Definition of Incidental, Mutually exclusive, integral procedure with Example

Claims are reviewed to determine eligibility for payment. Services considered incidental, mutually exclusive, integral to the primary service rendered, or part of a global allowance, are not eligible for separate reimbursement. Definitions for incidental, mutually exclusive, integral, or global procedures or services are as follows:

A. Incidental Procedures

An incidental procedure is carried out at the same time as a more complex primary procedure. These procedures require little additional provider resources and are generally not considered necessary to the performance of the primary procedure. For example, the removal of an asymptomatic appendix is considered an incidental procedure when done during hysterectomy surgery.
An incidental procedure is not reimbursed separately on a claim.

B. Mutually Exclusive Procedures

Mutually exclusive procedures are two or more procedures that are usually not performed on the same patient on the same date of service. Mutually exclusive rules may also include different procedure code descriptions for the same type of procedures for which the provider should be submitting only one of the procedure codes. Only the most clinically intense procedure will be allowed. Generally, an open procedure and a closed procedure in the same anatomic site are not both reimbursed. If both codes accomplish the same result, the clinically more intense procedure supersedes and the comparative code is denied as mutually exclusive.

C. Integral Procedures

Procedures considered integral occur in multiple surgery situations when one or more of the procedures are included in the major or principle procedure. Integral procedures are those commonly carried out as part of a total service and do not meet all the criteria listed under the policy “Multiple Surgical Procedure Guidelines.” Some of the procedures or services listed in the CPT manual that are commonly carried out as an integral component of a total service or procedure have been identified by the term “separate procedure.” These codes should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.

D. Global Allowance

Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work. Reimbursement for these services is based on a global allowance. Claims for services considered to be directly related to pre-procedure, intra-procedure, and post-procedure work are included in the global reimbursement and will not be paid separately.

The pre- and post-operative global days are based on CMS standards. The global period is defined as the period of time during which claims for related services will be denied as an unbundled component of the total surgical package. Major procedures have a global period of 90 days. Minor procedures have a global period of 10 or 0 days.

The global surgical package includes all necessary services normally furnished by the surgeon before, during and after a surgical procedure. The global period also includes Evaluation and Management services that are related to the procedure.

Payment for related medical or surgical services performed the day prior to, the day of, or within 90 days of a major surgical procedure is included in global allowance. Payment for related medical or surgical services performed the same day as a minor surgical procedure, as well as medical or surgical services performed within 10 days of a 10 day procedure, is included in the global allowance.



Bundling Guidelines

Bone Marrow or Stem Cell Services/Procedures - Codes 38204, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214 and 38215 are considered incidental to 38240, 38241 and 38242. Separate reimbursement is not allowed for incidental services.

Cardiac Stress Test - A stress test may require the administration of pharmacological agents. An IV injection of a pharmacological agent is considered an integral component of the stress test. It does not warrant separate reimbursement.

Casting Application and Strapping - Separate reimbursement is allowed for an initial Evaluation and Management code when billed with a casting/strapping code. In a situation where a separate, identifiable evaluation and management service is provided in addition to the casting/strapping service, such as treat-ment of an acute/chronic illness, modifier 25 should be used when billing. In these cases, further review of the claim and supporting documentation may be necessary to make the appropriate reimbursement decision.

Separate reimbursement will be allowed for A4590, ‘special casting materials, hexcilite and light cast,’ when submitted with casting and strapping procedures 29000-29799. Due to the significantly greater cost of fiberglass, it is considered over and above what is included in standard casting application.

Casting/strapping services 29000-29799 are considered integral to surgical procedures. Established Evaluate and Management services will be denied when billed with casting/strapping services.

Reapplication and supplies necessary for casting/strapping during the follow-up period are eligible for separate reimbursement. The office visit is considered to be within the global period of the original fracture repair.

Chemotherapy - Evaluation and Management services will generally be denied when submitted on the same date of service as a chemotherapy administration code. If a significant, separately identifiable service is performed, modifier 25 is used. Office notes must document the significant, separately identifiable service.

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.

Clinical photography - for documentation/record-keeping purposes is considered to be an integral part of an evaluation and management (E&M) service or procedure and not eligible for separate reimbursement consideration.

Critical Care Services - Codes 36000, 36410, 36415, 36591, 36600, 43752, 43753, 71010, 71015, 71020, 92953, 93561, 93562, 94002, 94003, 94004, 94660, 94662, 94760, 94761, 94762, and 99090 are considered incidental to 99291 and 99292(Critical Care Services). Critical care service procedures will be denied as incidental when submitted with Neonatal and Pediatric Critical Care services (99466, 99467, 99468, 99469, 99471, 99472, 99475, 99476). The critical care service procedures are included in the pediatric and neonatal critical care codes. Separate reimbursement is not allowed for incidental services.

Electrical Stimulation Electrodes - The supply of electrodes is considered incidental to electrical stimulation. Separate reimbursement is not allowed for incidental supplies.

