Tagged with CPT Coding

UHC – Genetic and Molecular Testing Prior Auth. Requirement

Effective Nov. 1, UnitedHealthcare will start its online prior authorization/notification program for genetic and molecular testing performed in an outpatient setting for fully insured UnitedHealthcare Commercial Plan members. Providers requesting laboratory testing will be required to complete the prior auth. process as well as indicate the laboratory and test name for specific services.

Anthem Updates Assistant Surgeon Policy and Code List

Anthem has posted its updated Assistant Surgeon policy and code list to reflect CPT® and Healthcare Common Procedure Coding System (HCPCS Level II) coding changes for 2017 as well as updates based on American College of Surgeons (ACS) and CMS information.

CMS Releases Proposed 2018 Medicare Physician Fee Schedule (MPFS) and Outpatient Prospective Payment System (OPPS)

CMS has released two proposed rules regarding Medicare reimbursement and requirements. The 2018 Proposed Medicare Physician Fee Schedule (MPFS) Proposed Rule addresses Medicare payment and quality provisions for physicians in 2018 and the 2018 Proposed Update to the Outpatient Prospective Payment System (OPPS) will update the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program.

CMS 2018 MA, Part D Final Payment Rates Announced with 0.45% Increase

CMS has released 2018 Medicare Advantage and Part D payment rates, announcing a 0.45% average rate increase. According to CMS, the changes made aim at providing benefit flexibility and efficiency which will allow Medicare enrollees to choose the care that best fits their health needs.

OH – Medicaid Oversight Committees Announce Changes to State Behavioral Health Redesign

The Ohio Department of Medicaid (ODM) and Ohio Department of Mental Health and Addiction Services (OhioMHAS) has announced two major policy and operational updates related to Behavioral Health Redesign. These policy modifications include the expansion of MH Day Treatment service for Qualified Mental Health Specialists (QMHSs) as well as the removal of the limit of 24 hours for Mental Health or SUD Nursing services per patient, per calendar year.

DOJ v. UnitedHealth

The DOJ moves forward with legal action against two insurers accused of erroneous coding and inflated billing – UnitedHealth and WellMed Medical Management.

CMS Releases Final 2017 Physician Fee Schedule

CMS has issued the final rule updating the Medicare’s physician fee schedule for 2017. Under the final rule, physician payment rates increase slightly, as called for by the Medicare Access and CHIP Reauthorization Act.

CMS Offers Revised Q&A for End of ICD-10 Grace Period

As of October 1, the year-long grace period for ICD-10 claims submissions has ended. To assist coders and hospitals, CMS has revised its Q&A “Questions and Answers Related to the July 6, 2015, CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities.”

New HCPCS Codes Now Effective

In the most recent quarterly update, CMS HCPCS code additions and changes affect drugs, biosimilars and biologicals.

Humana Updating Surgery Claim Processing Edits

Effective September 19, Humana will update claim processing edits for Surgery procedures, including: sigmoidoscopy, colonoscopy, other medical and surgical service during the postoperative period, FL Medicaid services included in delivery, birth center non-covered services, Florida Medicaid, and extracorporeal photopheresis.

Aetna Updates 99285 Edits

Effective December 1, Aetna will update its ER level of care policy for CPT code 99285 will downcode 99285 used with a designated minor diagnosis code.

Humana Updating Internal Medicine Claim Processing Edits

Effective September 19, Humana will update claim processing edits for Internal Medicine procedures, including: Sequential IV push, Telephone assessment and management, Home visit, Polysomnography, and Immune globulin.

Humana Updating Anesthesia Claim Processing Edits

Effective September 19, Humana will update claim processing edits for Anesthesia procedures, including: Medical supervision and medical direction of anesthesia services, Consistency of reduced or discontinued anesthesia services between professional and facility providers, Discontinued anesthesia services between professional and facility providers, and Anesthesia for colorectal cancer screening.

Humana Updating Lab/Pathology Claim Processing Edits

Effective September 19, Humana will update claim processing edits for Lab / Pathology procedures, including: prenatal screening, Independent Labs – Covered Services and frequency limits, and services included in prenatal care.