Humana Claim Processing Edits

April 2018 ~

Humana has released a number new claim processing edits that became effective as of April 5.

Humana notes that claim edits do not supersede the necessity to obtain preauthorization. Preauthorization requirements are still applicable. Modifiers should be used when appropriate to accurately represent the services rendered. The use of modifiers may impact Humana’s application of these edits. These edits are as follows:

Velaglucerase Alfa

CategoryHCPCS – Drugs & Biologicals

Providers affected:

  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers

Impacted products:

  • Medicaid – Florida

Update:

Reimbursement of velaglucerase alfa, 100 units, submitted with modifier JW (drug amount discarded/not administered to any patient) will be limited to no more than a total quantity of three per date of service. Injection, velaglucerase alfa, 100 units, is eligible for reimbursement up to three units when billed with modifier JW (drug amount discarded/not administered to any patient).

The smallest single-use velaglucerase alfa vial contains 400 units, which is equivalent to a quantity of four for the relevant HCPCS Level II code. Therefore, consistent with Humana’s policy, reimbursement for discarded velaglucerase alfa will not exceed a total quantity of three, the reimbursement that is appropriate for the HCPCS code.

Ipilimumab Injection, 1 mg

Category: HCPCS – Drugs & Biologicals

Providers affected:

  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers

Impacted products:

  • Select self-funded* products
  • Commercial fully insured products
  • Medicare Advantage HMO products
  • Medicare Advantage PFFS products
  • Medicare Advantage PPO products

Update:

Reimbursement for ipilimumab, 1 mg, will be limited to no more than one injection in any three-week period for any of these diagnoses:

  • Central nervous system metastasis (melanoma)
  • Melanoma

According to the FDA-approved package insert and prescribing information and pharmaceutical compendia, ipilimumab, 1 mg, should not be administered more frequently than once in a three-week period for the above-listed diagnoses.

Doxorubicin Hydrochloride, Liposomal

Category: HCPCS – Drugs & Biologicals

Providers affected:

  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers

Impacted products:

  • Select self-funded* products
  • Commercial fully insured products
  • Medicare Advantage HMO products
  • Medicare Advantage PFFS products
  • Medicare Advantage PPO products

Update:

Reimbursement for injection, doxorubicin hydrochloride, liposomal (imported Lipodox or not otherwise specified), 10 mg, is limited to no more than the following:

  • Four units per date of service for an indication of Hodgkin’s lymphoma
  • Eight units per date of service for an indication of diffuse large B-cell lymphoma

According to Medicare local coverage determinations and pharmaceutical compendia, for the indications above, administration of doxorubicin hydrochloride, liposomal, should not exceed the dosages above.

Note: The pharmaceutical compendia establishes maximum daily dosages of doxorubicin hydrochloride, liposomal. The limitations described above are based on maximum dosages established in units. If any units are denied, the provider may dispute the decision through the appropriate process(es). The provider may submit information, including medical notes showing the patient’s skin surface area, that substantiates the medical necessity of the additional units.

Always Therapy and DisciplineSpecific Therapy Services

Category: Modifiers

Providers affected:

  • Physician/Health Care Providers

Impacted products:

  • Medicare Advantage PFFS products

Update:

A charge for an always-therapy service or for a discipline-specific therapy service will not be eligible for reimbursement if it is not submitted with a modifier that indicates the discipline of the plan of care under which the service was provided. The following modifiers are available for that purpose:

  • Modifier GN – Speech-language pathology (SLP)
  • Modifier GO – Occupational therapy (OT)
  • Modifier GP – Physical therapy (PT)

According to the Medicare Claims Processing Manual, claims containing any of the always-therapy codes must have one of the appropriate therapy modifiers appended, and therapy services defined as discipline-specific must have the appropriate discipline-specific modifier appended.

Modifiers 96 and 97

Category: Modifiers

Providers affected:

  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers

Impacted products:

  • Select self-funded* products
  • Commercial fully insured products

Update:

If a specific procedure code could be reported for either habilitative or rehabilitative services, a charge for that code will be eligible for reimbursement only if it is submitted with one of these modifiers:

  • 96 Habilitative services
  • 97 Rehabilitative services

The Patient Protection and Affordable Care Act (ACA) requires health insurance plans in the individual and small group markets to include essential health benefits (EHB). One category of EHB coverage that the ACA requires is rehabilitative and habilitative services and devices. Related regulations necessitate differentiating between habilitative and rehabilitative services in some scenarios. To facilitate differentiation, Current Procedural Terminology (CPT®) adds the modifiers above for 2018. Also, Humana has published a policy that states the requirements indicated above.

Note: This requirement applies to Humana commercial plans in the individual and small-group markets.

Services Prior to the FDA Approval Date

Category: Outpatient Prospective Payment System (OPPS)

Providers affected:

  • Inpatient/Outpatient Facilities

Update:

For the following institutional claim type of bill (TOB) codes, a charge for a service that requires FDA approval will not be eligible for reimbursement if there was no FDA approval effective for the date of service:

  • Inpatient hospital part B (012x)
  • Outpatient hospital part B (013x)
  • Outpatient hospital other (014x)

Impacted products:

  • Select self-funded* products
  • Commercial fully insured products
  • Medicare Advantage HMO products
  • Medicare Advantage PFFS products
  • Medicare Advantage PPO products

For the TOB codes above, the Integrated Outpatient Code Editor (I/OCE) edits line-item date of service against the date of FDA approval for a CPT or HCPCS Level II procedure code.