Electrocardiogram - Electrocardiograms are considered incidental to a stress test, a cardiac test which includes an ECG as part of the test, and as part of initial hospital care. A 3 lead ECG is considered incidental to a 12 lead ECG. Separate reimbursement is not provided for ECGs which are considered incidental.

An ECG is considered mutually exclusive to provider services for cardiac rehabilitation (93797). Separate reimbursement is not provided for ECGs which are considered mutually exclusive. See also policy titled, “ECG Reimbursement.”

Intra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty (0396T) is considered incidental to the primary procedure being performed and is not eligible for separate reimbursement.

Lab Tests - Lab codes 80047 - 80076 are lab panels that were developed for coding purposes. When the lab tests performed on a particular patient constitute one of the listed panels, the panel should be reported. The individual lab tests are rebundled into the lab panel code for reimbursement. Individual lab codes which constitute a panel are considered mutually exclusive to the lab panel.

Lesion Biopsy - Lesion biopsy of separate anatomical sites will be allowed in addition to surgical procedures such as removal of skin tags/ lesions and closure.

Lesion Excision and Closure - Separate reimbursement is allowed for the excision of lesion procedures when submitted with intermediate, complex, or reconstructive closures; 12031-12057, 13100-13160, 14000-14350, 15002 - 15261, and 15570-15770. Simple wound repair procedures, 12001 through 12021, will be found incidental to excision of lesions, unless the excision is a Mohs’ procedure.

Lumbar Laminectomy, Facetectomy or Foraminotomy reported with a Lumbar Spinal Fusion - When a lumbar laminectomy, facetectomy or foraminotomy is performed in conjunction with a posterior approach for a lumbar spinal fusion procedure, the laminectomy, facetectomy or foraminotomy is generally incidental, and should be bundled with the fusion. Modifier 59 will not allow additional payment when appended to CPT4 codes 63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047 and 63048 and when performed in conjunction with 22630, 22632, 22633, and/or 22634. Based on the most common clinical scenario, it is expected that when a lumbar laminectomy, facetectomy, and/or foraminotomy is billed with a lumbar arthrodesis, posterior interbody technique, the procedures are being performed on the same level. In the unusual clinical circumstance when the procedures are performed at different vertebral levels, clinical information will be required to be submitted on appeal.

Myocardial strain imaging (0399T) – the quantitative assessment of myocardial mechanics using image-based analysis of local myocardial dynamics for the detection of myocardial malformation is considered incidental to the primary procedure being performed and is not eligible for separate reimbursement.

Pediatric and Neonatal Critical Care - Codes 36000, 36140, 36620, 36510, 36555, 36400, 36405, 36406, 36420, 36600, 31500, 94002, 94003, 94004, 94375, 94610, 94660, 94760, 94761, 94762, 36430, 36440, 43752, 51100, 51701, 51702 and 62270 are considered incidental to 99468, 99471 and 99475(Inpatient Neonatal and Pediatric Critical Care). The critical care procedure codes listed as a part of 99291 and 99292 are included in the Pediatric Neonatal Critical care and are considered incidental. Separate reimbursement is not allowed for incidental services.

New Visit Frequency code 99201 - 99205 – BCBSNC does not automatically reassign or reduce the code level of Evaluation and Management codes billed for covered services, with the exception of the new visit frequency editing as described here. When a claim is received reporting a new patient evaluation and management service more than once within a 3 year period, the new patient evaluation and management service code will be replaced with the equivalent established patient evaluation and management code if one is available. Otherwise the claim will be denied.

BCBSNC will replace a code billed for a subsequent office or other outpatient consultation within 6 months of the initial office or other outpatient consultation by the same provider for the same member with the appropriate level of established office visit. The crosswalk is as follows:

99241 to 99212

99242 to 99212

99243 to 99213

99244 to 99214

99245 to 99215

Office Visits - Office services provided on an emergency basis (99058) are considered mutually exclusive to the primary services provided.

Office visit (99211) is considered mutually exclusive to 95115-95117(allergen immunotherapy). Separate reimbursement is not allowed for mutually exclusive services.

Pap Smears - Obtaining a pap smear is integral to the office visit. This includes both preventive and routine office visits. Separate reimbursement is not allowed for Q0091.

Pathologists - Claims submitted by pathologists (provider specialty 29) for clinical interpretation of laboratory results will be allowed for codes 83020, 84165, 84166, 84181, 84182, 85060, 85390, 85576, 86255, 86256, 86320, 86325, 86327, 86334, 86335, 87164, and 87207. Pathology interpretation of all other codes in the 80002-87999 range is considered integral to the laboratory test. Separate reimbursement is not allowed for integral services.

Pulse Oximetry - Pulse oximeters are considered incidental to office visits or procedures. Separate reim-bursement is not provided for incidental procedures.

Respiratory Treatments - Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB devise is considered mutually exclusive to an office visit. Separate reimbursement is not provided for mutually exclusive services.

Robotic Surgical Systems - Payment for new technology is based on the outcome of the treatment rather than the “technology” involved in the procedure. Additional reimbursement is not provided for the robotic surgical technique.

