Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
Policy #:MA00.037h

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

PROFESSIONAL PROVIDERS

When a professional provider who performs a service that is considered by the Company to be an office-based service (e.g., office visit, outpatient consultation, professional interpretation and report) in an office-based setting located within a hospital, a hospital facility campus, hospital affiliate, or hospital or hospital affiliate-owned site, division, or other location (e.g., clinic, treatment room), the professional provider must submit a CMS-1500 claim form or the electronic equivalent 837p for the office-based service. In such cases, the office-based service fee is inclusive of the professional provider service performed, as well as the office-based overhead (i.e., practice expense).

FACILITIES

When a professional provider who performs a service that is considered by the Company to be an office-based service (e.g., office visit, outpatient consultation, professional interpretation and report) in an office-based setting located within a hospital, a hospital facility campus, hospital affiliate, or hospital or hospital affiliate-owned site, division, or other location (e.g., clinic, treatment room), the facility is not eligible to receive reimbursement for the professional provider office-based services (i.e., room charge) and any item or service included in the payment to the professional provider. If a UB04 claim form or the electronic equivalent 837i is received from the facility for the office-based services, reimbursement will not be made to the facility.

The facility is eligible to receive reimbursement for any covered ancillary service (e.g., laboratory test, radiologic study) related to the office visit or consultation according to their contract.
  • Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) products require that the member obtain capitated services at the primary care provider's (PCP's) designated capitated site. Capitated services obtained from providers other than the member's PCP must be pre-approved by the Company.

BILLING SCENARIO

A professional provider (e.g., physician specialist) completes an initial outpatient evaluation and management (E & M) service in their office or clinic that is located within a facility or on a facility campus.
  • Reimbursement to the professional provider for an E & M service includes payment for the E & M services and any costs associated with office-based overhead to the professional provider.
  • The facility is not eligible to receive reimbursement for a facility component for the outpatient E & M service performed by the consulting professional provider because payment to the professional provider is inclusive of the office-based overhead (i.e., practice expense).

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

For Preferred Provider Organization (PPO) members to receive the highest level of benefits, diagnostic services should always be performed by a participating professional provider. Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) require that the member obtain capitated services at the primary care physician's (PCP's) designated capitated site.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, professional provider services performed in certain outpatient settings are covered under the medical benefits of the Company's Medicare Advantage products.

Description

Professional providers may perform outpatient office-based services (e.g., office visit, outpatient consultation, professional interpretation and report) in a variety of settings. These settings include, but are not limited to:

  • A freestanding office
  • An office or outpatient clinic located within a hospital, on or within a hospital facility campus, hospital affiliate, hospital or hospital affiliate-owned site, division, or other location (e.g., clinic, treatment room)

As used in this policy:
  • Professional provider refers to the professional provider who performs the health care service, as well as to any professional provider in the same provider group practice.
  • Facility refers to a hospital, a hospital facility campus, hospital affiliate, or hospital or hospital affiliate--owned site, division, or other location (e.g., clinic, treatment room).
  • Office-based service refers to office visits, outpatient consultations, minor office procedures, and any related items or services included in the payment of these services.
  • Capitation is the reimbursement that a participating facility, ancillary provider (e.g., freestanding outpatient radiology site), or professional provider receives in advance of services for a Health Maintenance Organization (HMO) member or for a Health Maintenance Organization Point-of-Service (HMO-POS) member who utilizes their referred benefit.
    References

    Company Hospital Manuals

    Company Provider Manuals


    Coding

    Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

    The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

    In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

    The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

See Attachment A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

See Attachment A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
Description: CPT/HCPCS Codes







Policy History

REVISIONS FROM MA00.037h:
01/13/2020This policy update becomes effective 01/13/2020. The policy update reaffirms the Company's continuing position on Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus. However, the following five consultation codes will be removed from Attachment A because they are not eligible for reimbursement at all: 99241, 99242, 99243, 99244, 99245.

REVISIONS FROM MA00.037g:
01/01/2020This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2020.

The following CPT codes have been added to the policy: 99421, 99422, 99423, 99473, 99474.

The following HCPCS codes have been added to the policy: G2058, G2061, G0262, G2063, G2064, G2065.

The following CPT code has been deleted from the policy: 99444.

The narrative for the following CPT code has been revised: 93790.


REVISIONS FROM MA00.037f:
01/01/2019This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following CPT codes have been added to the policy:

92273: Electroretinography (ERG), with interpretation and report; full field (ie, ffERG, flash ERG, Ganzfeld ERG)

92274: Electroretinography (ERG), with interpretation and report; multifocal (mfERG)

This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following CPT code has been termed from the policy:

92275: Electroretinography with interpretation and report

This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following CPT narratives have been revised in this policy:

93924

FROM: Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional

TO: Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system, or leadless pacemaker system with interim analysis, review(s) and report(s) by a physician or other qualified health care professional

93927

FROM: Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors, analysis, review(s) and report(s) by a physician or other qualified health care professional

TO: Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors, analysis, review(s) and report(s) by a physician or other qualified health care professional

93928

FROM: Interrogation device evaluation(s), (remote) up to 30 days; implantable loop recorder system, including analysis of recorded heart rhythm data, analysis, review(s) and report(s) by a physician or other qualified health care professional

TO: Interrogation device evaluation(s), (remote) up to 30 days; subcutaneous cardiac rhythm monitor system, including analysis of recorded heart rhythm data, analysis, review(s) and report(s) by a physician or other qualified health care professional

This policy has been identified and updated for the HCPCS code update effective 01/01/2019.

The following HCPCS code has been added to the policy:
G2011: Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., audit, dast), and brief intervention, 5-14 minutes


REVISIONS FROM MA00.037e:
01/01/2018This policy has been identified for the CPT/HCPCS code update.

The following CPT/HCPCS codes have been added to this policy, effective 01/01/2018:

93792, 93793, G0511, G0512, G0513, G0514, 95249, 99483, 99484, 99492, 99493, 99494

The following CPT codes have been deleted from this policy, effective 01/01/2018:

0180T, 99393, 99364

The following CPT code has been revised to this policy, effective 01/01/2018:

95251

REVISIONS FROM MA00.037d:
12/27/2017This policy will become effective 12/27/2017. When a professional provider

The policy was updated to be consistent with current template wording and format.

The following HCPCS code been added to this policy:

G0463: Hospital outpatient clinic visit for assessment and management of a patient

REVISIONS FROM MA00.037c:
01/01/2017This policy has been identified for the CPT code update.

The following CPT codes have been added to this policy, effective 01/01/2017: 96160, 96161, 0462T, 0463T, 0464T, D9311, G0501, G0505, G0506, G0508, G0509

The following CPT code has been deleted from this policy, effective 12/31/2016: 99420

REVISIONS FROM MA00.037b:
01/01/2016This policy has been identified for the CPT/HCPCS code update, effective 01/01/2016.

The following CPT/HCPCS been added to this policy:

0405T, G0296, 99177, 99415, 99416

The following CPT/HCPCS narratives have been revised in this policy:

99174, 99354, 99355

MA00.037a:
01/02/2015This is a coding update.

MA00.037:
01/01/2015This is a new policy.




Version Effective Date: 01/13/2020
Version Issued Date: 01/13/2020
Version Reissued Date: N/A