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)

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)


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


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.


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.


** 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.


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)


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.


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.


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.

Medicare Regulatory Terms and abbreviations

V. Regulatory Impact Analysis Regulations Text Acronyms

In addition, because of the many organizations and terms to which we refer by acronym in this final rule, we are listing these acronyms and their corresponding terms in alphabetical order below:

A1c Hemoglobin A1c

AAA Abdominal aortic aneurysms

ACO Accountable care organization

AMA American Medical Association

ASC Ambulatory surgical center

ATA American Telehealth Association

ATRA American Taxpayer Relief Act (Pub. L. 112–240)

AWV Annual wellness visit

BBA Balanced Budget Act of 1997 (Pub. L. 105–33)

BBRA [Medicare, Medicaid and State Child Health Insurance Program] Balanced Budget Refinement Act of 1999 (Pub. L. 106–113)

BLS Bureau of Labor Statistics

CAD Coronary artery disease

CAH Critical access hospital

CBSA Core-Based Statistical Area

CCM Chronic care management

CEHRT Certified EHR technology

CF Conversion factor

CG–CAHPS Clinician and Group Consumer Assessment of Healthcare Providers and Systems

CLFS Clinical Laboratory Fee Schedule

CoA Certificate of Accreditation

CoC Certificate of Compliance

CoR Certificate of Registration

CNM Certified nurse-midwife

CP Clinical psychologist

CPC Comprehensive Primary Care

CPEP Clinical Practice Expert Panel

CPT [Physicians] Current Procedural Terminology (CPT codes, descriptions and other data only are copyright 2015 American Medical Association. All rights reserved.)

CQM Clinical quality measure

CSW Clinical social worker

CT Computed tomography

CW Certificate of Waiver

CY Calendar year

DFAR Defense Federal Acquisition Regulations

DHS Designated health services

DM Diabetes mellitus

DSMT Diabetes self-management training  eCQM Electronic clinical quality measures

ED Emergency Department

EHR Electronic health record

E/M Evaluation and management

EMT Emergency Medical Technician

EP Eligible professional eRx Electronic prescribing

ESRD End-stage renal disease

FAR Federal Acquisition Regulations

FDA Food and Drug Administration

FFS Fee-for-service

FQHC Federally qualified health center

FR Federal Register

FSHCAA Federally Supported Health Centers Assistance Act

GAF Geographic adjustment factor

GAO Government Accountability Office

GPCI Geographic practice cost index

GPO Group purchasing organization

GPRO Group practice reporting option

GTR Genetic Testing Registry

HCPCS Healthcare Common Procedure Coding System

HHS [Department of] Health and Human Services

HOPD Hospital outpatient department

HPSA Health professional shortage area

IDTF Independent diagnostic testing facility

IPPE Initial preventive physical exam

IPPS Inpatient Prospective Payment System

IQR Inpatient Quality Reporting

ISO Insurance service office

IT Information technology

IWPUT Intensity of work per unit of time

LCD Local coverage determination

MA Medicare Advantage

MAC Medicare Administrative Contractor

MACRA Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. 114– 10)

MAP Measure Applications Partnership

MAPCP Multi-payer Advanced Primary Care Practice

MAV Measure application validity [process]

MCP Monthly capitation payment MedPAC Medicare Payment Advisory Commission

MEI Medicare Economic Index

MFP Multi-Factor Productivity

MIPPA Medicare Improvements for Patients and Providers Act (Pub. L. 110–275)

MMA Medicare Prescription Drug, Improvement and Modernization Act of 2003 (Pub. L. 108–173, enacted on December 8, 2003)

MP Malpractice

MPPR Multiple procedure payment reduction

MRA Magnetic resonance angiography

MRI Magnetic resonance imaging

MSA Metropolitan Statistical Areas

MSPB Medicare Spending per Beneficiary

MU Meaningful use

NCD National coverage determination

NCQDIS National Coalition of Quality Diagnostic Imaging Services

NP Nurse practitioner

NPI National Provider Identifier

NPP Nonphysician practitioner

NQS National Quality Strategy

OACT CMS’s Office of the Actuary

OBRA ’89 Omnibus Budget Reconciliation Act of 1989 (Pub. L. 101–239)

OBRA ’90 Omnibus Budget Reconciliation Act of 1990 (Pub. L. 101–508)

OES Occupational Employment Statistics

OMB Office of Management and Budget

OPPS Outpatient prospective payment system

OT Occupational therapy

PA Physician assistant

PAMA Protecting Access to Medicare Act of 2014 (Pub. L. 113–93)

PAMPA Patient Access and Medicare Protection Act (Pub. L. 114–115)

