of e policy on is Website. However, e information presented in is policy is accurate and current as of e date of publication. *CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of e American Medical Association. Table of Contents Application 1 Policy 2 Overview 2 Reimbursement Guidelines 2 MFD Determination 2 Part I 2 Part II 3 Reimbursement 3 Modifiers 4 Anatomic Modifiers 5 Questions and Answers 5 Attachments 7 Resources 8 History 8 Application

2 This policy applies to services reported using e 1500 Heal Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products, all network and non-network physicians and oer qualified heal care professionals, including, but not limited to, non-network auorized and percent of charge contract physicians and oer qualified heal care professionals. This policy does not apply to: network home heal services and supplies/home heal agencies; anesesia management; ambulance services; network physicians and oer qualified heal care professionals contracted at a case rate (in some markets known as a flat rate) unless e code description for e service or supply indicates it should be reported only once daily or has a Medically Unlikely Edits Adjudication Indicator (MAI) of 2. For HCPCS codes reported wi rental modifiers (KH, KI, KJ, KR, or RR) or e Maintenance and Service modifier (MS) by a participating network and non-network durable medical equipment (DME), orotics or prosetics vendor, please refer to UnitedHealcare's Durable Medical Equipment, Orotics and Prosetics Multiple Frequency Policy. Policy Overview The purpose of is policy is to ensure at UnitedHealcare reimburses physicians and oer heal care professionals for e units billed wiout reimbursing for obvious billing submission and data entry errors or incorrect coding based on anatomic considerations, HCPCS/CPT code descriptors, CPT coding instructions, established UnitedHealcare policies, nature of a service/procedure, nature of an analyte, nature of equipment, and unlikely clinical treatment. The term units refers to e number of times services wi e same Current Procedural Terminology (CPT ) or Healcare Common Procedure Coding System (HCPCS) codes are provided per day by e same individual physician or oer heal care professional. To do is, UnitedHealcare has established maximum frequency per day (MFD) values, which are e highest number of units eligible for reimbursement of services on a single date of service. Reimbursement also may be subject to e application of oer UnitedHealcare Reimbursement policies such as "Laboratory Services" or "Professional/Technical Component." This policy applies wheer a physician or oer heal care professional submits one CPT or HCPCS code wi multiple units on a single claim line or multiple claim lines wi one or more unit(s) on each line. It is common coding practice for some CPT and HCPCS codes to be submitted wi multiple units. MFD values will be evaluated and/or quarterly to reflect new, changed, and deleted codes. Review of MFD values for existing CPT and HCPCS codes based on criteria wiin is policy will be completed annually. For e purpose of is policy, e same individual physician or oer heal care professional is e same individual rendering heal care services reporting e same Federal Tax Identification number. Reimbursement Guidelines MFD Determination Part I The following criteria are first used to determine e MFD values for codes to which ese criteria are applicable: The service is classified as bilateral (CMS Indicators 1 or 3) on e Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule (NPFS) or e term 'bilateral' is included in e code descriptor. For e majority of ese codes, e MFD value is one (1). There are some codes at describe more an one anatomical site or vertebral level at can be treated bilaterally where e MFD value may be more an 1. Where e CPT or HCPCS code description/verbiage references reporting e code once per day, e MFD value is 1. The service is anatomically or clinically limited wi regard to e number of times it may be performed, in which case e MFD value is established at at value. The CPT or HCPCS code description/verbiage indicates e number of times e service can be performed, in which case e MFD value is set at at value. CMS Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Local Coverage Determination (LCD) assigns an MFD value in which case e MFD value is set at at value. Where e criteria above has not defined an MFD value, e CMS Medically Unlikely Edits (MUE) value, where available, will be utilized to establish an MFD value.

