Subject: Frequency Editing NY Policy: 0016 Effective: 11/24/2014 04/30/2015 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed below. DESCRIPTION The Health Plan uses claims processing logic based on ClaimsXten rationale to determine when the use of multiple units is appropriate. The Health Plan also uses, among other factors, the nomenclature for a particular Current Procedural Terminology (CPT ) or Healthcare Common Procedure Coding System (HCPCS Level II) code or the ability to clinically perform or report a particular service more than one time on a single date of service or within a particular date span per member per provider in making these determinations. POLICY 1. All or any of the following factors identify when a procedure will be limited in units, or number of times a code is eligible for reimbursement on a single date of service. a. The description of a procedure code includes the word(s) bilateral or unilateral or bilateral b. A procedure code description specifies unilateral and there is another CPT code for the bilateral service or another add-on code for additional services (the unilateral CPT code cannot be submitted more than once on a single date of service) c. The description of a procedure code includes a specified time frame (e.g. per 30 day period) d. The description of a procedure code implies multiplicity (e.g. evaluation(s); muscle(s); injection(s); area(s); material(s); etc.) e. The total number of times it is clinically possible or clinically reasonable to perform a given procedure on a single date of service is limited In some circumstances a RT/LT or site specific modifier ( e.g. F5, T3; etc.) will allow a code to process when used more than once, since these modifiers will identify the specific side or digit when more than one site is being treated or evaluated. f. A procedure code is reported more than one time, but typically is not performed more than once on a single date of service. 2. When a procedure code is submitted with multiple units, and only a single unit is acceptable, reimbursement will be based on only one unit. 3. The Health Plan will apply all unit/frequency edits pre-adjudication, using both the unit field and multiple submissions of line items. NY 0016 Page 1 of [7]
4. The Health Plan will apply a frequency edit, when applicable, to a base code which has a related addon code listed in CPT Appendix D. Since the related add-on code(s) describes a phrase such as each additional or list separately in addition to the primary procedure, the base code is eligible for reimbursement only once per date of service (e.g., only one of the following initial vaccine administration codes 90471 or 90473 is allowed per date of service.) 5. The Health Plan will apply some frequency edits across dates of service. 6. For Durable Medical Equipment (DME), the Health Plan will apply frequency maximums per day and/or per date span (usually based on the Centers for Medicare & Medicaid Services (CMS s) Medically Unlikely Edits (MUEs), industry standards, and/or HCPCS description). (See also our Durable Medical Equipment reimbursement policy.) The Health Plan has customized ClaimsXten unit/frequency logic for some procedure codes. Please see the table in the Coding Section for these customizations. CODING The following occurrence restrictions are examples of some frequency edits added to certain codes that do not fit into one of the categories identified in the policy section above, or the description of the code includes a designated time frame. Services billed in excess of these restrictions are not eligible for reimbursement even when billed with an override modifier (e.g., modifier 59 or modifier 91). The inclusion or exclusion of a specific code does not indicate eligibility for coverage under all circumstances. 36415 Collection of venous blood by venipuncture ** limit includes 36415, 36416, and S9529 36416 Collection of capillary blood specimen (eg, finger, heel, ear stick) 76942 Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injections, localization device), imaging supervision and interpretation ** limit includes 36415, 36416, and S9529 77002 Fluoroscopic guidance for needle placement (eg, NY 0016 Page 2 of [7]