STAT or After Hours Laboratory Charges - Additional charges for STAT or after hours laboratory services are considered an integral part of the laboratory charge.

Surgical Supplies - Surgical supplies will be considered incidental to Surgical; Laboratory; Inpatient, Outpatient or Office Medical Evaluation and Management; and Consultation services.

Surgical dressings applied in the provider’s office are considered incidental to the professional services of the health care practitioner and are not separately payable. Surgical dressings billed in the provider’s office (place of service 11) will be denied.

Surgical trays and miscellaneous medical and/or surgical supplies are generally considered incidental to all medical, chemotherapy, surgery, and radiology services, including those performed in the office setting.

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.

Supplies are not covered when they do not require a prescription and can be purchased by the member over-the-counter or when they are given to the member as take-home supplies. Medical and/or surgical supplies, such as dressings and packings, used during the course of an office visit are generally considered incidental to the office visit.

Compression/pressure garments, elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered.

Transvaginal Ultrasound - Transvaginal ultrasound (76830) is considered mutually exclusive to a hysterosonography with or without color flow Doppler (76831).

Venipuncture - Refer to policy “Code Bundling Rules Not Addressed in Claim Check.”

Vision Services - please refer to CEC's bundling guidelines related to routine vision services.

X-Rays - When single view and double view chest X-Rays are billed together (71010 and 71020), only the double view X-Ray is allowed. When the entire spine, survey study is billed (72082) with cervical spine films (72040), thoracic spine films (72070) or lumbosacral spine films (72100) only the entire spine, survey study code is allowed. When a single view X-Ray code is billed with a multiple view X-Ray code, only the multiple view X-Ray code is allowed (e.g., 72020 with 72040, 72070, or 72100). Only one professional and one technical component are allowable per X-Ray.



CPT CODE 80091, 84443, 80092, 84436, 84479 - Thyroid tes

Frequency Limitations:

Testing may be covered up to two times a year in clinically stable patients; more frequent testing may be reasonable and necessary for patients whose thyroid therapy has been altered or in whom symptoms or signs of hyperthyroidism or hypothyroidism are noted.




CPT CODES: 80091 Thyroid panel, includes Thyroxine, total (84436) and Thyroid

hormone (T3 or T4) uptake or thyroid hormone binding ration (84479)

80092 Thyroid panel with TSH
84436 Thyroxine, total
84439 Thyroxine Free
84443 Thyroid Stimulating Hormone (TSH)
84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR)

CMS (Medicare) has determined that Thyroid Testing (CPT Codes 84436, 84439, 84443, 84479) is only medically necessary and, therefore, reimbursable by Medicare when ordered for patients with any of the diagnostic conditions listed below in the “ICD-9-CM Codes Covered by Medicare Program.” If you are ordering this test for a diagnostic condition other than those listed below, please have your patient sign and date an Advanced Beneficiary Notice (ABN). All ICD-9-CM codes provided must be consistent with the documentation in the patient’s medical records for the date of service.


ICD 10 Code Description

D64.9 Anemia, unspecified
E03.8 Other specified hypothyroidism
E03.9 Hypothyroidism, unspecified
E05.90
Thyrotoxicosis, unspecified without thyrotoxic crisis or
storm
E07.9 Disorder of thyroid, unspecified
E11.65 Type 2 diabetes mellitus with hyperglycemia
E11.9 Type 2 diabetes mellitus without complications
E78.0 Pure hypercholesterolemia
E78.2 Mixed hyperlipidemia
E78.4 Other hyperlipidemia
E78.5 Hyperlipidemia, unspecified
F32.9 Major depressive disorder, single episode, unspecified
I10 Essential (primary) hypertension
I48.91 Unspecified atrial fibrillation
I50.9 Heart failure, unspecified
R53.81 Other malaise
R53.82 Chronic fatigue, unspecified
R53.83 Other fatigue
R63.4 Abnormal weight loss
Z79.899 Other long term (current) drug therapy



COVERED DIAGNOSIS:

193 Malignant neoplasm of thyroid gland
198.82 Secondary malignant neoplasm of genital organs
198.89 Secondary malignant neoplasm of other specified site
226 Benign neoplasm of thyroid glands
227.3 Pituitary gland and craniopharyngeal duct (pouch)
234.8 Carcinoma in situ of other specified sites
237.0 Neoplasm of uncertain behavior of pituitary gland and craniopharyngeal duct
237.4 Neoplasm of uncertain behavior of other and unspecified endocrine glands
239.7 Neoplasm of unspecified nature, endocrine glands and other parts of nervous system
240.0-240.9 Simple and unspecified goiter
241.0-241.9 Nontoxic nodular goiter
242.00-242.91 Thyrotoxicosis with or without goiter
243 Congenital hypothyroidism
244.0-244.9Acquired hypothyroidism
245.0-245.9Thyroiditis
246.0-246.9Other disorders of thyroid
252.1Hypoparathyroidism
253.1 Other and unspecified anterior pituitary hyperfunction
253.2 Panhypopituitarism
253.3 Pituitary dwarfism
253.4 Other anterior pituitary disorders
253.7 Iatrogenic pituitary disorders
255.2 Adrenogenital disorders
255.3 Other corticoadrenal overactivity
255.4 Corticoadrenal insufficiency
256.3 Other ovarian failure
257.2 Other testicular hypofunction
258.0-258.9 Polyglandular activity in multiple endocrine adenomatosis, up to and including
polyglandular dysfunction, unspecified
266.0 Deficiency of B-complex components ariboflavinosis
272.0 Pure hypercholesterolemia

