Humana CPT Code Edits for Certain Specialties

November 2017 ~

Humana has issued several CPT^® code edits for specialties including Surgery, Pathology, and Radiology. These updates are as follows:

CPT Lab / Pathology – Human Papillomavirus (HPV) Testing

UPDATE: Humana will not reimburse for human papillomavirus (HPV) screening for a patient younger than 30 years old when ICD coding indicates screening.
Effective Date: 11/2/2017
Providers Affected:
- Inpatient/Outpatient Facilities
- Physician/Health Care Providers
Impacted Products:
- Select self-funded products
- Commercial fully insured products

CPT Lab / Pathology – Human Immunodeficiency Virus (HIV) Testing

UPDATE: Humana will reimburse for HIV screening, whether as distinct screening test(s) or as a component of an obstetric panel, during a term of pregnancy, only as follows:
- Once when the diagnosis of pregnancy is known
- Once during the third trimester
- Once at labor, if ordered by the woman’s clinician
Effective Date: 11/2/2017
Providers Affected:
- Inpatient/Outpatient Facilities
- Physician/Health Care Providers
Impacted Products:
- Medicare Advantage HMO products
- Medicare Advantage PFFS products
- Medicare Advantage PPO products

CPT Radiology – Magnetic Resonance Imaging (MRI)

UPDATE:When submitted with an ICD-10 code indicating either implanted permanent pacemaker (PM) or automatic implantable cardiac defibrillator (ICD), MRI will be eligible for reimbursement only if all of these are true:
- Claim was submitted with an ICD-10 code indicating participation in a clinical research study.
- Charge was submitted with a modifier indicating that medical policy requirements have been met, as shown in the Medicare National Coverage Determinations Manual.
- Charge was submitted with a modifier indicating an investigational clinical service provided in an approved clinical research study.
- If claim is an institutional claim type, claim was submitted with a condition code indicating non-research services provided to a patient enrolled in a qualified clinical trial.
Effective Date: 1/4/2018
Providers Affected:
- Inpatient/Outpatient Facilities
- Physician/Health Care Providers
Impacted Products:
- Medicare Advantage HMO products
- Medicare Advantage PFFS products
- Medicare Advantage PPO products

Surgery – Global Surgery Package

UPDATE: Humana does not reimburse for a service performed during the global period of a procedure performed by the same provider, unless one of the following modifiers is appropriate for the later service and the charge for the later service is submitted with that appropriate modifier:
- Modifier 58 – Staged or related procedure or service by the same physician during the postoperative period
- Modifier 78 – Unplanned return to the operating room by the same physician for a related procedure during the postoperative period
- Modifier 79 – Unrelated procedure or service by the same physician during the postoperative period
- For this purpose, Humana considers two health care professionals to be the same provider if they are in the same group and have the same specialty.
Effective Date: 2/1/2018
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

Surgery – Florida Medicaid Pain Management

UPDATE: Humana will reimburse for no more than four percutaneous radiofrequency neurolysis treatments in any four-month period.
Effective Date: 1/4/2018
Providers Affected:
- Physician/Health Care Providers
Impacted Products:
- Medicaid – Florida