3 Where no oer definitive value has been established based on e criteria above, drug HCPCS codes will have an MFD value of 999 which indicates ey are exempt from e MFD policy. Where no oer definitive value has been established based on e criteria above, unlisted CPT and HCPCS codes will have an MFD value of 999 which indicates ey are exempt from e MFD policy. Where no oer definitive value has been established based on e criteria above, new CPT codes released by e American Medical Association and new HCPCS codes released by CMS since e last MFD value update (not covered by any of e above criteria), will have an MFD value of 100. Part II When none of e criteria listed in Part I apply to a code, data analysis is conducted to establish MFD values according to common billing patterns. When a code has 50 or more claim occurrences in a data set, e MFD values are determined rough claim data analysis and are set at e 100 percentile (i.e. e highest number of units billed for at CPT or HCPCS code in e data set). If e 100 percentile exceeds e 98 percentile by a factor of four, e MFD value will be set at e 98 percentile. When a code has less an 50 claim occurrences in a data set, e MFD values will be set at e default of 100 until e next annual analysis. In any case where, in UnitedHealcare's judgment, e 98 percentile does not account for e clinical circumstances of e services billed, e MFD for a code may be increased so as to capture only obvious billing submission and data entry errors. The "MFD CPT Values" and e "MFD HCPCS Values lists below contain e most current MFD values/codes Maximum Frequency per Day CPT Policy List 2017 Maximum Frequency per Day HCPCS Policy List Reimbursement The MFD values apply wheer a physician or oer heal care professional submits one CPT or HCPCS code wi multiple units on a single claim line or multiple claim lines wi one or more unit(s) on each line. It is common coding practice for some CPT and HCPCS codes to be submitted wi multiple units. However, when reporting e same CPT or HCPCS code on multiple and/or separate claim lines, e claim line may be classified as a duplicate service and/or subject to additional UnitedHealcare reimbursement policies such as "Laboratory Services" or "Professional/Technical Component." Services provided are reimbursable services up to and including e MFD value for an individual CPT or HCPCS code. In some instances, a modifier may be necessary for correct coding and corresponding reimbursement purposes. See Q & A #3, 4 and 5. Modifiers LT and RT Restrictions Bilateral payment via e use of modifiers LT or RT is inappropriate for procedures, services, and supplies where e concept of laterality does not apply. UnitedHealcare will pay up to e maximum frequency per day value for codes wi "bilateral" or "unilateral or bilateral" in description or for codes where e concept of laterality does not apply, wheer submitted wi or wiout modifiers LT and/or RT by e same individual physician or oer healcare professional on e same date of service for e same member. Use of modifiers LT and/or RT on e codes identified in e "Codes Restricting Modifiers LT and RT" list will be considered informational only Codes Restricting Modifiers LT and RT There may be situations where a physician or oer healcare professional reports units accurately and ose units exceed e established MFD value. In such cases, UnitedHealcare will consider additional reimbursement if reported wi an appropriate modifier such as modifier 59, 76, 91, XE, XS, or XU. Medical records are not required to be submitted wi e claim when modifiers 59, 76, 91, XE, XS, or XU are appropriately reported. Documentation wiin e medical

4 record should reflect e number of units being reported and should support e use of e modifier. Medically Unlikely Edit (MUE) Adjudication Indicator (MAI) 2 CMS has identified CPT/HCPCS codes where e units of service (UOS) on e same date of service in excess of e MUE value would be considered impossible because it is contrary to statute, regulation or sub-regulatory guidance. Therefore, UnitedHealcare will not allow units in excess of e MFD value to be reimbursed for CPT/HCPCS codes assigned an MAI indicator of 2. Per CMS guidelines, no modifier override will be allowed nor will e MFD value be overridden by supplying documentation for adjustment requests. MFD MAI2 Indicator Codes Modifiers Modifier XE XS XU Modifier Description Distinct Procedural Service Under certain circumstances, it may be necessary to indicate at a procedure or service was distinct or independent from oer non-e/m services performed on e same day. Modifier 59 is used to identify procedures/services, oer an E/M services, at are not normally reported togeer but are appropriate under e circumstances. Documentation must support a different session, different procedure or surgery, different size or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on e same day by e same individual. However, when anoer already established modifier is appropriate it should be used raer an modifier 59. Only