PC Professional component

PCIP Primary Care Incentive Payment

PE Practice expense

PE/HR Practice expense per hour

PEAC Practice Expense Advisory Committee

PECOS Provider Enrollment, Chain, and Ownership System

PFS Physician Fee Schedule

PLI Professional Liability Insurance

PMA Premarket approval

PPM Provider-Performed Microscopy

PQRS Physician Quality Reporting System

PPIS Physician Practice Expense Information Survey

PPS Prospective Payment System

PT Physical therapy

PT Proficiency Testing

PT/INR Prothrombin Time/International Normalized Ratio

PY Performance year

QA Quality Assessment

QC Quality Control

QCDR Qualified clinical data registry

QRUR Quality and Resources Use Report

RBRVS Resource-based relative value scale

RFA Regulatory Flexibility Act

RHC Rural health clinic

RIA Regulatory impact analysis

RUC American Medical Association/ Specialty Society Relative (Value) Update Committee

RUCA Rural Urban Commuting Area

RVU Relative value unit

SBA Small Business Administration

SGR Sustainable growth rate

SIM State Innovation Model

SLP Speech-language pathology

SMS Socioeconomic Monitoring System

SNF Skilled nursing facility

TAP Technical Advisory Panel

TC Technical component

TIN Tax identification number

TCM Transitional Care Management

UAF Update adjustment factor

UPIN Unique Physician Identification Number

USPSTF United States Preventive Services Task Force

VBP Value-based purchasing

VM Value-Based Payment Modifier

What is the new Therapy Cap process

New Therapy Cap Process: Frequently Asked Questions

What is the new Therapy Cap process? 


Starting October 1, 2012, claims for patients who meet or exceed $3,700 in therapy expenditures will be subject to prior authorization. For outpatient therapy services that exceed $3700 there will be a prior authorization approval process that will be implemented in three distinct phases. Providers will be assigned to one of three phases for manual medical review and will receive notification from CMS by letter and contractor websites regarding which phase they are included.

Why is CMS doing this? 

This process is required by Section 1833(g)(5)(C) of the Social Security Act, as added by Section 3005 of the Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJA), which was signed into law on February 22, 2012.

What is the prior authorization threshold?

Starting October 1, 2012, claims for patients who meet or exceed $3,700 in therapy expenditures will be subject to prior authorization. For outpatient therapy services that exceed $3700 there will be a prior authorization approval process that will be implemented in three distinct phases.

How is the $3,700 calculated?

The $3,700 is calculated using all outpatient therapy services provided (except those provided in Critical Access Hospitals) within the category of physical therapy/speech language therapy and then a separate category for occupational therapy services.

What does the $3,700 threshold represent?

The threshold represents the total allowed charges under Part B for services furnished by independent practitioners, and institutional services under Part B (hospital outpatient departments, skilled nursing facilities, and home health agencies).

Does therapy provided in a critical access hospital (CAH) count? 

No. Services provided in a CAH are not counted and CAHs are not subject to the prior authorization process.

What are the Phases? 

Phase I October 1, 2012 to December 31, 2012
Phase II November 1, 2012 to December 31, 2012
Phase III December 1, 2012 to December 31, 2012

How do I know what Phase I am in?

Each provider subjected to a phase will be notified via US Mail. There will also be a posting to the CMS website external link  with the providers in phase I and II. Providers not on the list are deemed to be in Phase III.

How did CMS come up with the phases?

The phases were developed taking into account specific provider characteristics (e.g., claims volume and payment) and then adjusted to distribute workload evenly at the Medicare Administrative Contractor.

If I am in Phase III, what happens to my claims during the timeframe of October 1, 2012 to November 30, 2012?

Phase III is scheduled to begin for services expected to be furnished on or after December 1, 2012. Claims for services furnished before this time will be treated in the same manner as claims for services below the $3,700 threshold.

If I am in Phase III would a Medicare contractor conduct review of my claims from October 1, 2012 to November 30, 2012?

Medicare contractors have the authority to review any claim at any time. However, pre-approval requests shall not be reviewed any sooner than 15 calendar days before the start of each Phase.

How to I know where to submit my request for prior authorization?

We prefer you submit your request via Faxgate. The Faxgate numbers and addresses are noted on the job aids and on the forms located on the Palmetto GBA website.

What are the guidelines CMS contractors will use when conducting the review?

The contractors will use the coverage and payment policy requirements contained within Pub. 100-02, Section 220 of the Medicare Benefit Policy manual and any applicable local coverage decisions when making decisions as to whether a service shall be preapproved.

How long will a contractor have to make a decision on a pre-approval request?

10 business days.

What happens if a contractor’s decision about request for an exception is not made within 10 business days?

If a decision is not made within 10 business days, the request for exception will be deemed to be approved. You will receive a letter from Palmetto GBA indicating the approval of your request.

If a decision was made within 10 business days and the request for an exception was denied, and the provider furnishes the service to the beneficiary and submits a claim, what happens?

The claim is not payable under Medicare, the claim will be denied, and the
beneficiary will be liable for the services. You will receive a decision letter that will detail the reason for the denial.

Will claims that are pre-approved be guaranteed payment?

Authorization does not guarantee payment. Retrospective review may still be performed.

Why would a Medicare contractor review therapy that has been preapproved?

There are many reasons retrospective review would be needed after a preapproval:

Clinically inappropriate modalities
Patient’s clinical therapy needs do not match what was reported, e.g.
Patient’s functional level is greater than reported
Patient reached functional independence more quickly than predicted
Excessive or inappropriate therapy was furnished, e.g.
Therapy more often or of longer duration than is reasonable and medically necessary
Therapy provided to clinical treatment area not reasonable and necessary, e.g. therapy to shoulder when knee is the issue

Can I appeal the claim? 