272.1 Pure hyperglyceridemia
272.2 Mixed hyperlipidemia
272.4 Other and unspecified hyperlipidemia
275.40-275.49   Disorders of calcium metabolism
276.1 Hyposmolality and/or hyponatremia
278.00 Obesity, unspecified
278.01 Morbid obesity
290.0 Senile dementia, uncomplicated
290.10-290.13 Presenile dementia
290.20-290.21 Senile dementia with delusional or depressive features
290.3 Senile dementia with delirium
292.89 Other specified drug-induced mental disorders
293.0-293.1 Acute and subacute delirium
293.81-293.89 Other specified transient organic mental disorders
293.9 Unspecified transient organic mental disorders
294.0 Amnestic syndrome
294.10-294.11   Dementia in conditions classified elsewhere
294.8 Other specified organic brain syndromes (chronic)
294.9 Unspecified organic brain syndrome (chronic)
295.00-295.95 Schizophrenic disorders
296.00-296.99 Affective psychoses
297.1 Paronoia
298.8 Other and unspecified reactive psychosis
298.9 Unspecified psychosis
300.00-300.02 Anxiety states, up to generalized anxiety disorder
300.81 Somatization disorder
301.13 Cyclothymic disorder
307.1 Anorexia nervosa
307.51 Bulimia
310.1 Organic personality syndrome
311 Depressive disorder, not elsewhere classified
331.0-331.2Other cerebral degenerations
333.1 Essential and other specified forms of tremor
333.5 Other choreas
354.0 Carpal tunnel syndrome
356.9 Hereditary and idiopathic peripheral neuropathy, unspecified
357.8 Inflammatory and toxic neuropathy; other
358.1 Myasthenic syndromes in diseases classified elsewhere
359.5 Myopathy in endocrine diseases classified elsewhere
368.2 Diplopia
374.41 Lid retraction or lag
374.82 Edema of eyelid
376.21 Thyrotoxic exophthalmos
376.22 Exophthalmic ophthalmoplegia
376.30 Exophthalmos, unspecified
376.31 Constant exophthalmos
376.33 Orbital edema or congestion
376.34 Intermittent exophthalmos
376.35 Pulsating exophthalmos
389.10-389.18 Sensorineural hearing loss
389.2 Mixed conductive and senorineural hearing loss
401.0-401.9 Hypertension
423.9 Unspecified disease of pericardium
425.7 Nutritional and metabolic cardiomyopathy
427.0 Paroxysmal supraventricular tachycardia
427.2 Paroxysmal tachycardia, unspecified

427.31 Atrial fibrillation
427.32 Atrial flutter
427.60-427.61 Premature beats
427.81-427.89 Other specified cardiac dysrhythmias
427.9 Cardiac dysrhythmia, unspecified
428.0 Congestive heart failure
428.1 Left heart failure
429.2 Cardiovascular disease, unspecified
429.3 Cardiomegaly
560.1 Paralytic ileus
564.0 Constipation
564.5 Functional diarrhea
564.7 Megacolon, other than Hirschsprung’s
611.1 Hypertrophy of breast
611.6 Galactorrhea not associated with childbirth
625.3 Dysmenorrhea
626.0-626.2 Disorders of menstruation and other abnormal bleeding, female genital tract
626.4 Irregular menstrual cycle
626.6 Metrorrhagia
626.8 Disorders of menstruation and other abnormal bleeding from female genital tract, other
648.10-648.14   Other current conditions in the mother, classifiable elsewhere, but complicating
pregnancy, childbirth, or the puerperium, thyroid dysfunction
676.20-676.24 Engorgement of breast associated with childbirth and disorders of lactation
698.9 Pruritus
701.1 Keratoderma, acquired (dry skin)
703.8 Other specified diseases of nail (brittle nails)
704.00 Alopecia, unspecified
709.01 Vitiligo
710.0 Systemic lupus erythematosus
710.1 Systemic sclerosis
710.2 Sicca syndrome
714.0 Rheumatoid arthritis
716.90-716.99 Arthropathy, unspecified
728.9 Unspecified disorder of muscle, ligament, and fascia
729.1 Myalgia and myositis, unspecified
729.82 Cramp
730.30-730.39   Periostitis without mention of osteomyelitis
733.00-733.03 Osteoporosis
733.09 Osteoporosis, drug induced
750.15 Macroglossia
759.2 Anomalies of other endocrine glands
775.3 Neonatal thyrotoxicosis
780.09 Alteration of consciousness, other
780.1 Hallucinations
780.51-780.53 Sleep disturbances
780.57 Other and unspecified sleep apnea
780.79 Other malaise and fatigue
780.8 Hyperhidrosis
780.9 Malaise and fatigue, other general symptoms
781.0 Abnormal involuntary movements
781.3 Lack of coordination
782.3 Edema
782.8 Changes in skin texture
783.1 Abnormal weight gain
783.21 Abnormal loss of weight
784.1 Throat pain