if no more descriptive modifier is available, and e use of modifier 59 best explains e circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service wi a non-e/m service performed on e same date, see modifier 25. Repeat Procedure or Service by Same Physician or Oer Qualified Heal Care Professional It may be necessary to indicate at a procedure or service was repeated by e same physician or oer qualified heal care professional subsequent to e original procedure or service. This circumstance may be reported by adding modifier 76 to e repeated procedure or service. Note: This modifier should not be appended to an E/M service. To report a separate and distinct E/M service performed on e same date, see modifier 25. It is also inappropriate to use modifier 76 to indicate repeat laboratory services. Modifiers 59 or 91 should be used to indicate repeat or distinct laboratory services, as appropriate according to e AMA and CMS. Separate consideration for reimbursement will not be given to laboratory codes reported wi modifier 76. Repeat Clinical Diagnostic Laboratory Test In e course of treatment of e patient, it may be necessary to repeat e same laboratory test on e same day to obtain subsequent (multiple) test results. Under ese circumstances, e laboratory test performed can be identified by its usual procedure number and e addition of modifier 91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems wi specimens or equipment; or for any oer reason when a normal, one-time, reportable result is all at is required. This modifier may not be used when oer code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more an once on e same day on e same patient. Separate Encounter A Service That Is Distinct Because It Occurred During A Separate Encounter Separate Structure A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure Unusual Non-Overlapping Service The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service

5 Anatomic Modifiers Modifier Modifier Description Modifier Modifier Description E1 Upper left, eyelid E3 Upper right, eyelid E2 Lower left, eyelid E4 Lower right, eyelid F1 Left hand, second digit F5 Right hand, umb F2 Left hand, ird digit F6 Right hand, second digit F3 Left hand, four digit F7 Right hand, ird digit F4 Left hand, fif digit F8 Right hand, four digit FA Left hand, umb F9 Right hand, fif digit T1 Left foot, second digit T5 Right foot, great toe T2 Left foot, ird digit T6 Right foot, second digit T3 Left foot, four digit T7 Right foot, ird digit T4 Left foot, fif digit T8 Right foot, four digit TA Left foot, great toe T9 Right foot, fif digit LC Left circumflex coronary artery RC Right coronary artery LD Left anterior descending coronary artery RI Ramus intermedius coronary artery LM Left main coronary artery RT Right side LT Left side Questions and Answers Q: Why do you exclude network home heal services and supplies/home heal agencies, anesesia management, and ambulance providers from is policy? A: There are many contracts specific to ese physicians and oer heal care professionals at permit codes to be used in a different manner an intended by CPT and HCPCS, which make e application of is policy unworkable. Billing practices may also dictate at e units field is used to report someing oer an how many times a service was performed (i.e. mileage), which again may make e application of is policy unworkable. These providers were excluded until contract language and/or billing practices can be reviewed and changed. Q: When e frequency of a billed service on a date of service is greater an e established MFD value, will ere be additional reimbursement? A: When a physician or oer healcare professional reports units accurately, yet ose units exceed e established MFD value, an appropriate modifier such as 59, 76, 91, XE, XS, or XU may be utilized. The MFD value is a reshold set solely to avoid overpayment due to billing and data entry errors. UnitedHealcare intends to reimburse all services performed and reported wi proper coding in accordance wi its reimbursement policies and benefit or provider contracts. Medical records do not need to be submitted for e purposes of is policy, unless e processed claim is being submitted on appeal. When reporting e same CPT or HCPCS code on multiple and/or separate claim lines, e claim line may be classified as a duplicate service and subject to additional UnitedHealcare reimbursement policies such as "Laboratory Services" or "Professional/Technical Component." Q: Why has UnitedHealcare set e MFD value at 1 for bilateral procedures? A: UnitedHealcare has set e MFD value for most bilateral procedures at 1. The preferred meod of billing a bilateral eligible procedure is wi 1 unit on one claim line wi modifier 50. Modifier 50 indicates at one procedure was performed bilaterally. Bilateral eligible procedures may also be billed on two lines wi 1 unit each and modifiers RT and LT. There are some codes at describe more an one anatomical site or vertebral level at can be treated bilaterally where e MFD value may be more an 1.