biopsy, aspiration, injection, localization device) 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) 77012 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation 77021 Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation 77338 Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan 77600, 77605 Hyperthermia, externally generated; superficial (i.e., heating to a depth of 4 cm or less) or deep (i.e., heating to depths greater than 4 cm) 81479 Unlisted molecular pathology procedure 88305 Level IV - Surgical pathology, gross and microscopic examination needle biopsy prostate 90378 Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each 92250 Fundus photography with interpretation and report 93268, 93270, Wearable patient activated EKG event recording 93271, 93272 per 30 day period of time 93293, 93294, Transtelephonic rhythm strip pacemaker 93295, 93296 evaluation(s) system up to 90 days 93297, 93298, Implantable cardiovascular monitor system, 93299 interrogation device evaluation(s) up to 30 days 93325 Doppler echocardiography color flow velocity mapping 9 units per date of service when reported for specimens related to needle biopsy of the prostrate 4 per date of service 1 per 30 days 1 per 90 days of service 1 per 30 days 2 per date of service NY 0016 Page 3 of [7]
94014, 94015, Patient-initiated spirometric recording per 30 1 per 30 days 94016 day period of time 94774, 94775, Pediatric home apnea monitoring event 1 per 30 days 94776, 94777 recording per 30 day period of time 95165 Professional services for the supervision of 120 doses per 365 days preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses) 95250, 95251 Continuous glucose monitoring 1 per 3 days of service 95800 Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (e.g., by airflow or peripheral arterial tone), and sleep time 95801 Sleep study, unattended, simultaneous recording; minimum of heart rate, oxygen saturation, and respiratory analysis (e.g., by airflow or peripheral arterial tone) 95806 Sleep study, unattended, simultaneous recording of, heart rate, oxygen saturation, respiratory airflow, and respiratory effort (eg, thoracoabdominal movement) 96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist's or physician's time, both face-toface time with the patient and time interpreting test results and preparing the report 96150, 96151, 96152, 96153, 96154 Health and behavior assessment/intervention; each 15 minutes 5 per 365 days 8 per date of service NY 0016 Page 4 of [7]
96367 Additional sequential infusion, up to 1 hour 6 per date of service 96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic 96416 Initiation of prolonged IV Chemotherapy administration (more than 8 hours) requiring the use of a portable or implantable pump 97012,97014, Physical medicine modalities 97016, 97018, 97022,97024, 97026, 97028 99183 Physician attendance and supervision of hyperbaric oxygen therapy, per session for the administration of drugs such as omalizumab (Xolair ) 3 per date of service 99363, 99364 Anticoagulant management 1 per 90 days of service A4210 Needle-free injection device, each 2 per 365 days A4230 Infusion set for external insulin pump, non 60 per 90 days needle cannula type A4231 Infusion set for external insulin pump, needle 60 per 90 days type A4232 Syringe with needle for external insulin pump, 60 per 90 days sterile, 3CC A4244 Alcohol or peroxide, per pint 12 per 90 days A4245 Alcohol wipes, per box 24 per 90 days A4250 Urine test or reagent strips or tablets (100 tablets 4 per 90 days or strips) A4253 Blood glucose test or reagent strips for home 11 per 90 days blood glucose monitor, per 50 strips A4257 Replacement lens shield cartridge for use with 1 per 30 days laser skin piercing device, each A4258 Spring powered device for lancet, each 2 per 365 days A4259 Lancets, per box of 100 5 per 90 days NY 0016 Page 5 of [7]
A4595 Electrical stimulator supplies, 2 lead, per month, 2 per 30 days (e.g., TENS, NMES) A6530 Compression stockings 8 stockings per 365 days A6549 E0441, E0442, Oxygen one month s supply 1 per 30 days E0443, E0444 E1812 Dynamic knee, extension/flexion device, include 1 per 30 days soft interface material G0249 Provision of test materials and equipment for 3 per 90 days of service home INR monitoring includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests G0398 Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG, ECG/heart rate, airflow, respiratory effort and oxygen saturation G0399 G0400 G0431 G0434 Home sleep test (HST) with type III portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation] Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter NY 0016 Page 6 of [7]
J1560 Gamma globulin injection codes J7321, J7323, Hyaluronan or derivative for intra-articular 2 per date of service J7324, J7326 injection, per dose J9355 Injection, trastuzumab, 10 mg (Herceptin ) 95 units per date of service Q4101 Apligraf, per sq cm 44 per date of service S9529 Routine venipuncture for collection of specimen(s), single homebound, nursing home, or skilled nursing facility patient ** limit includes 36415, 36416, and S9529 1 CPT is a registered trademark of the American Medical Association Use of Reimbursement Policy: This policy is subject to federal and state laws, to the extent applicable, as well as the terms, conditions, and limitations of a member s benefits. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan. 2014 Empire BlueCross BlueShield NY 0016 Page 7 of [7]