Notification



Notification Issue Date:



Claim Payment Policy


Title:PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services

Policy #:00.01.25ar

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

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

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

The PPO Network Rules and limited circumstances are as follows:

DURABLE MEDICAL EQUIPMENT RULES AND LIMITED CIRCUMSTANCES
  • Durable medical equipment (DME) (which includes prosthetics and orthotics) under the PPO benefit program (DME Network Rules and Limited Circumstances, Attachments A1 and A2) is considered eligible for payment in an office, in an outpatient setting, and in a home setting, when supplied by an ancillary provider with the DME specialty, such as DME and pharmacy/DME.
  • The limited circumstances of DME services that a participating specialist, (this includes certified registered nurse practitioners (CRNPs) and Physician Assistants (PAs) practicing within these specialty groups), other than a DME provider, may provide, and for which the provider may be eligible for reimbursement, are listed in Attachment A3. Refer to Attachment A3 for the specific provider specialties and eligible codes.
  • All other provider specialties are considered ineligible to provide DME/prosthetic/orthotic equipment, unless otherwise identified by specialty and code in attachment A3.

LABORATORY RULES AND LIMITED CIRCUMSTANCES
  • Laboratory services under the PPO benefit program are determined by the Bureau of Laboratories, and defined by the Pennsylvania Department of Health. For the PPO line of business, all laboratory services listed in Attachment B1 of this policy are considered eligible for payment in an office or outpatient setting, when performed by any type of participating PPO provider. Laboratory services listed in Attachment B2 of this policy are only eligible for payment when performed by an independent or a physiological laboratory.
  • The limited circumstances of laboratory services that a participating specialist, (this includes CRNPs and PAs practicing within these specialty groups), other than an independent or a physiological laboratory, may provide, and for which the provider may be eligible for reimbursement, are listed in Attachment B3 of this policy.
  • All other provider specialties are considered ineligible to provide laboratory services, unless otherwise identified by specialty and code in attachment B3.

RADIOLOGY RULES AND LIMITED CIRCUMSTANCES
  • Radiology services under the PPO benefit program (Radiology Network Rules and Limited Circumstances, Attachment C1) are considered eligible for payment in an outpatient and office setting when performed by a radiologist or pediatric radiologist at a contracted radiology site.
  • The limited circumstances of radiology services that a participating specialist, (this includes CRNPs and PAs practicing within these specialty groups), other than a radiology provider, may provide, and for which the provider may be eligible for reimbursement, are listed in Attachment C2. Refer to attachment C2 for the specific provider specialties and eligible codes.
  • All other provider specialties are considered ineligible to provide radiology services, unless otherwise identified by specialty and code in attachment C2.

PHYSICAL MEDICINE AND REHABILITATIVE RULES AND LIMITED CIRCUMSTANCES
  • Physical medicine and rehabilitative services under the PPO benefit program (Physical Medicine and Rehabilitation Network Rules and Limited Circumstances, Attachment D) are considered eligible for payment in an office and outpatient setting, when performed by a physical therapist at a contracted physical therapy site.
  • The limited circumstances of physical medicine and rehabilitative services that a participating specialist, (this includes CRNPs and PAs practicing within these specialty groups), other than a physical therapist provider, and for which the provider may be eligible for reimbursement, are also listed in Attachment D. Refer to Attachment D for the specific provider specialties and eligible codes.
  • All other provider specialties are considered ineligible to provide physical medicine and rehabilitative services, unless otherwise identified by specialty and code in Attachment D.

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.

BILLING REQUIREMENTS

Services performed in the outpatient setting are subject to facility global payment rules. The presence of a code on the exception list will not result in separate payment to the professional provider when the reimbursement to the facility includes payment for both the professional and the technical component of the service.
Guidelines

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

Description

This Network Rules policy documents the Company’s reimbursement position for participating Preferred Provider Organization (PPO) professional and ancillary providers who supply durable medical equipment (DME) and perform laboratory, radiology, and physical medicine and rehabilitative services. This policy addresses these services provided in the office or outpatient settings, in the home setting for DME, and at an independent laboratory for laboratory services. The Network Rules policy identifies the specific provider specialties that are eligible for payment when billing Current Procedural Terminology (CPT) or Healthcare Common Procedural Coding System (HCPCS) codes within the four service or equipment types, as defined below:
  • DME (which includes prosthetics and orthotics) refers to equipment and/or a device that meets the following identified criteria:
    • DME criteria:
      • It is durable and can withstand repeated use.
      • It is medical equipment, meaning it is primarily and customarily used to serve a medical purpose.
      • It generally is not useful to an individual in the absence of an illness or injury.
      • It is appropriate for use in the home.
    • Prosthetics criteria:
      • Prosthetics are devices that replace all or part of either of the following:
        • An absent body organ, including contiguous tissue
        • The function of a permanent inoperative or malfunctioning body organ
    • Orthotics criteria:
      • Orthotics are fabricated or fitted braces or supports (in some cases custom) that are designed to provide alignment/correction in or prevention of neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity.
  • Laboratory services are tests that are performed on biological specimens in order to obtain information about an individual’s health. These tests, which involve measurements, are conducted under controlled conditions.
  • Radiology services encompass the scientific discipline of medical imaging, which utilizes ionization radiation, radionuclides, magnetic resonance, and ultrasound.
  • Physical medicine and rehabilitative care services consist of the combined use of medical, physical, social, technological, educational, and vocational services that enable individuals with disabilities or impairments resulting from disease, injury, prior therapeutic intervention, or congenital anomaly to achieve the highest possible level of functional ability and/or independence in activities of daily living.

