Medical Policy Updates

Notification of Policy Revisions Effective May 29, 2012 (Posted March 30, 2012)

Medical Policy	Revision
Bundling Guidelines	Added information to the Discussion section, Item D, regarding Global Allowance. The global surgical package includes all necessary services normally furnished by the surgeon before, during, and after a surgical procedure. The following was noticed and will be effective 5/29/2012: Supplies (except those related to splinting and casting) are considered components of the 0, 10, and 90-day global surgical package, and are not separately billable on the same date of service as the 0, 10, or 90-day procedure. For global payment of diagnostic tests and radiology services, total payment will be based on no more than the equivalent global service regardless of whether the billing is from the same or different provider. If one provider bills for the global service and the same or different provider also bills for either the technical or professional component for the same test or service, then the first claim processed will be processed normally. The second claim processed will either be denied (if the first claim processed was for the global service), or will have the remaining component service appended to the global (if the first claim processed was for either the technical or professional component). Claims for surgical dressings billed in the provider's office (place of service 11) will be denied, because they are considered part of the professional/procedural service. Supplies and materials furnished by the provider (drugs, trays, and materials) above and beyond those usually included with the procedure(s) performed should be separately reported by the provider. Professional radiology services in the inpatient or outpatient hospital setting are not eligible for payment unless the provider is an anesthesiologist, neurologist, obstetrician/gynecologist, emergency medicine specialist, physical medicine specialist, radiologist, or radiation oncologist. The intent of this edit is to avoid duplicate payment for services that were performed by another provider. Normally, the radiology group associated with the hospital will bill these procedures because they performed the official interpretation; an additional allowance for a second provider's interpretation of the test results will not be allowed. (A specific exception to this policy is made for supervision and interpretation of angiography). In the unusual situation where a provider not included among the above specialties furnishes the sole interpretation of the professional radiology service, documentation of this circumstance could be submitted for reconsideration. In the Topics of Frequent Interest section, the following statement was added under subtitle for Chemotherapy: Intravenous infusion codes are not allowed in addition to intravenous chemotherapy administration services unless the intravenous infusion represents a treatment apart from chemotherapy administration. The reason for a separate intravenous infusion should be noted in the medical record, and the service code modifier for a distinct procedure appended to the procedure code for intravenous infusion. Added description of "out of sequence" claims to Policy Guidelines section.
Code Bundling Rules Not Addressed in ClaimCheck® or Correct Coding Initiative	Description section revised. The following was noticed and will be effective 5/29/2012: "Incident to" Services: CMS defines "incident to" services as those services furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of a condition. A physician may be reimbursed directly for "incident to" services performed by auxiliary personnel only when an employer relationship exists between the physician and the auxiliary personnel, and when the place of service code indicates the service was performed at a location typical for such an employer relationship (typically a physician office or other non-facility clinic). When the place of service code indicates the service was performed at a location not typical of a physician employer relationship (such as, but not limited to, inpatient or outpatient hospital), the service is considered an "incident to" service and is not eligible for separate reimbursement. In the unusual circumstance when an employer relationship exists between the physician and an auxiliary personnel performing a service in an inpatient or outpatient facility, documentation of this arrangement could be submitted for reconsideration. Obstetrical ultrasound: Ultrasound add-on codes indicating multiple gestation will be denied when the diagnosis code does not specify multiple gestation. Observation services: By their CPT definition, the initial observation care codes and codes that include the initial observation care are for the first day of treatment. Therefore, the subsequent day of treatment should be billed with another code, such as an observation care discharge, observation follow up, or an initial hospital visit. Initial observation care and codes that include the initial observation care will be denied the day following another initial observation care code for up to three consecutive days. Electromyography: Nerve Conduction Tests and Reflex Tests with Evaluation and Management Services. Evaluation and Management service will be denied when billed the same date as electromyography, nerve conduction tests or reflex tests, unless the evaluation and management service consisted of a significant, separately identifiable service. Supplies and Equipment Provided in the Facility Setting: Supplies and equipment services billed in a facility setting are not reimbursable as professional services, and will be denied when billed with inpatient or facility places of service.
Co-Surgeon, Assistant Surgeon, Team Surgeon and Assistant-at-Surgery Guidelines	Added "Team Surgeon" to policy title. Revised the definitions in the Description section. Added the following to the Policy statement: "Team Surgeon: Benefits are allowed for medically necessary procedures and allowance(s) will be determined on an individual consideration basis." The following was noticed and will be effective 5/29/2012: Co-surgeon claims for procedures designated as co-surgeon allowed will be denied when both surgeons have the same specialty or subspecialty. When a claim for a non-surgical procedure is submitted with modifier -62 for co-surgeon, the claim will be denied because the co-surgeon concept does not apply. Procedures that are minor, non-surgical, or that are not of sufficient complexity to require multiple physicians of different specialties and other highly skilled personnel and equipment, do not satisfy the definition of team surgery, and will be denied if submitted with modifier -66 (Team Surgery).Procedures billed with modifier -62 will be denied when a claim for the same procedure code without modifier -62 has been previously submitted and processed for a different provider. Procedures billed with modifier -66 will be denied when a claim for the same procedure code without modifier -66 has been previously submitted and processed for a different provider. Modifier -62 will be added to claims for procedures designated as "co-surgeon allowed" when a claim for the same procedure code with modifier -62 has been previously submitted and processed for a different provider.
Maximum Units of Service "Notification"	New payment policy developed. BCBSNC will not provide reimbursement for claims with units that exceed the assigned maximum for that procedure. The total number of units will be adjusted to the maximum and the excess units will be denied. Notification given 3/30/12 for effective date 5/29/12.