We use clinical policies to help administer health plan benefits, either with prior authorization or payment rules. These policies include, but aren’t limited to, evolving medical technologies and procedures, as well as pharmacy policies.
Clinical policies help determine whether services are medically necessary based on:
Generally accepted standards of medical practice
Peer-reviewed medical literature
Government agency/program approval status
Positions of leading national health professional organizations
Views of physicians practicing in relevant clinical areas affected by the policy
Available clinical information
We may delegate utilization management of specific services. In these situations, we may use the delegated vendor’s guidelines to support medical necessity and other coverage determinations.
We use health care claims payment policies to help administer payment rules based on generally accepted principles of correct coding. These policies help determine whether health care services are correctly coded for reimbursement.
Generally accepted coding principles inform each payment rule. These principles include, but aren’t limited to:
Claims processing guidelines referenced by the Centers for Medicare & Medicaid Services (CMS)
Medicare Claims Processing Manual (Publication 100-04) for physicians/nonphysician practitioners
The CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits)
Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services
Health plan clinical policies based on the appropriateness of health care and medical necessity
State-specific claims reimbursement guidance
We may use a vendor that applies payment policies to specific services. In these situations, we may also use the vendor’s guidelines to determine whether a service has been correctly coded.
We regularly augment our clinical, payment and coding policy positions as part of our ongoing policy review processes. In an effort to keep our providers informed, please see the below chart of upcoming new policies.
Per our policy, which is based on AMA CPT and HCPCS Level II manuals, the removal of impacted cerumen is only medically necessary when reported with a diagnosis of impacted cerumen.
Per our policy, which is based on CMS guidelines, certain service codes have been identified that may only be performed in an inpatient setting. When these services are performed in any other setting, they will be denied. The reasons cited by CMS for restricting these procedures to the inpatient setting include:
· The invasive nature of the procedures
· The need for postoperative care following surgery
· The underlying physical condition of the patient requiring surgery
Hydration is defined as the replacement of necessary fluids by IV infusion which consists of pre-packaged fluid and electrolytes. Per our policy, which is based on CMS Coverage guidelines, the following criteria must be met for hydration infusion to be considered appropriate:
· Diagnosis Requirement-Hydration therapy for adults should be provided for an appropriate diagnosis, e.g. patients being treated for nausea and vomiting or syncope/collapse.
· IV Fluids-per CMS policy and AMA/CPT certain IV fluids (Example-J7030-Normal saline; 1000cc) should not be separately reported with hydration infusion; basic IV fluids are included in hydration infusion.
· Minimum IV Fluid Units-Per our policy, based on CMS policy and the National Institute for Health and Care Excellence, hydration is allowed when provided in volume greater than 501 ML. Anything less than that is considered not reasonable and necessary.
Per our policy, which is based on the AMA/CPT manual, according to the AMA CPT Manual, moderate sedation services performed by a second physician/provider should only be reported in a facility setting.
Per our policy, E&M services billed with a venipuncture service is considered bundled and the E&M service will be denied except when the E&M is a significant and separately identifiable from the venipuncture.
Per our policy, E&M services should not be billed when on the same date of service as venipuncture in a facility setting; use of a room to draw blood is not separately payable. Exceptions are allowed for E&M services that are significant. and separately identifiable service.
Per our policy, which is based on CMS guidelines, modifiers exist to indicate that a surgical service was performed on the wrong body part, wrong patient, or wrong procedure, or that a service is related to one of these Never Events. These 'never events' are not reimbursed.
Per our policy, attended polysomnography services are not appropriate in a home setting.
Per our policy, which is based on AMA/CPT and CMS guidelines, a new patient is one who has not received any professional services from the physician or another physician of the same specialty and subspecialty who belongs to the same group practice, within the past three years.
Per our policy, office consultation services should not be reported more than once in a 6-month period by the same provider.
Per our policy, during the course of a physician or other qualified health professional’s face-to-face encounter with a patient, the provider may determine that diagnostic lab testing is necessary to establish a diagnosis and/or to select the best treatment option to manage the patient’s care. These are tests that are needed immediately in order to manage medical emergencies or urgent conditions. To this end, specific clinical laboratory tests have been designated as appropriate to be performed in the office setting. Any lab service not listed as a STAT lab should not be reported in the physician's office.
Per our policy, which is based on the NCCI Policy Manual, providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing. For example, if a laboratory performs a urinary pH, specific gravity, creatinine, nitrates, oxidants, or other tests to confirm that a urine specimen is not adulterated, this testing is not separately billed.
Per our policy, which is based AMA/CPT manual and CMS guidelines, only one evaluation and management (E/M) code is allowed for a single date of service for the same provider group and specialty, regardless of place of service. Additionally, preventive medicine services include insignificant or trivial problems/abnormalities that are encountered in the process of performing the preventive medicine E/M service. If an abnormality is encountered or a pre-existing problem is addressed in the process of performing the preventive medicine E/M service, which requires significant time to address, then the appropriate problem-oriented E/M service can be reported separately.
Per our policy:
-Ophthalmic and/or direct nasal mucous membrane tests are not covered
-Allergy testing (allergen specific IgE/percutaneous/intracutaneous testing) should be reported with a supporting diagnosis indicating significant allergic symptoms
-Patch/application testing should be reported with a supporting diagnosis indicating skin-related allergies
-Photo patch testing should be reported with a supporting diagnosis indicating photoallergic responses/dermatitis/solar urticaria
-Food ingestion change testing should be reported with a supporting diagnosis indicating food allergies
-Allergy immunotherapy/professional services for supervision of preparation/provision of antigens should be reported with a supporting diagnosis indicating significant allergic symptoms
-Rapid desensitization procedures should be reported with a supporting diagnosis indicating allergies to drugs/insects/etc.
Per our policy, endometrial ablation should be reported with a supporting diagnosis indicating excessive/abnormal menstruation/vaginal bleeding.
Per our policy, Holter monitors should be reported with a supporting diagnosis indicating a cardiac event/symptom (syncope/arrhythmia/cardiomyopathy etc.).
Per our policy, insulin/thyroid testing is not indicated for pediatric patients when the diagnosis is obesity or screening.
Per our policy, vitamin D (25 hydroxy) testing is not indicated for pediatric patients when the only diagnosis is obesity or screening.
Per our policy, ambulatory EEG procedures should be reported with a supporting diagnosis indicating seizures/convulsions.
Per our policy, screening of asymptomatic pregnant women for bacterial vaginosis (BV) to reduce the incidence of pre-term birth or other complications of pregnancy is not medically necessary as there is no evidence that treatment of BV in asymptomatic pregnant women reduces these complications. Unspecified amplified DNA-probe testing for genitourinary conditions for asymptomatic women during routine exams, contraceptive management care, or pregnancy care is considered not medically necessary for members ≥ 13 year of age as it has not been shown to improve clinical outcomes over direct DNA-probe testing. Unspecified amplified DNA-probe testing for the diagnostic evaluation of symptomatic women for the following genitourinary conditions is considered not medically necessary for members ≥ 13 of age as it has not been shown to improve clinical outcomes over direct DNA-probe testing.
Per our policy, urodynamic testing should be reported with a diagnosis indicating urologic dysfunction.
Per our policy, wheelchair seating is allowed for members that need special seating (e.g. current/history of pressure ulcers, absent/impaired sensation in the area of contact with the seating service, significant postural asymmetries due to other underling issues (monoplegia of lower limbs due to stroke, traumatic brain injury, etc.)).
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