Thursday, June 30, 2016

Payment Guide for CPT CODE 52005, 52234, AND 52240

Urinary and Male Genital Systems (Codes 50010 - 55899)

A. Cystourethroscopy With Ureteral Catheterization (Code 52005)

Code 52005 has a zero in the bilateral field (payment adjustment for bilateral procedure does not apply) because the basic procedure is an examination of the bladder and urethra (cystourethroscopy), which are not paired organs. The work RVUs assigned take into account that it may be necessary to examine and catheterize one or both ureters. No additional payment is made when the procedure is billed with bilateral modifier “-50.” Neither is any additional payment made when both ureters are examined and code 52005 is billed with multiple surgery modifier “-51.” It is inappropriate to bill code 52005 twice, once by itself and once with modifier “-51,” when both ureters are examined.

B. Cystourethroscopy With Fulgration and/or Resection of Tumors (Codes 52234, 52235, and 52240)

The descriptors for codes 52234 through 52240 include the language “tumor(s).”

This means that regardless of the number of tumors removed, only one unit of a single code can be billed on a given date of service. It is inconsistent to allow payment for removal of a small (code 52234) and a large (code 52240) tumor using two codes when only one code is allowed for the removal of more than one large tumor. For these three codes only one unit may be billed for any of these codes, only one of the codes may be billed, and the billed code reflects the size of the largest tumor removed.

Tuesday, June 28, 2016

Psychotherapy Treatment CPT CODES LIST

CPT Description

90899 Unlisted psychiatric service. This code was previously, Individual Psychiatric Therapy.
Note: This is an interim code to be used by schools to be able to bill for psychotherapy services. This code should be used instead of 90804, 90806, and 90808. Professional only. 1 Unit = 15 Minutes

90853 Group psychotherapy; Two or more students. Professional only. Specify exact time. 1 Unit = 15 Minutes.

90847 Family psychotherapy (conjoint psychotherapy) (with patient present). Professional only.
Specify exact time. 1 Unit = 15 Minutes.

90846 Family psychotherapy without patient present. Must be face-to-face with at least one family participant present. The participant must be the focus of services. Professional only. Goals of treatment must be specified on the participants individualized treatment plan.
1 Unit = 15 Minutes.

H0004 Behavioral health counseling and therapy, individual.
Specify exact time. 1 Unit = 15 Minutes.

90853 Psychotherapy; two or more individuals.
Specify exact time. 1 Unit = 15 Minutes.

Family psychotherapy; (with patient present).
Specify exact time. 1 Unit = 15 Minutes.

Saturday, June 25, 2016

Part 2 - What is Correct coding policy - For Beginners

F. Designation of Sex

Many procedure codes have a sex designation within their narrative. These codes are not billed with codes having an opposite sex designation because this would reflect a conflict in sex classification either by the definition of the code descriptions themselves, or by the fact that the performance of these procedures on the same beneficiary would be anatomically impossible.

G. Family of Codes

In a family of codes, there are two or more component codes that are not billed separately because they are included in a more comprehensive code as members of the code family. Comprehensive codes include certain services that are separately identifiable by other component codes. The component codes as members of the comprehensive code family represent parts of the procedure that should not be listed separately when the complete procedure is done. However, the component codes are considered individually if performed independently of the complete procedure and if not all the services listed in the comprehensive codes were rendered to make up the total service.

H. Most Extensive Procedures

When procedures are performed together that are basically the same or performed on the same site but are qualified by an increased level of complexity, the less extensive procedure is bundled into the more extensive procedure.

I. Sequential Procedures

An initial approach to a procedure may be followed at the same encounter by a second, usually more invasive approach. There may be separate CPT codes describing each service. The second procedure is usually performed because the initial approach was unsuccessful in accomplishing the medically necessary service. These procedures are considered “sequential procedures.” Only the CPT code for one of the services, generally the more invasive service, should be billed.

J. With/Without Procedures

In the CPT manual, there are various procedures that have been separated into two codes with the definitional difference being “with” versus “without” (e.g., with and without contrast). Both procedure codes cannot be billed. When done together, the “without” procedure is bundled into the “with” procedure.

