Notification



Notification Issue Date:



Claim Payment Policy


Title:Physician/Nonphysician Standby Services

Policy #:00.10.16d

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 does not reimburse for physician standby services because no direct patient care is actually rendered. The Company considers physician standby services to be integral to care and, therefore, not eligible for reimbursement, whether billed alone or in conjunction with other services.

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, the following: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, other health care professionals, 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

BILLING GUIDELINES

Attendance and initial stabilization of a newborn at a vaginal or Cesarean delivery, by a physician other than the physician performing the delivery, is not the same as a physician standby service where no service is actually rendered. This code specifies that active pediatric care and services are being provided during the period of attendance.

Inclusion of a code in this policy does not guarantee reimbursement. Eligibility, benefits, limitations, exclusions, pre-certification/referral requirements, provider contracts, and Company policies apply.

Description

Physician standby services involve a period of time in which a physician remains available during a procedure in the event that their particular skills are needed. No direct patient care is rendered.

Examples of physician/nonphysician standby services include the following:
  • An anesthesiologist's or Certified Registered Nurse Practitioner's (CRNP's) availability in the event that a procedure requires an anesthesiologist's particular skills
  • A cardiac surgeon's availability during percutaneous transluminal coronary angioplasty (PTCA) in the event that a complication develops requiring open heart surgery

When a physician provides standby services, care, or services by the physician may not be made to other individuals during the standby period.
References


Centers for Medicare and Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12: Physicians/Nonphysician Practitioners. 30.6.15.3: Physician Standby Service (Code 99360). [CMS Web site]. 05/01/18. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed October 3, 2018.




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)

99360


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

REVISIONS FROM 00.10.16d
11/21/2018This policy has been reviewed and reissued to communicate the Company’s continuing position on physician standby services.


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


Version Effective Date: 01/01/2013
Version Issued Date: 01/01/2013
Version Reissued Date: 11/21/2018

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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.