Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Always Bundled Procedure Codes
Policy #:MA00.026g

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.

Refer to the following News Article:
Coverage of Interprofessional Internet Consultation

This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

The procedure codes listed in Attachment A of the policy are always considered bundled into the reimbursement for other services and, therefore, are not eligible for separate reimbursement, whether billed alone or in conjunction with other services. Participating providers may not bill members for these services.
Policy Guidelines

This policy does not contain an all-inclusive list of procedure codes that may have editing applied to them. Procedure codes not listed in this policy continue to be subject to Company claims adjudication logic, eligibility, benefits, limitations, exclusions, pre-certification/referral requirements, provider contracts, and Company policies.

Description

The Company takes into consideration the Medicare Physician Fee Schedule database (MPFSD) and other appropriate sources.

The MPFSD identifies procedure codes with the status B indicator. The Status B Indicator is used when the reimbursement for certain procedure codes is always considered bundled into the reimbursement for other services.
References

Centers for Medicare & Medicaid Services (CMS). National Physician Fee Schedule Relative Value File. [CMS Web site]. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html. Accessed November 26, 2019.

Centers for Medicare and Medicaid Services Medicare Claims Processing Manual.Chapter 23-Fee Schedule Administration and Coding.Requirements. Table of Contents. (Rev. 4188, 12-28-18). Available at:http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf. Accessed November 26, 2019.



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: Always Bundled Procedure Codes
Description: CPT Codes and HCPCS Codes



 Policy: MA00.003n:Preventive Care Services

 Policy: MA00.006f:Care Management and Care Planning Services

 Policy: MA00.009g:Reporting and Documentation Requirements for Anesthesia Services

 Policy: MA00.010z:PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services

 Policy: MA00.044b:Criteria for Reimbursement of Emergency Room Services

 Policy: MA07.007g:Pulmonary Function Tests

 Policy: MA07.024c:Medical and Surgical Treatment of Temporomandibular Joint Disorder

 Policy: MA10.003f:Physical Medicine & Rehabilitation Services: Physical Therapy (PT) and Occupational Therapy (OT)

 Policy: MA11.002h:Hematopoietic Stem Cell Transplantation

 Policy: MA11.056e:Percutaneous Transluminal Angioplasty (PTA) Concurrent with or without Stenting and Extracranial- Intracranial (EC-IC) Arterial Bypass Surgery

 Policy: MA11.108d:Spinal Fusion




Policy History

REVISIONS FROM MA00.026g:
01/01/2020This version of the policy will become effective 01/01/2020. Effective 01/01/2020, the following three Healthcare Common Procedure Coding System (HCPCS) codes will be included in the Always Bundled Procedure Codes policy. They are not eligible for separate reimbursement.

99360
G0175
S0220
S0221

CPT code 99360 previously resided in the policy entitled Physician/Nonphysician Standby Services (MA00.013). The other three codes previously resided in the policy entitled Medical Team Conferences (MA00.017).

REVISIONS FROM MA00.026f
07/01/2019This version of the policy will become effective 07/01/2019.

Effective 07/01/2019, language regarding Healthcare Common Procedure Coding System (HCPCS) code S8030 will be removed from the Proton Beam Therapy Radiation policy. It is not eligible for separate reimbursement, as the service is included in the treatment planning. As such, it will be included in the Always Bundled Procedure Codes policy. This policy update reflects this change.

S8030 Scleral application of tantalum ring(s) for localization of lesions for proton beam therapy

REVISIONS FROM MA00.026e
01/01/2019This version of the policy will become effective 01/01/2019.

The following CPT codes has been deleted from this policy: 99090.

The following CPT codes have been added to this policy: 0537T, 0538T, 0539T.

REVISIONS FROM MA00.026d
11/26/2018This version of the policy will become effective 11/26/2018.

This policy has been updated as a result of the quarterly update to the Medicare Physician Fee Schedule.

The following Procedure codes have been added to Attachment A of the policy:
34839, G0501

The following Procedure codes have been deleted from Attachment A of the policy:
99091, 99487, 99488, 99489

REVISIONS FROM MA00.026c
01/01/2017Claim payment policy MA00.026b has been updated, and has been re-issued as policy MA00.026c on 01/01/2017.
----------------------------
Note: On 09/25/2017 codes 99358 and 99359 were removed from Attachment A. These codes were inadvertently included in this version.

REVISIONS FROM MA00.026b
10/01/2016Claim payment policy MA00.026a has been updated, and has been re-issued as policy MA00.026b on 10/01/2016.

The following Procedure codes have been added to Attachment A of the policy: 99100, 99116, 99135, 99140

REVISIONS FROM MA00.026a
08/05/2015This version of the policy will become effective 08/05/2015.

The policy has been reviewed and reissued to communicate the Company’s reimbursement position for procedure codes that are always bundled.

Procedure code 96040 has been removed from Attachment A.

REVISIONS FROM MA00.026
01/01/2015This is a new policy.






Version Effective Date: 01/01/2020
Version Issued Date: 12/31/2019
Version Reissued Date: N/A