K. Laboratory Panels

When components of a specific organ or disease oriented laboratory panel (e.g., codes 80061 and 80059) or automated multi-channel tests (e.g., codes 80002 - 80019) are billed separately, they must be bundled into the comprehensive panel or automated multi-channel test code as appropriate that includes the multiple component tests. The individual tests that make up a panel or can be performed on an automated multi-channel test analyzer are not to be separately billed.

L Mutually Exclusive Procedures

There are numerous procedure codes that are not billed together because they are mutually exclusive of each other. Mutually exclusive codes are those codes that cannot reasonably be done in the same session.

An example of a mutually exclusive situation is when the repair of the organ can be performed by two different methods. One repair method must be chosen to repair the organ and must be billed. Another example is the billing of an “initial” service and a “subsequent” service. It is contradictory for a service to be classified as an initial and a subsequent service at the same time.

CPT codes which are mutually exclusive of one another based either on the CPT definition or the medical impossibility/improbability that the procedures could be performed at the same session can be identified as code pairs. These codes are not necessarily linked to one another with one code narrative describing a more comprehensive procedure compared to the component code, but can be identified as code pairs which should not be billed together.

M. Use of Modifiers

When certain component codes or mutually exclusive codes are appropriately furnished, such as later on the same day or on a different digit or limb, it is appropriate that these services be reported using a HCPCS code modifier. Such modifiers are modifiers E1 - E4, FA, F1 - F9, TA, T1 - T9, LT, RT, LC, LD, RC, -58, -78, -79, and -94.

Modifier -59 is not appropriate to use with weekly radiation therapy management codes (77427) or with evaluation and management services codes (99201 - 99499).

Application of these modifiers prevent erroneous denials of claims for several procedures performed on different anatomical sites, on different sides of the body, or at different sessions on the same date of service. The medical record must reflect that the modifier is being used appropriately to describe separate services.

Thursday, June 23, 2016

What is Correct coding policy - For Beginners - Part 1

Correct Coding Policy

The Correct Coding Initiative was developed to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims.

The principles for the correct coding policy are:

The service represents the standard of care in accomplishing the overall procedure;

The service is necessary to successfully accomplish the comprehensive procedure. Failure to perform the service may compromise the success of the procedure; and

The service does not represent a separately identifiable procedure unrelated to the comprehensive procedure planned.

For a detailed description of the correct coding policy, refer to

The CMS as well as many third party payers have adopted the HCPCS/CPT coding system for use by physicians and others to describe services rendered. The system contains three levels of codes. Level I contains the American Medical Association’s Current Procedural Terminology (CPT) numeric codes. Level II contains alpha-numeric codes primarily for items and services not included in CPT. Level III contains carrier specific codes that are not included in either Level I or Level II. For a list of CPT and HCPCS codes refer to the CMS Web site.

The following general coding policies encompass coding principles that are to be applied in the review of Medicare claims. They are the basis for the correct coding edits that are installed in the claims processing systems effective January 1, 1996.

A. Coding Based on Standards of Medical/Surgical Practice

All services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code. Many of these generic activities are common to virtually all procedures and, on other occasions, some are integral to only a certain group of procedures, but are still essential to accomplish these particular procedures. Accordingly, it is inappropriate to separately report these services based on standard medical and surgical principles.
Because many services are unique to individual CPT coding sections, the rationale for rebundling is described in that particular section of the detailed coding narratives that are transmitted to carriers periodically.

B. CPT Procedure Code Definition

The format of the CPT manual includes descriptions of procedures, which are, in order to conserve space, not listed in their entirety for all procedures. The partial description is indented under the main entry. The main entry then encompasses the portion of the description preceding the semicolon. The main entry applies to and is a part of all indented entries, which follow with their codes.

In the course of other procedure descriptions, the code definition specifies other procedures that are included in this comprehensive code. In addition, a code description may define a rebundling relationship where one code is a part of another based on the language used in the descriptor.