Yes you may appeal unapproved services.

Why is the beneficiary liable?

Medicare only covers therapy services up to $1,880 cap in 2012. For services between $1,880 and $3,700, if the conditions for an exception are not met, the beneficiary is financially responsible. For services above the $3,700 threshold, if a request for an exception to the $3,700 threshold is not met, the beneficiary is financially responsible.

Am I required to provide the beneficiary an Advanced Beneficiary Notice (ABN) for services above the therapy cap of $1,880?

There is no legal requirement for issuance of an ABN. However, CMS strongly recommends a voluntary ABN where the provider believes that Medicare may not cover the services.

What happens if I request pre-approval and gain approval for 20 treatment days and I actually furnish 30 treatments?

The claim will be subject to prepayment medical review.

How is CMS educating beneficiaries about the therapy cap and the threshold?

CMS conducted a mailing in September to beneficiaries who have received therapy services at or near the cap. The mailing informed them of the cap and of the fact that if services above the cap are denied, that they will be financially liable.

What is the therapy cap amount for 2012?

The annual per beneficiary therapy cap amount for 2012 is $1880 for physical therapy and speech language pathology services combined (PT/SLP). There is a separate $1880 amount allotted for occupational therapy services.

What provider settings are subject to the therapy cap in 2012?

Effective January 1, 2012, the $1880 therapy cap with an exceptions process, applies to services furnished in the following outpatient therapy settings: physical therapists in private practice, physician offices, skilled nursing facilities (SNF) (Part B), rehabilitation agencies (or ORFs), and comprehensive outpatient rehabilitation facilities (CORFs). In addition, the therapy cap with an exceptions process will apply to hospital outpatient departments no later than October 1, 2012, until the end of 2012.

Does the therapy cap with no exceptions process go back into effect on January 1, 2013?

Unless Congress passes legislation by the end of the year there will be a therapy cap with no exceptions process for all outpatient therapy settings, except hospitals. Effective January 1, 2013, the therapy cap would not apply to hospitals unless Congress passes legislation.

Does the therapy cap apply to Medicare beneficiaries enrolled in a Medicare Advantage plan?

The Medicare Advantage Plan may apply the $1880 therapy cap with an exceptions process if it chooses; however, many Medicare Advantage plans chose not to apply the therapy cap in the past. You should check with your Medicare Advantage plan regarding its payment policies.

If we are not contracted with a Medicare Advantage Plan and they are not required to pay our normal Medicare payment then would we apply the therapy cap for beneficiaries with those plans?

The cap will only be tracked through outpatient therapy claims that process through the regular fee for service Medicare system.

Does the cap amount 'reset' for each diagnosis? For instance, if a patient receives PT services January-March for a hip replacement and is discharged, then returns in September as a result of a stroke, is there one cap for the first episode of treatment and a new cap for the second episode of treatment?

No. The therapy cap is an annual per beneficiary cap.

With the cap for 2012 of $1880 for Part B PT/SLP benefits, how does the cap count toward the patient responsibility of 20%?

For example, the patient is responsible for 20% of allowable charges as an outpatient. Medicare will pay 80% of the allowed charges ($1504.00) and the beneficiary will be responsible for the remaining 20% ($376.00).

Where do I find information about the amount of dollars that my patient has accrued toward the therapy cap?

All providers and contractors may access the accrued amount of therapy services from the ELGA screen inquiries into CWF. Providers/suppliers may access the remaining therapy services limitation dollar amount through the 270/271 eligibility inquiry and response transaction. Providers who bill to fiscal intermediaries (FIs) will find the amount a beneficiary has accrued toward the financial limitations on the HIQA. Some suppliers and providers billing to carriers may, in addition, have access to the accrued amount of therapy services from the ELGB screen inquiries into CWF. Suppliers who do not have access to these inquiries may call the contractor to obtain the amount accrued.

Do providers need to include national provider identifiers of the physician who reviews the therapy plan of care on the claim form?

Yes. Starting October 1, 2012, each request for payment must include the national provider identifier (NPI) of the physician who periodically reviews the therapy plan of care. APTA anticipates CMS will issue further guidance to providers regarding placement of the NPI on the claim form.

Where can I find additional resources regarding the therapy cap?

CMS has issued a fact sheet and a question and answer document external link  regarding manual medical review which are now available.

Why was my redetermination request denied when I submitted a letter showing my patient was no longer incarcerated at the time of my service?

The claim cannot be allowed until the Common Working File (CWF) is updated with the incarceration end date. Your patient will need to contact the Social Security Administration to have their record updated.

If I submit my Appeal through Palmetto GBA's eServices, do I need to submit the Appeal request and documentation hard copy as well?

There is no need to mail or fax a hard copy form once an eAppeals is submitted via Palmetto GBA's eServices. You will receive an acceptance message confirming receipt and then another message with the Document Control Number (DCN) when the appeal has started processing.

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