Network Rules for provision of specialty services include limited circumstances when participating PPO professional and ancillary providers, other than the designated specialty providers, may be eligible for payment for the provision of certain specialty services. These limited circumstances are identified by specific selected procedures that are eligible when billed by providers with specific specialties in an office or outpatient setting.
References


Agency for Healthcare Research and Quality. Vision rehabilitation for elderly individuals with low vision or blindness. http://www.cms.gov/Medicare/Coverage/InfoExchange/downloads/rtcvisionrehab.pdf. Accessed July 28, 2014.

American Optometric Association. Low vision. http://www.aoa.org/patients-and-public/caring-for-your-vision/low-vision?sso=y. Accessed July 28, 2014.

Company Benefit Contracts.




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 Attachments


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)

See Attachment D


HCPCS Level II Code Number(s)

See Attachments


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A1: PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Description: DME Network Rules and Limited Circumstances

Attachment A2: PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Description: DME Network Rules and Limited Circumstances cont'd.

Attachment A3: PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Description: DME Network Rules and Limited Circumstances

Attachment B1: PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Description: Laboratory Network Rules and Limited Circumstances

Attachment B2: PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Description: Laboratory Network Rules and Limited Circumstances cont'd.

Attachment B3: PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Description: Laboratory Network Rules and Limited Circumstances cont'd.

Attachment C1: PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Description: Radiology Network Rules and Limited Circumstances

Attachment C2: PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Description: Radiology Network Rules and Limited Circumstances cont'd.

Attachment D: PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Description: Physical Medicine & Rehabilitation Network Rules and Limited Circumstances



Policy History

00.01.25ar:
01/01/2019This version of the policy will become effective 01/01/2019.

The following CPT & HCPCS codes have been deleted from this policy: 0346T, 77058, 77059, 78270, 78271, 78272, 81211, 81213, 81214, K0903

The following CPT & HCPCS codes have been added to this policy: E0447, E0467, A6460, A6461, L8698, 0541T, 0542T, 76978, 76979, 76981, 76982, 76983, 77046, 77047, 77048, 77049, 81163, 81164, 81165, 81166, 81167, 81171, 81172, 81173, 81174, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81204, 81233, 81234, 81236, 81237, 81239, 81271, 81274, 81284, 81285, 81286, 81289, 81305, 81306, 81312, 81320, 81329, 81333, 81336, 81337, 81343, 81344, 81345, 81443, 81518, 81596, 82642, 83722, 0080U, 0081U, 0082U, 0083U.

The following CPT & HCPCS codes have been revised in this policy: 77387, 81162, 81212, 81215, 81216, 81217, 81244, 81287, 81327, E0218, E0483


REVISIONS FROM 00.01.25aq:
04/01/2018Revised policy number 00.01.25aq was issued effective 04/01/2018.

The below limited circumstances have been removed from Attachment B3, effective 04/01/2018, and are no longer eligible for reimbursement when performed by participating physician specialty office-based pathologists or free-standing office pathology practices:
    • Service codes 88187, 88188, 88189, 88291, 88302 modifier 26, 88304 modifier 26, 88305, 88312 modifier 26, 88313 modifier 26, 88341 modifier 26 and 88342 modifier 26 when performed by a Pathologist, Anatomic pathologists, or Anatomic and Clinical pathologists in place of service office.
    • 88313, 88341, 88342, 88313 modifier 26, 88341 modifier 26, 88342 modifier 26, 88304 modifier 26, 88305 modifier 26, and 88312 modifier 26 when performed by a Oral and Maxillofacial Pathology in place of service office.
    New code K0903 For diabetics only, multiple density insert, made by direct carving with cam technology from a rectified cad model created from a digitized scan of the patient, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each

REVISIONS FROM 00.01.25ap:
01/01/2018This policy becomes effective 01/01/2018.

The following HCPCS codes have been added to Attachment A1 of this policy:

E0953, E0954, L3761, L8625, L8694, L7700


The following HCPCS code narratives have been revised to Attachment A2 of this policy:

L3760, L8618, L8624, L8691

The following CPT codes have been added to Attachment B2 of this policy:

0011M, 0024U, 0025U, 0026U, 0027U, 0028U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0500T, 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81175, 81176, 81230, 81231, 81232, 81238, 81247, 81248, 81249, 81258, 81259, 81269, 81283, 81328, 81334, 81335, 81346, 81361, 81362, 81363, 81364, 81448, 81520, 81521, 81541, 81551, 86794, 87634, 87662, 86008

The following CPT codes have been deleted from Attachment B2 of this policy:

83499, 84061, 86185, 86243, 86378, 86729, 86822, 87277, 87470, 87477, 87515, 88154

The following CPT code narratives have been revised to Attachment B2 of this policy:

80305, 80306, 80307, 81257, 81432, 81439, 82042, 82043, 82044

The following CPT codes have been added to Attachment C1 of this policy:

0482T, 0501T, 0502T, 0503T, 0504T, 71045, 71046, 71047, 71048, 74018, 74019, 74021

The following CPT codes have been deleted from Attachment C1 of this policy:

71010, 71015, 71020, 71021, 71022, 71023, 71030, 71034, 71035, 74000, 74010, 74020, 77422, 78190, G0202, G0204, G0206

The following CPT code narratives have been revised to Attachment C1 of this policy:

76000, 76881, 76882

The following CPT codes have been deleted from Attachment C2:

G0202, G0204, G0206

The following CPT codes have been added to Attachment D of this policy:

97127, G0515, 97763

The following CPT codes have been deleted from Attachment D of this policy:

97532, 97762

The following CPT code narratives have been revised to Attachment D of this policy:

97760, 97761

REVISIONS FROM 00.01.25ao:
12/01/2017This policy becomes effective 12/01/2017.

This policy has been expanded to include Physician Assistants (PAs) to be eligible to perform services in a specialty group.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2019
Version Issued Date: 01/29/2019
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.