C. CPT Coding Manual Instruction/Guideline

Each of the six major subsections include guidelines that are unique to that section. These directions are not all inclusive of nor limited to, definitions of terms, modifiers, unlisted procedures or services, special or written reports, details about reporting separate, and multiple or starred procedures and qualifying circumstances.

D. Coding Services Supplemental to Principal Procedure (Add-On Codes) Code

Generally, these are identified with the statement “list separately in addition to code for primary procedure” in parentheses, and other times the supplemental code is used only with certain primary codes, which are parenthetically identified. The reason for these CPT codes is to enable physicians and others to separately identify a service that is performed in certain situations as an additional service. Incidental services that are necessary to accomplish the primary procedure (e.g., lysis of adhesions in the course of an open cholecystectomy) are not separately billed.

E. Separate Procedures

The narrative for many CPT codes includes a parenthetical statement that the procedure represents a “separate procedure.”

The inclusion of this statement indicates that the procedure, while possible to perform separately, is generally included in a more comprehensive procedure, and the service is not to be billed when a related, more comprehensive, service is performed. The “separate procedure” designation is used with codes in the surgery (CPT codes 10000-69999), radiology (CPT codes 70000-79999), and medicine (CPT codes 90000-99199) sections. When a related procedure from the same section, subsection, category, or subcategory is performed, a code with the designation of “separate procedure” is not to be billed with the primary procedure.

Monday, June 20, 2016

POS comes under Facility and non facility payment fee schedule

Site of Service Payment Differential

Under the Medicare Physician Fee schedule (MPFS), some procedures have separate rates for physicians’ services when provided in facility and nonfacility settings. The CMS furnishes both rates in the MPFSDB update.

The rate, facility or nonfacility, that a physician service is paid under the MPFS is determined by the Place of service (POS) code that is used to identify the setting where the beneficiary received the face-to-face encounter with the physician, nonphysician practitioner (NPP) or other supplier. In general, the POS code reflects the actual place where the beneficiary receives the face-to-face service and determines whether the facility or nonfacility payment rate is paid. However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS codes 19 or 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred. For the professional component (PC) of diagnostic tests, the facility and nonfacility payment rates are the same – irrespective of the POS code on the claim. See chapter 13, section 150 of this manual for POS instructions for the PC and technical component of diagnostic tests.

The list of settings where a physician’s services are paid at the facility rate include:

• Outpatient Hospital-Off campus (POS code 19);

• Inpatient Hospital (POS code 21);

• Outpatient Hospital-On campus (POS code 22);

• Emergency Room-Hospital (POS code 23);

• Medicare-participating ambulatory surgical center (ASC) for a HCPCS code included on the ASC approved list of procedures (POS code 24);

• Medicare-participating ASC for a procedure not on the ASC list of approved procedures with dates of service on or after January 1, 2008. (POS code 24);

• Military Treatment Facility (POS Code 26);

• Skilled Nursing Facility (SNF) for a Part A resident (POS code 31);

• Hospice – for inpatient care (POS code 34);

• Ambulance – Land (POS code 41);

• Ambulance – Air or Water (POS code 42);

• Inpatient Psychiatric Facility (POS code 51);

• Psychiatric Facility -- Partial Hospitalization (POS code 52);

• Community Mental Health Center (POS code 53);

• Psychiatric Residential Treatment Center (POS code 56); and

• Comprehensive Inpatient Rehabilitation Facility (POS code 61).

