Notification



Notification Issue Date:



Claim Payment Policy


Title:Computer Analysis and Generation of Automated Data in Conjunction with Diagnostic Studies

Policy #:06.00.01e

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

The Company considers the computer analysis and generation of automated data to be integral parts of a covered, diagnostic study and are, therefore, not eligible for separate reimbursement consideration.

Computer analysis and generation of automated data reported independently of a diagnostic procedure (from the same or different provider) or with a noncovered diagnostic procedure are not eligible for separate reimbursement.

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 health care professional'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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, diagnostic studies with computer analysis and generation of automated data are covered under the medical benefits of the Company's products. Individual member benefits must be verified.

Description

The results of diagnostic studies may be computer analyzed and generated by an automated system. Examples of studies for which computer analysis and generation of automated data may be available include, but are not limited to:
  • Electrocardiogram (ECG)
  • Cardiovascular stress test (without radiopharmaceutical injection)
  • Rhythm ECG
  • Electromyelogram (EMG)
  • Urea breath test, carbon-14 (C-14)
  • Cardiac blood pool imaging
  • Apnea monitoring
  • Ambulatory ECG monitoring
  • Noninvasive peripheral arterial test and pulse volume recording
  • Papanicolaou (Pap) smears

References


Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 13: Radiology services and other diagnostic procedures. [CMS Web site]. 03/06/08. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c13.pdf. Accessed July 29th, 2015.




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)

99090


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)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements



Policy History

Effective 10/05/2017 this policy has been updated to the new policy template
format.
Version Effective Date: 08/26/2015
Version Issued Date: 08/26/2015
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.