6 Q: Would e MFD value for bilateral procedures remain at 1 unit if it is possible to perform ese procedures more an once per day? A: If e bilateral procedure is provided more an once per day, modifiers 59, 76, or XS may be appropriate to bill depending on e circumstance. Additional reimbursement will be considered wi e use of ese modifiers. Q: Would e MFD value for hand or foot bilateral procedures remain at 1 unit if it is possible to perform e procedure on multiple digits such as fingers or toes? A: The MFD value would remain at 1 unit, however, HCPCS modifiers FA or F1-9 may be used to report specific fingers; TA or T1-9 may be used to report specific toes. Q: Will UnitedHealcare allow more an 1 unit for a CPT or HCPCS code wi per diem or per day in e code description? A: UnitedHealcare will allow 1 unit of a procedure code wi per diem or per day or oer verbiage describing once daily in e code description. There are no modifiers at will override e MFD value. For example, if a patient requires home infusion antibiotic erapy twice daily, it would be more appropriate to report 1 unit of HCPCS code S9501 raer an 2 units of S9500. The MFD applies wheer a physician or oer heal care professional submits one CPT or HCPCS code wi multiple units on a single claim line or multiple claim lines wi 1 or more unit(s) on each line. S9500 Home infusion erapy, antibiotic, antiviral, or antifungal erapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem S9501 Home infusion erapy, antibiotic, antiviral, or antifungal erapy; once every 12 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem Q: What is an example of a code at is limited because of anatomical or clinical reasons? A: CPT code Appendectomy would be set at e MFD value of 1 unit because a person only has one appendix. Q: How should and/or be reported when multiple immunizations wi face-to-face counseling are performed on e same date of service? For example, if e physician or oer heal care professional administers immunizations for a 2-mon-old infant on e same date of service according to e current immunization schedule, how should e following immunizations be reported? 8 Immunization Components CPT Code DtaP intramuscular administration x 2 Rotavirus oral administration Hepatitis B and Hemophilus influenza b intramuscular administration Poliovirus intramuscular administration Pneumococcal conjugate vaccine A: Coding practices may vary by physician or oer healcare professional offices. It is appropriate to report e immunization administration of e first and additional vaccine/toxoid component wi face-to-face counseling on one line wi multiple units and a link to all associated ICD-9-CM codes or report each component on a separate line. In e example above, e claim could be reported as wi 5 units on one line and wi 3 units on a separate line wi e associated ICD-9-CM diagnoses linked to each line. It is also appropriate to report e administration of each vaccine component on separate lines; e.g. reporting 5 lines for wi 1 unit each and 3 lines for wi 1 unit each. However, when reporting e same CPT or HCPCS

7 code on multiple lines and/or on separate claims, e additional claim line(s) reported wi e same procedure code may be denied as a duplicate service. Q: How are MFD values for immunization administration CPT codes and determined? 9 A: UnitedHealcare follows e recommendations from e Center for Disease Control's (CDC) Advisory Committee on Immunization Practices (ACIP) to set e MFD value for additional immunization administration codes. Q: What is an example of a CPT or HCPCS codes where e "description/verbiage" clearly indicates e number of units at can be performed on a single date of service? 10 A: Two examples are CPT Codes and Code Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless oerwise listed; single lesion. Because e code description includes "single lesion", it should only be billed wi 1 unit. Code Drug test(s) presumptive, any number of drug classes, any number of devices or procedures (eg, immunoassay); capable of being read by direct optical observation only (eg, dipsticks, cups, cards, cartridges) includes sample validation when performed, per date of service. The code description includes "per date of service", erefore it should only be billed wi 1 unit per date of service. Q: Why are unlisted CPT and HCPCS codes set at an MFD value of 999? 