Physicians’ services are paid at nonfacility rates for procedures furnished in the following settings:

• Pharmacy (POS code 01);

• School (POS code 03);

• Homeless Shelter (POS code 04);

• Prison/Correctional Facility (POS code 09);

• Office (POS code 11);

• Home or Private Residence of Patient (POS code 12);

• Assisted Living Facility (POS code 13);

• Group Home (POS code 14);

• Mobile Unit (POS code 15);

• Temporary Lodging (POS code 16);

• Walk-in Retail Health Clinic (POS code 17);

• Urgent Care Facility (POS code 20);

• Birthing Center (POS code 25);

• Nursing Facility and SNFs to Part B residents (POS code 32);

• Custodial Care Facility (POS code 33);

• Independent Clinic (POS code 49);

• Federally Qualified Health Center (POS code 50);

• Intermediate Health Care Facility/Mentally Retarded (POS code 54);

• Residential Substance Abuse Treatment Facility (POS code 55);

• Non-Residential Substance Abuse Treatment Facility (POS code 57);

• Mass Immunization Center (POS code 60);

• Comprehensive Outpatient Rehabilitation Facility (POS code 62);

• End-Stage Renal Disease Treatment Facility (POS code 65);

• State or Local Health Clinic (POS code 71);

• Rural Health Clinic (POS code 72);

• Independent Laboratory (POS code 81);and

• Other Place of Service (POS code 99).

Nonfacility rates are applicable to outpatient rehabilitative therapy procedures, including those relating to physical therapy, occupational therapy and speech-language pathology, regardless of whether they are furnished in facility or nonfacility settings. Nonfacility rates also apply to all comprehensive outpatient rehabilitative facility (CORF) services. In addition, payment is made at the nonfacility rate for physician services provided to CORF patients and appropriately billed using POS code 62 for CORF.

Friday, June 17, 2016

Development therapy CPT code list

CPT/ HCPCS Description 

H2011 Intervention for participant in crisis situations. (See IDAPA 16.03.10, Subsection 613.13 for specific requirements). Service is limited to a maximum of 20 hours per crisis, for 5 consecutive days. Service may not exceed 20 hours per crisis. 1 Unit = 15 Minutes.

H2000 Developmental Therapy Evaluation: Specify exact time. 1 Unit = 15 Minutes.

H2032 Center Based Individual Developmental Therapy for Adults Individual activity therapy. 1 Unit = 15 Minutes. (PA required for adults in the DD care management process)

H2032 HQ Center Based Group Developmental Therapy for Adults Group activity therapy. 1 Unit = 15 Minutes. (PA required for adults in the DD care management process)

97003 OT evaluation. Specify exact time. 1 Unit = 1 evaluation. 97004 OT re-evaluation

97535 Individual Occupational Therapy Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, individual.
Specify exact time. 1 Unit = 15 Minutes.

97537 Individual Home/community Developmental Therapy for Adults 1 Unit = 15 Minutes. (PA required for adults in the DD care management process)

97537 HQ Group Home/community Developmental Therapy for Adults, two or more individuals. 1 Unit = 15 Minutes. (PA required for adults in the DD care management process)

Wednesday, June 15, 2016

Home health - Patient Eligibility criteria - Part 2 - Re-certification requirements -

Certification Requirements: Who Can Perform a Face-to-Face Encounter

According to 42 CFR 424.22(a)(1)(v)(A), the face-to-face encounter can be performed by:

** The certifying physician;

** The physician who cared for the patient in an acute or post-acute care facility (from which the patient was directly admitted to home health);

** A nurse practitioner or a clinical nurse specialist who is working in collaboration with the certifying physician or the acute/post-acute care physician; or

** A certified nurse midwife or physician assistant under the supervision of the certifying physician or the acute/post-acute care physician.
According to 42 CFR 424.22(d)(2), the face-to-face encounter cannot be performed by any physician or allowed NPP (listed above) who has a financial relationship with the HHA.

Certification Requirements: Management and Evaluation Narrative

According to 42 CFR 424.22(a)(1)(i) if a patient's underlying condition or complication requires a Registered Nurse (RN) to ensure that essential non-skilled care is achieving its purpose and a RN needs to be involved in the development, management and evaluation of a patient's care plan, the physician will include a brief narrative describing the clinical justification of this need.

If the narrative is part of the certification form then the narrative must be located immediately prior to the physician's signature. If the narrative exists as an addendum to the certification form in addition to the physician's signature on the certification form, the physician must sign immediately following the narrative in the addendum.