784.49 Voice disturbance, other
785.0 Tachycardia, unspecified
785.1 Palpitations
787.2 Dysphagia
787.99 Other symptoms involving digestive system, other
790.6 Other abnormal blood chemistry, lithium
793.2 Other intrathoracic organ
794.5 Nonspecific abnormal results, thyroid
796.1 Abnormal reflex
799.2 Nervousness
990 Effects of radiation, unspecified
995.2 Unspecified adverse effect of drug, medicinal and biological substance
V10.87 Personal history of malignant neoplasm of thyroid
V18.1 Other endocrine and metabolic diseases
V58.69 Long term (current) use of other medications
V77.7 Other inborn errors of metabolism

In house laboratory CPT code list

All In-Office Laboratory Testing and Procedures: 

  Marked with *, **, ***, ****, and ***** will be limited to one procedure within the same family of asterisks, per visit.

Example: All laboratory testing/procedure codes that are marked with one * will only be allowed to have one laboratory test/procedure performed, per visit, out of all of the codes designated with the single *.

  Marked with the # symbol will only be considered for reimbursement if the member has an infertility benefit and the provider has the appropriate specialty. Refer to the policy titled Infertility Diagnosis and Treatment for additional information related to infertility coverage.


CPT Code Description

Primary Care Physicians and Specialists

80305 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); capable of being read by direct optical observation only (e.g., dipsticks, cups, cards, cartridges) includes sample validation when
performed, per date of service

80306 Drug test(s), presumptive, any number of drug classes, any number of devices or procedures (e.g., immunoassay); read by instrument assisted direct optical observation (e.g., dipsticks, cups, cards, cartridges), includes sample validation when
performed, per date of service


81000* Urinalysis, non-automated, with microscopy

81001* Urinalysis, automated, with microscopy

81002* Urinalysis, non-automated, without microscopy

81003* Urinalysis, automated, without microscopy

81025 Urine pregnancy test, by visual color comparison methods

 82270***** Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection)


CPT Code Description

Hematologists/Oncologists/Pediatric Hematologists

85097 Bone marrow; smear interpretation only, with or without differential cell count

86077 Blood bank physician services; difficult cross-match and/or evaluation of irregular antibody(s), interpretation and written report

86078 Blood bank physician services; investigation of transfusion reaction, including suspicion of transmissible disease, interpretation and written report

86079 Blood bank physician services; authorization for deviation from standard bloodbanking procedures, with written report

86927-86999 Transfusion medicine Ophthalmologists and Connecticut CLIA Certified Optometrists

Note: Connecticut optometrists may be reimbursed for CPT code 83861 in the office if they are CLIA Certified (Clinical Laboratory Improvement Amendments of 1988 (CLIA)). If no CLIA certification is on file, the service is not eligible for reimbursement.

83861 Microfluidic analysis utilizing an integrated collection and analysis device, tear osmolarity

Ophthalmologists and Optometrists

83516 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method

87809 Infectious agent antigen detection by immunoassay with direct optical observation; adenovirus

Pulmonologists 82803 Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation)
Rheumatologists

89060 Crystal Identification by light microscopy with or without polarizing lens analysis; tissue or any body fluid (except urine) Urologists

 89264# Sperm identification from testis tissue, fresh or cryopreserved

89300 Semen analysis; presence and/or motility of sperm including Huhner test (post coital)

89310 Semen analysis; motility and count (not including Huhner test)

89320 Semen analysis; volume, count, motility and differential

89321 Semen analysis; sperm presence and motility of sperm, if performed

89322 Semen analysis; volume, count, motility, and differential using strict morphologic criteria (e.g., Kruger)



REIMBURSEMENT GUIDELINES

In-Office Laboratory Testing and Procedures

Reimbursement of network physicians for the performance of in-office laboratory testing/procedures is limited to those codes listed on the in-office laboratory testing and procedures list. Reimbursement for some of the Laboratory testing/procedures is limited to certain physician specialties. Refer to the Applicable Codes section below for a list of specific CPT codes.



  Marked with a # symbol, will only be considered for reimbursement if the member has an infertility benefit and the provider has the appropriate specialty. Refer to the policy titled Infertility Diagnosis and Treatment for additional information related to infertility coverage.