11 A: Unlisted CPT and HCPCS codes are set at an MFD value of 999 because unlisted codes are individually reviewed. The review of documentation will identify e accurate number of services performed for e unlisted code. Q: Why are many new CPT and HCPCS codes set at an MFD value of 100? 12 A: There is no data or previous claim history for new codes. Setting e MFD value at 100 allows claims to be processed and prevents most overpayments from occurring due to billing errors and data entry errors. Once claims data is available on a code, e MFD value will be established. Q: What is an example of determining e MFD value at e 100 percentile unless e 100 percentile exceeds e 98 percentile by greater an a factor of 4? 13 A: Statistical calculation: (A) x 4 = (C); if (B) is greater an (C), en e 98 percentile is set for e MFD value. If (B) is less an or equal to (C), en e 100 percentile is set for e MFD value. Here are two examples of determining MFD values based on a factor of 4. Code (A) (B) (C) Factor of 4 56 Set MFD at: 27 E Q: What is an example of a clinical circumstance where UnitedHealcare would assign a specific MFD value? 14 A: A4595-Electrical stimulator supplies, 2 lead, per mon, (e.g.tens, NMES). According to standard criteria, e data showed e 98 percentile at 10 units and e 100 percentile at 72 units. The statistical calculation would have set e MFD value at 10. However, based on e code description allowance of per mon and subject to e UnitedHealcare Time Span Codes Reimbursement Policy, e MFD value was decreased to 1. Attachments Designates e maximum frequency per day value assignments for CPT codes. MFD CPT Codes Policy List Designates e maximum frequency per day value assignments for HCPCS codes. MFD HCPCS Codes Policy List Codes at allow up to e MFD value at have "bilateral" or "unilateral or bilateral" in e description or where e concept of laterality does not apply. MFD Codes Restricting

8 Modifiers LT and RT MAI2 Indicator Codes Codes at CMS has identified where e Units of Service (UOS) on e same date of service in excess of e MUE value would be considered impossible. Resources American Medical Association, Current Procedural Terminology (CPT ) and associated publications and services Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices Centers for Medicare and Medicaid Services, Healcare Common Procedure Coding System, HCPCS Release and Code Sets History 8/27/2017 Policy List Change: MFD HCPCS Policy list 8/20/2017 8/26/2017 Policy List Change: MFD CPT and HCPCS Policy lists 7/12/2017 Policy Approval Date Change (No new version) 7/2/2017 8/19/2017 Policy List Change: MFD CPT, HCPCS, Codes Restricting Modifiers LT and RT and MAI2 Indicator Codes Policy lists 5/28/2017 7/1/2017 Policy List Change: MAI2 Indicator Codes Policy List 5/20/2017 5/27/2017 Preamble and Logo Updated Policy List Change: MAI2 Indicator Codes Policy List added 4/2/2017-5/19/2017 Policy List Change: MFD CPT and HCPCS Policy lists 2/12/2017 4/1/2017 1/8/2017 2/11/2017 Policy List Change: MFD HCPCS and Codes Restricting Modifiers LT and RT Policy lists 1/1/2017 1/7/2017 Annual Policy Version Change Questions and Answers: Q&A #10 Entries prior to 1/1/2015 archived 11/13/2016 Policy List Change: MFD CPT Codes Policy List 12/31/ /2/ /12/2016 8/28/ /1/2016 Policy List Change: MFD CPT and Codes Restricting Modifiers LT and RT Policy lists 7/13/2016 Policy Approval Date Change (No new version) 7/3/2016 8/27/2016 5/22/2016 7/2/2016 Policy List Change: MFD HCPCS Policy list 4/3/2016 5/21/2016 2/13/2016 4/2/2016 Policy Change: Reimbursement Guideline Section to add Medically Unlikely Edit Adjudication Indicator (MAI) 2 Policy List Change: MFD HCPCS and Codes Restricting Modifiers LT and RT Policy lists (Implemented 2/14/2016)

9 1/1/2016 2/12/2016 Annual Policy Version Change Entries prior to 1/1/2014 archived 11/22/2015 Policy List Change: MFD CPT and HCPCS Policy lists 12/31/ /4/ /21/2015 8/23/ /3/2015 Policy List Change: MFD HCPCS Policy list 7/8/2015 Policy Approval Date Change (No new version) 7/5/2015 8/22/2015 4/5/2015 7/4/2015 2/14/2015 4/4/2015 Policy Change: Application and Reimbursement Guidelines Sections Questions and Answers Section: Q&A #6 added and oer items renumbered and Q&A #10. 1/1/2015 2/13/2015 Annual Policy Version Change Policy Change: Reimbursement and Modifier Sections Questions and Answers: Q&A s # 2 and 4 Entries prior to 1/1/2013 archived