For skilled nursing care to be reasonable and necessary for management and evaluation of the patient's plan of care, the complexity of the necessary unskilled services that are a necessary part of the medical treatment must require the involvement of a registered nurse to promote the patient's recovery and medical safety in view of the patient's overall condition.

For more information about SN for management and evaluation refer to Section, Chapter 7 of the “Medicare Benefit Policy Manual” at on the CMS website.

Certification Requirements: Supporting Documentation

** Documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility. If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided.

** According to the regulations at 42 CFR 424.22(c), Certifying physicians and acute/post-acute care facilities must provide, upon request, the medical record documentation that supports the certification of patient eligibility for the Medicare home health benefit to the home health agency, review entities, and/or CMS. Certifying physicians who show patterns of non-compliance with this requirement, including those physicians whose records are inadequate or incomplete for this purpose, may be subject to increased reviews, such as provider-specific probe reviews.

** Information from the HHA, such as the patient’s comprehensive assessment, can be incorporated into the certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient.

** Information from the HHA must be corroborated by other medical record entries and align with the time period in which services were rendered.

** The certifying physician must review and sign off on anything incorporated into the patient’s medical record that is used to support the certification of patient eligibility (that is, agree with the material by signing and dating the entry).

** The certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient must contain information that justifies the referral for Medicare home health services. This includes documentation that substantiates the patient’s:

1. Need for the skilled services; and

2. Homebound status.

** The certifying physician’s and/or the acute/post-acute care facility’s medical record for the patient must contain the actual clinical note for the face-to-face encounter visit that demonstrates that the encounter:

1. Occurred within the required timeframe;

2. Was related to the primary reason the patient requires home health services; and

3. Was performed by an allowed provider type.

This information can be found most often in, but is not limited to, clinical and progress notes and discharge summaries.

Please review the following examples included at the end of this article:

1. Discharge Summary;

2. Progress Note;

3. Progress Note and Problem List; or

4. Discharge Summary and Comprehensive Assessment.


At the end of the initial 60-day episode, a decision must be made as to whether or not to recertify the patient for a subsequent 60-day episode. According to the regulations at 424.22(b)(1) recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode and unless there is a:

** Patient-elected transfer; or

** Discharge with goals met and/or no expectation of a return to home health care.

(These situations trigger a new certification, rather than a recertification)

Medicare does not limit the number of continuous episodes of recertification for patients who continue to be eligible for the home health benefit.

Recertification Requirements:

1. Must be signed and dated by the physician who reviews the plan of care;

2. Indicate the continuing need for skilled services (the need for OT may be the basis for continuing services that were initiated because the individual needed SN, PT or SLP services); and

3. Estimate how much longer the skilled services will be required.

Physician Billing for /Certification/Recertification

Certifying/recertifying patient eligibility can include contacting the home health agency and reviewing of reports of patient status required by physicians to affirm the implementation of the plan of care that meets patient’s needs.

1. Healthcare Common Procedure Coding System (HCPCS) code G0180 - Physician certification home health patient for Medicare-covered home health service under a home health plan of care (patient not present).

2. HCPCS code G0179 -Physician recertification home health patient for Medicare-covered home health services under a home health plan of care (patient not present)

Physician claims for certification/recertification of eligibility for home health services (G0180 and G0179 respectively) are not considered to be for “Medicare-covered” home health services if the HHA claim itself was non-covered because the certification/recertification of eligibility was not complete or because there was insufficient documentation to support that the patient was eligible for the Medicare home health benefit.

Monday, June 13, 2016

Home health - Patient Eligibility criteria - Part 1

Certifying Patients for the Medicare Home Health Benefit

This MLN Matters® SE1436 article gives Medicare-enrolled providers an overview of the Medicare home health services benefit, including patient eligibility requirements and certification/recertification requirements of covered Medicare home health services.