Note: Although this edit applies only to the TOB codes above, services without required FDA approval are not coverable, regardless of claim type and, for institutional claims, regardless of TOB.

Inhalation Drugs

Category: Diagnoses

Providers affected:

  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers

Impacted products:

  • Medicare Advantage HMO products
  • Medicare Advantage PFFS products
  • Medicare Advantage PPO products

Update:

A controlled-dose inhalation drug-delivery system (HCPCS code K0730) will be eligible for reimbursement only when submitted with one of these diagnoses:

  • Primary pulmonary hypertension
  • Secondary pulmonary hypertension

According to Medicare local coverage determinations, a controlled-dose inhalation drug-delivery system is only covered for patients with the above-listed indications.

Inhalation Drugs

Category: HCPCS

Providers affected:

  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers

Impacted products:

  • Medicare Advantage HMO products
  • Medicare Advantage PFFS products
  • Medicare Advantage PPO products

Update:

A charge for an individual accessory for an aerosol compressor or generator will be eligible for reimbursement only when submitted on the same claim as a charge for that compressor or generator.

Medicare local coverage determinations require same-claim billing of compressors/generators and their accessories.

Erectile Dysfunction (ED) Treatments

Category: HCPCS

Providers affected:

  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers

Impacted products:

  • Commercial fully insured products

Update:

The following devices are not eligible for reimbursement because the devices are not covered:

  • HCPCS code L7900 – Male vacuum erection system
  • HCPCS code L7902 – Tension ring, for vacuum erection device, any type, replacement only, each

Humana’s policy for ED treatments has been updated to indicate that the services listed above are not covered.

Vacuum erection devices are available without a prescription and may be obtained over the counter (OTC). Because the devices are OTC items, plan certificates generally exclude coverage of them. Additionally, the devices do not meet the medical necessity criteria in plan certificates.

Gastrointestinal (GI) Motility Monitoring

Category: CPT

Providers affected:

  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers

Impacted products:

  • Commercial fully insured products

Update:

We will not reimburse charges for the following GI motility monitoring services because the services are not covered:

  • CPT code 91020 – Gastric motility (manometric) studies
  • CPT code 91022 – Duodenal motility (manometric) study
  • CPT code 91117 – Colon motility (manometric) study, minimum six hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and report
  • CPT code 91132 – Electrogastrography, diagnostic, transcutaneous
  • CPT code 91133 – Electrogastrography, diagnostic, transcutaneous; with provocative testing

Humana’s GI motility monitoring policy has been updated to indicate that the services above are not covered expenses.

Iontophoresis

Category: CPT – Medicine

Providers affected:

  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers

Impacted products:

  • Select self-funded* products
  • Commercial fully insured products

Update:

Iontophoresis is eligible for reimbursement only when submitted with a diagnosis of primary focal hyperhidrosis. According to Humana’s Medical Coverage Policy, iontophoresis is eligible for reimbursement only when submitted with a diagnosis of primary focal hyperhidrosis.

Abdominal Ultrasound

Category: CPT – Radiology

Providers affected:

  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers

Impacted products:

  • Select self-funded* products
  • Commercial fully insured products

Update:

Abdominal ultrasound is not eligible for reimbursement when the only diagnosis submitted is infectious mononucleosis. According to the American Medical Society for Sports Medicine and the Emergency Medicine Journal, an abdominal ultrasound is not indicated for a diagnosis of infectious mononucleosis.

Genetic TestingCYP2C19, CYP2C9

Category: CPT

Providers affected:

  • Inpatient/Outpatient Facilities
  • Physician/Health Care Providers

Impacted products:

  • Commercial fully insured products

Update:

We will not reimburse for the following genetic testing services because they are not covered.

  • CPT code 81225 – CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19; e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *8, *17)
  • CPT code 81227 – CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9; e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *5, *6)

Humana’s policy concerning genetic testing for diagnosis and monitoring of noncancer indications has been updated to indicate that the services listed above are not covered because they are considered experimental/investigational. Nationally recognized peer-reviewed literature does not identify them as widely used and generally accepted for the proposed uses.

Florida MedicaidTherapy Treatments on the Same Day as Evaluation

Category: CPT

Providers affected:

  • Physician/Health Care Providers

Impacted products:

  • Medicaid – Florida

Update:

We will not reimburse for physical therapy, occupational therapy and speech-language pathology treatments when provided the same day as an evaluation service for the same discipline.

Agency for Health Care Administration (AHCA) coverage policies indicate that treatment visits are not covered when provided the same day as evaluation services.

Complete details regarding these policies updates can be found on Humana’s Claim Processing Edits page.

 

CPT® is a registered trademark of the American Medical Association.

 

 

Source(s): Humana Claim Processing Edits;

 

 

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