Specimen Handling and Venipuncture CODE 36415

When specimen handling and venipuncture codes are billed;

With a laboratory/procedure code on the in-office laboratory testing and procedures list, only the laboratory testing/procedure and venipuncture codes will be considered for reimbursement. Note: The laboratory testing/procedure code will only be considered for reimbursement if the code is listed in the Applicable Codes section of the policy and the provider has the appropriate specialty, if required.

  Without a laboratory testing/procedure code on the in-office laboratory testing and procedures list or with other non-laboratory testing/procedure services, the specimen handling and venipuncture codes will be considered for reimbursement.

CPT 59400, 59510 - obstetrical policy

REIMBURSEMENT GUIDELINES

Global Obstetrical (OB) Care

As defined by the American Medical Association (AMA), "the total obstetric package includes the provision of antepartum care, delivery, and postpartum care." When the Same Group Physician and/or Other Health Care Professional provides all components of the OB package, report the global OB package code.

The Current Procedural Terminology (CPT®) book identifies the Global OB codes as:

59400 - Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care

59510 - Routine obstetric care including antepartum care, cesarean delivery and postpartum care

59610 - Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery

59618 - Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery Oxford reimburses for these global OB codes when all of the antepartum, delivery and postpartum care is provided by the Same Group Physician and/or Other Health Care Professional.

Oxford will adjudicate claims submitted with either a single date of service or a date span when submitting global OB codes.

To facilitate claims processing, a single date of service may be utilized.





OVERVIEW

Maternity care includes antepartum care, delivery services, and postpartum care. This policy describes reimbursement for global obstetrical (OB) codes and itemization of maternity care services. In addition, the policy indicates what services are and are not separately reimbursable to other maternity services.

Unless otherwise specified, for the purposes of this policy Same Group Physician and/or Other Health Care Professional includes all physicians and/or other health care professionals of the same group reporting the same federal tax identification number.



Oxford may allow a newly enrolled woman to continue maternity care on an in plan basis with a non-participating provider. This is referred to as Transitional Care. This will most likely result in a prorated claim.



Services Included in the Global Obstetrical Package

Per CPT guidelines and the American Congress of Obstetricians and Gynecologists (ACOG), the following services are included in the Global OB package (CPT codes 59400, 59510, 59610, 59618):

** All routine prenatal visits until delivery (approximately 13 for uncomplicated cases)


** Initial and subsequent history and physical exams

** Recording of weight, blood pressures and fetal heart tones

** Routine chemical urinalysis (CPT codes 81000 and 81002)

** Admission to the hospital including history and physical

** Inpatient Evaluation and Management (E/M) service provided within 24 hours of delivery

** Management of uncomplicated labor

** Vaginal or cesarean section delivery (limited to single gestation; for further information, see Multiple Gestation section)

** Delivery of placenta (CPT code 59414)

** Administration/induction of intravenous oxytocin (CPT codes 96365 - 96367)

** Insertion of cervical dilator on same date as delivery (CPT code 59200)

** Repair of first or second degree lacerations

** Simple removal of cerclage (not under anesthesia)

** Uncomplicated inpatient visits following delivery

** Routine outpatient E/M services provided within 6 weeks of delivery

** Postpartum care only (CPT code 59430)

Oxford will not separately reimburse the above services when reported separately from the global OB code.

Exceptions:

** Participating and non-participating New Jersey providers may elect to be reimbursed for maternity services rendered to a covered person enrolled with a New Jersey line of business on either a global (one payment for all services rendered during the term of the pregnancy for antepartum care, delivery and postpartum care) or on an installment basis (3 equal payments that when combined are the equivalent of the global payment for services rendered during the term of the pregnancy) for pregnancies that begin January 5, 2012 and after.

** If a non-participating provider in New York is eligible for a global payment and payment is requested before delivery, two dates of service prior to delivery may be reimbursed. Per ACOG coding guidelines, reporting of third and fourth degree lacerations should be identified by appending modifier 22 to the global OB code (CPT codes 59400 and 59610) or delivery only code (CPT codes 59409, 59410, 59612 and 59614). Claims submitted with modifier 22 must include medical record documentation that supports the use of the modifier; please refer to the Increased Procedural Services section of this policy and Oxford's Increased Procedural Services policy.

Services Excluded from the Global Obstetrical Package Per CPT guidelines and ACOG, the following services are excluded from the Global OB package (CPT codes 59400, 59510, 59610, 59618) and may be reported separately if warranted:

** Initial E/M to diagnose pregnancy if antepartum record is not initiated at this confirmatory visit. This confirmatory visit would be supported in conjunction with the use of ICD-10-CM diagnosis code Z32.01 (Encounter for pregnancy test, result positive).

** Laboratory tests (excluding routine chemical urinalysis)

** Maternal or fetal echography procedures (CPT codes 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76820, 76821, 76825, 76826, 76827 and 76828). For additional information, see E/M Service with an Obstetrical (OB) Ultrasound Procedure section.