Key Points

To be eligible for Medicare home health services a patient must have Medicare Part A and/or Part B per Section1814(a)(2)(C) and Section 1835(a)(2)(A) of the Social Security Act (the Act):

** Be confined to the home;

** Need skilled services;

** Be under the care of a physician;

** Receive services under a plan of care established and reviewed by a physician; and

** Have had a face-to-face encounter with a physician or allowed Non-Physician Practitioner (NPP).

Care must be furnished by or under arrangements made by a Medicare-participating Home Health Agency (HHA).

Patient Eligibility—Confined to Home

Section 1814(a) and Section 1835(a) of the Act specify that an individual is considered “confined to the home” (homebound) if the following two criteria are met:

First Criteria  

 One of the Following must be met:
1. Because of illness or injury, the individual needs  the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation;  or the assistance of another person to leave their place of residence.

2. Have a condition such that leaving his or her home is medically contraindicated.

Second Criteria

Both of the following must be met:

1. There must exist a normal inability to leave home.

2. Leaving home must require a considerable and taxing effort.

The patient may be considered homebound (that is, confined to the home) if absences from the home are:

** Infrequent;

** For periods of relatively short duration;

** For the need to receive health care treatment;

** For religious services;

** To attend adult daycare programs; or

** For other unique or infrequent events (for example, funeral, graduation, trip to the barber).

Some examples of persons confined to the home are:

** A patient who is blind or senile and requires the assistance of another person in leaving their place of residence;

** A patient who has just returned from a hospital stay involving surgery, who may be suffering from resultant weakness and pain and therefore their actions may be restricted by their physician to certain specified and limited activities such as getting out of bed only for a specified period of time or walking stairs only once a day; and

** A patient with a psychiatric illness that is manifested, in part, by a refusal to leave home or is of such a nature that it would not be considered safe for the patient to leave home unattended, even if they have no physical limitations.

Patient Eligibility—Need Skilled Services

According to Section 1814(a)(2)(C) and Section1835(a)(2)(A) of the Act, the patient must be in need of one of the following services:

Skilled nursing care on an intermittent basis (furnished or needed on fewer than 7 days each week or less than 8 hours each day for periods of 21 days or less, with extensions in exceptional circumstances when the need for additional care is finite and predictable per Section 1861(m) of the Act);

** Physical Therapy (PT);

** Speech-Language Pathology (SLP) services; or

** Continuing Occupational Therapy (OT).

Patient Eligibility—Under the Care of a Physician and Receiving Services Under a Plan of Care

Section 1814(a)(2)(C) and Section 1835(a)(2)(A) of the Act require that the patient must be under the care of a Medicare-enrolled physician, defined at 42 CFR 424.22(a)(1)(iii) as follows:

** Doctor of Medicine;

** Doctor of Osteopathy; or

** Doctor of Podiatric Medicine (may perform only plan of treatment functions that are consistent with the functions he or she is authorized to perform under State law).
According to Section 1814(a)(2)(C) and Section 1835(a)(2)(A) of the Act, the patient must receive home health services under a plan of care established and periodically reviewed by a physician. Based on 42 CFR 424.22(d)(1) a plan of care may not be established and reviewed by any physician who has a financial relationship with the HHA.

Physician Certification of Patient Eligibility

As a condition for payment, according to the regulations at 42 CFR 424.22(a)(1):
** A physician must certify that a patient is eligible for Medicare home health services according to 42 CFR 424.22(a)(1)(i)(v); and

** The physician who establishes the plan of care must sign and date the certification.

The Centers for Medicare & Medicaid Services (CMS) does not require a specific form or format for the certification as long as a physician certifies that the following five requirements, outlined in 42 CFR Section 424.22(a)(1), are met:

1. The patient needs intermittent SN care, PT, and/or SLP services;

2. The patient is confined to the home (that is, homebound);

3. A plan of care has been established and will be periodically reviewed by a physician;

4. Services will be furnished while the individual was or is under the care of a physician; and

5. A face-to-face encounter:

a. Occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care;

b. Was related to the primary reason the patient requires home health services; and

c. Was performed by a physician or allowed Non-Physician Practitioner.

Note: The certifying physician must also document the date of the face-to-face encounter.

According to the regulations at 42 CFR 424.22(a)(2) physicians should complete the certification when the plan of care is established or as soon as possible thereafter. The certification must be complete prior to when an HHA bills Medicare for reimbursement.

Friday, June 10, 2016

Can we bill Attorney for Medical cost ?


Subrogation is another liability recovery activity in which medical costs that are the result of actions or omissions of a third party are recovered from the third party (and/or his insurer). In some instances, Tufts Health Plan has the right to recover the value of services provided to Members for which a third party is responsible.

Tufts Health Plan has outsourced subrogation recovery services to the Rawlings Company in La Grange, KY, and as a result you may receive correspondence from Rawlings related to duplicate claim payments (e.g., Tufts Health Plan and a motor vehicle carrier). Inquiries related to such claims should be directed to the Rawlings Company representative at the number indicated on the correspondence. All other subrogation questions should be directed to the Provider Relations Department at 1-800-279-9022.

Note: Do not bill the member or the member’s attorney directly even if you are requested to do so by either of them. If you choose to bill the member or attorney directly, you do so at your own risk.

Motor Vehicle Accidents (No-Fault or PIP Coverage)

Tufts Health Plan coordinates with no-fault auto insurance coverage Personal Injury Protection (PIP) and/or Medical Payment (Medpay) on claims for services rendered as a result of a motor vehicle accident (MVA). Members should not be billed or required to pay up front for services as a result of a MVA, other than applicable cost-sharing amounts. For motor vehicle accident claims, providers should bill the motor vehicle carrier directly. The no-fault auto insurance coverage is primary for the full PIP coverage and/or any available MedPay coverage.

After receiving the insurer’s statement or check, if further payment is requested for a Tufts Medicare Preferred HMO member, providers must bill Tufts Health Plan within the 60-day filing deadline date from the date the statement or check was issued.

Note: Under your Tufts Medicare Preferred HMO contract, once the member’s PIP and MedPay benefits are exhausted, you cannot balance bill the member or file a lien against the member’s third party settlement or judgment. For more information, refer to the Motor Vehicle Accident Payment Policy on our website. For questions regarding third-party liability, contact the Rawlings Company at 502.587.1279.

Wednesday, June 8, 2016

changes in reimbursement - Billing professional and technical component -

Modifier 26

Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure number.

Modifier TC

Technical Component. Under certain circumstances, a charge may be made for the technical component alone. Under those circumstances the technical component charge is identified by adding modifier TC to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians.

However, portable x-ray suppliers only bill for technical component and should utilize modifier TC. The charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles.

Global service

Unmodified CPT codes are intended to describe both the technical and professional components of a service. The professional and technical components together are
referred to as the "global service."

“If the technical and professional components of the service are performed by the same provider, then it is not appropriate to report the components of the service separately.”

When the service is furnished to a hospital outpatient or inpatient, the facility bills the technical component, which includes the cost of equipment, supplies, technician salaries, etc.

If the interpreting physician is not paid by the facility for services but will instead be billing the carrier separately, the physician may bill only for the professional component.

“Hospitals must provide directly or under arrangements all services furnished to hospital outpatients. Therefore, if a specimen (e.g., tissue, blood, urine) is taken from a hospital patient, the facility or technical component (TC) of the diagnostic test must be billed by the hospital. Only in cases where the patient leaves the hospital and obtains the service elsewhere is the hospital not required to bill for the service…At the request of the industry, the implementation of this rule was delayed to allow independent laboratories and hospitals sufficient time to negotiate arrangements…through February 29, 2012.”

 Reimbursement Guidelines

Procedures that are comprised of both a technical and professional component are identified on the National Medicare Physician Fee Schedule Database (MPFSDB) in Field 20 with a Professional Component (PC)/Technical Component (TC) Indicator of “1”. It is never appropriate for the technical and professional components to be unbundled and reported separately under the same TIN number (whether on separate line items of a single claim or on separate claims).  When determining if the technical and professional components were performed by the “same provider” or by different providers, if both components will be billed under the same tax ID number (TIN) then both components were performed by the same provider and are not eligible to be reported as separate components. Instead the global service should be billed without modifier TC or 26.