** Amniocentesis, any method (CPT codes 59000 or 59001)

** Amnioinfusion (CPT code 59070)

** Chorionic villus sampling (CVS) (CPT code 59015)

** Fetal contraction stress test (CPT code 59020)

** Fetal non-stress test (CPT code 59025)

** External cephalic version (CPT code 59412)

** Insertion of cervical dilator (CPT code 59200) more than 24 hours before delivery

** E/M services for management of conditions unrelated to the pregnancy (e.g., bronchitis, asthma, urinary tract infection) during antepartum or postpartum care; the diagnosis should support these services. For further information please refer to the Non-Obstetric Care section of this policy.

** Additional E/M visits for complications or high risk monitoring resulting in greater than the typical 13 antepartum visits; per ACOG these E/M services should not be reported until after the patient delivers. Append modifier 25 to identify these visits as separately identifiable from routine antepartum visits. For further information, please refer to High Risk/Complications section of this policy.

** Inpatient E/M services provided more than 24 hours before delivery

** Management of surgical problems arising during pregnancy (e.g., appendicitis, ruptured uterus, cholecystectomy). High Risk/Complications

A patient may be seen more than the typical 13 antepartum visits due to high risk or complications of pregnancy. These visits are not considered routine and can be reported in addition to the global OB CPT codes of 59400, 59510, 59610 or 59618. The submission of these high risk or complication services is to occur at the time of delivery, because it is not until then that appropriate assessment for the number of antepartum visits can be made. Per ACOG coding guidelines, if a patient sees an obstetrician for extra visits to monitor a potential problem and no problem actually develops, the physician is not to report the additional visits; only E/M visits related to a current complication can be reported separately. Oxford will separately reimburse for E/M services associated with high risk and/or complications when modifier 25 is appended to indicate it is significant and separate from the routine antepartum care and the claim is submitted with an appropriate high risk or complicated diagnosis code.


Evaluation and Management (E/M) Service with an Obstetrical Ultrasound Procedure

Oxford follows ACOG coding guidelines and considers an E/M service to be separately reimbursed in addition to an OB ultrasound procedures (CPT codes 76801-76817 and 76820-76828) only if the E/M service has modifier 25 appended to the E/M code.

If the patient is having an OB ultrasound and an E/M visit on the same date of service, by the Same Individual Physician or Other Health Care Professional, per ACOG coding guidelines the E/M service may be reported in addition to the OB ultrasound if the visit is identified as distinct and separate from the ultrasound procedure. Per CPT guidelines, modifier 25 should be appended to the E/M service to identify the service as separate and distinct.

Laboratory Tests

Oxford follows ACOG coding guidelines and considers CPT laboratory codes 81000 and 81002 as included in the global antepartum or global OB service when submitted with an OB diagnosis code in an office setting. Assistant Surgeon and Cesarean Sections Only a non-global cesarean section delivery code (CPT codes 59514 or 59620) is a reimbursable service when submitted with an appropriate assistant surgeon modifier. Refer to the Assistant Surgeon policy for additional information regarding modifiers and reimbursement.


Prolonged Physician Services

Prolonged physician services for labor and delivery services are not separately reimbursable services. CPT codes forprolonged physician services (99354, 99355, 99356, 99357, 99358, 99359, 99415 and 99416) are add-on codes used in conjunction with the appropriate level E/M code. As described in ACOG coding guidelines, prolonged services are not reported for services involving indefinite periods of time such as labor and delivery management.


QUESTIONS AND ANSWERS

1 Q: Will Oxford reimburse an attending physician for fetal monitoring during labor (CPT codes 59050 or 59051) ?

A: No, these codes are specifically for fetal monitoring during labor by a consulting physician.

2 Q: Why is insertion of cervical dilator (CPT code 59200) considered part of the delivery service and not reimbursed separately**

A: According to ACOG's coding guidelines, CPT code 59200 (insertion of a cervical dilator, e.g., laminaria, prostaglandin) performed on the day of delivery is a component included in the delivery service. Therefore, Oxford considers this service included in the patient's delivery service and does not consider it a separately reimbursable service unless performed and reported on a date of service other than the date of delivery.

3 Q: If one physician performs the delivery only, and a physician in another practice (different federal tax identification number) provides all of the postpartum care, how should these services be reported ?

A: The physician who performs the delivery only should report the delivery service without a postpartum component, e.g., CPT code 59409 (vaginal delivery only). The other physician should report the postpartum care only code (CPT code 59430).

4 Q: If one physician performs the delivery only (e.g., CPT code 59409), and a different physician in the same practice (same federal tax identification number) provides all of the postpartum care (i.e., CPT code 59430), how should these services be reported ?

A: Per the CPT book, the procedure code that most accurately reflects the services performed should be used. In this instance since these physicians are of the same physician group (same federal tax identification number), CPT code 59410 would be reported as the code description identifies both the delivery and postpartum care.

5 Q: How is an OB procedure reimbursed when reported by two different physicians with the same or different federal tax identification numbers reporting a component and a global OB care code during the same global obstetrical period ?