If the x-ray equipment is jointly owned by the physicians in a clinic, then the clinic must obtain a separate TIN number in order to separately submit the technical component (TC) of the service.

If the clinic has not obtained a separate TIN (and a separate contract with Insurance to be participating), then the global service must be billed by the interpreting clinic physician. The clinic must manage the equitable distribution of reimbursement for the technical component of the service internally through accounting and the joint ownership agreement for the shared equipment.

When the technical and professional components of a procedure are unbundled and billed to Insurance under the same TIN, the Insurance claims processing system will process the component procedures in a variety of ways (due to system constraints).

• Often the system will deny one component as a subset to the other component, resulting in an underpayment. In these situations, no override or bypass will be given for the edit.

Insurance requires a corrected claim with the procedure billed as a global service(without -TC or -26 modifier) for any adjustment or additional reimbursement to be

• The system may rebundle the component services into the global service. If this occurs, the claim will not be adjusted to process the components on separate lines. If the components were provided by separate entities, each component must be billed under a separate TIN on separate claims, and a corrected claim set will be required.

• In some cases both components may be separately allowed, but the total allowed fee will not be any higher than if the service had been correctly billed as the global service.

Only the components that have been actually performed by the billing provider may be billed to Insurance. If only one of the components has been performed, charges may not be submitted to Insurance for the component that has not been performed. The instructions in CMS Transmittal 1892/CR6733 are both optional and conditional, and do not apply to claims submitted to Insurance.

While CMS does sometimes instruct providers to re-bill the service as separate professional and technical component procedure codes, our research indicates this is specifically related to the calculation of CMS bonus payments in a health professional shortage area (HPSA), and does not apply to billing to commercial carriers such as Insurance. Submitting Only the Professional Component

• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 1, 6, or 8 (see field 20 on the MPFSDB) will be allowed with modifier 26 appended.

• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 0, 2, 3, 4, 5, 7, or 9 will be denied when submitted with modifier 26 appended. The denial explanation code will indicate that the procedure code is inconsistent with the modifier used (N27 or 514). For billing offices using 835 electronic remittance advice files, these explanation codes are mapped to claim adjustment reason code 4.

Submitting Only the Technical Component

• Procedure codes with a Professional Component (PC)/Technical Component (TC) Indicator of 1 (see field 20 on the MPFSDB) will be allowed when modifier TC is appended.
• Procedure code with a Professional Component (PC)/Technical Component (TC) Indicator of 0, 2, 3, 4, 5, 6, 7, 8, or 9 will be denied when submitted with modifier TC appended. The denial explanation code will indicate that the procedure code is inconsistent with the modifier used (N27 or 514). For billing offices using 835 electronic remittance advice files, these explanation codes are mapped to claim adjustment reason code 4.

Services Reported in a CMS POS 24 (Ambulatory Surgical Center) 

CMS guidelines, UnitedHealthcare Community Plan will not reimburse physicians or other health care professionals for the Technical Component of services included in the Ambulatory Surgery Center Fee Schedule (ASCFS) Addendum BB and reported with a CMS POS 24 as the ambulatory surgical center (ASC) is reimbursed for the Technical Component.

The Technical Component of services reported on a CM-1500 claim form with an SG modifier (Ambulatory surgical center [ASC] facility service) is not reimbursed as a professional claim.

 Claim lines reported with modifier SG indicate a facility charge and are reimbursed as a facility claim. PC/TC Indicator 1 Codes For codes included in the ASCFS Addendum BB PC/TC Indicator 1 Codes list, only the Professional Component (PC, modifier 26) will be reimbursed.

 When reported globally (no modifier), the Technical Component of the code will not be reimbursed.

  When reported with modifier TC, the code will not be reimbursed. PC/TC Indicator 3 Codes

Codes included in the ASCFS Addendum BB PC/TC Indicator 3 Codes list will not be reimbursed as they represent Technical Component services only.