A: When Obstetrical services are eligible for reimbursement under this policy, only one provider will be reimbursed when multiple providers bill duplicate obstetrical services. Oxford follows a "first in, first out" claim payment methodology in determining which claim will be considered for reimbursement when claims for duplicate obstetrical services are received that involve component and global OB care services.

6 Q: Should a postpartum visit be provided within the ACOG standard six-week period ?

A: The postpartum period includes routine office or outpatient postpartum visit(s) usually, but not necessarily, performed 6 weeks following delivery. If a physician routinely performs more than one postpartum outpatient visit in an uncomplicated case, the extra visit(s) is not billed separately. When a postpartum visit is scheduled, but the patient does not keep the appointment, the physician's documentation should reflect that the patient did not appear for the scheduled postpartum visit. This visit does not have to be refunded if a global OB code was previously submitted. If a patient returns to the office well after their scheduled postpartum visit (e.g., 6 months later) this visit may be reported separately since the global period would no longer apply.


7 Q: Are contraceptive management services included in postpartum care ?

 A: Oxford will consider separate reimbursement for contraceptive management services when provided during the postpartum period only when submitted with CPT codes 11975 (insertion, implantable contraceptive capsules), 57170 (diaphragm or cervical cap fitting with instructions), or 58300 (insertion of intrauterine device, IUD).


8 Q: How should the initial OB visit be reported ?

A: Per ACOG guidelines, if the obstetrical record is not initiated, then the office place of service visit should be reported separately by using the appropriate E/M CPT code (99201-99215, 99241-99245 and 99341- 99350) and ICD-10-CM diagnosis code of Z32.01. If the obstetrical record is initiated during the confirmatory visit, then the confirmatory visit becomes part of the global obstetric package and is not reported separately.


9 Q: What does the phrase "changes insurers" mean in relation to itemization of Obstetric (OB) Related E/M services ?

A: For the purposes of this policy, "insurer" means a third party payer. If a patient changed insurers during her obstetrical care, the provider and/or other health care professional would separate and submit the OB services that were provided in an itemized format to each insurer. For example, when reporting the antepartum care services, the code selection depends on how many visits were performed while covered under each insurer. The physician and/or other health care professional should report CPT code 59426 when 7 or more visits are provided, CPT code 59425 when 4-6 visits are provided, or an E/M visit when only providing 1-3 visits.

CPT 64727, 69990 - Microsurgery procedures

CPT Code                Description

64727  Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis)

69990  Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)

OVERVIEW

Microsurgical Technique is the use of an operating microscope during a surgical procedure. Use of an operating microscope, reported with Current Procedural Terminology (CPT) codes 64727 and 69990, is a reimbursable service in specified instances.


For the purpose of this policy, the Same Individual Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional is the same individual physician, hospital, or ambulatory surgical center rendering health care services reporting the same Federal Tax Identification number.



CPT Code 64727

Consistent with the CPT book coding guidelines for CPT code 64727, Oxford will only reimburse CPT code 64727 when submitted with internal neurolysis codes on the list of Services Allowed with CPT 64627.

The Centers for Medicare and Medicaid Services (CMS) Medicare Claims Processing Manual and the Correct Coding Initiative (CCI) state that CPT code 69990 is not to be reported in addition to CPT code 64727.


CPT Code 69990

CMS reimbursement guidelines differ from the CPT book coding guidelines. Oxford follows CMS reimbursement guidelines for reimbursement of 69990 with certain nervous system surgeries.

Oxford will reimburse CPT code 69990 when billed in conjunction with services described in the list of Services Allowed with CPT 69990.

DEFINITIONS

Microsurgery: The use of a microscope during a surgical procedure to perform Microsurgical Technique.

Microsurgical Technique: A surgical technique for dissecting tissues under a microscope.

Same Individual Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional: The same individual physician, hospital, ambulatory surgical center or other health care professional rendering health care services reporting the same Federal Tax Identification number.

QUESTIONS AND ANSWERS


1 Q: Why does Oxford choose to follow the Centers for Medicare and Medicaid Services (CMS) guidelines rather than the CPT book guidelines for bundling of code 69990?

A: More consistency was found in the CMS bundling rules. For example, CMS consistently considers 69990 included in eye and ear surgical procedures, while CPT varies within these CPT sections.


2 Q: Why does Oxford include add-on codes in the Services Allowed with CPT 69990 list when CMS National Correct Coding Initiative (NCCI) does not include these add-on codes in the range of services in which CPT code 69990 is allowable?

A: CMS guidelines state, "In general, NCCI procedure to procedure edits do not include edits with most add-on codes because edits related to the primary procedure(s) are adequate to prevent inappropriate payment for an add-on coded procedure." Oxford aligns with CMS and allows reimbursement of CPT code 69990 reported with add-on codes when the primary procedure codes are allowable. For example, primary procedure code 61304 (Craniectomy or craniotomy, exploratory; supratentorial) is allowable and, therefore, add-on code 61316 (Incision and subcutaneous placement of cranial bone graft (List separately in addition to code for primary procedure) is also allowable.

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