Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 00.10.01ab


Attachment:A

Policy #:00.10.01ab

Description:Pennsylvania Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers

Title:Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers


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.


PENNSYLVANIA (PA)
SERVICES PAID ABOVE CAPITATION FOR HEALTH MAINTENANCE ORGANIZATION (HMO) AND HEALTH MAINTENANCE ORGANIZATION POINT-OF-SERVICE (HMO-POS) PRIMARY CARE PHYSICIANS (PCPs)

NOTES:
  • The Effective Date indicates either the effective date of the code and/or the date the code became eligible for payment above capitation.
  • The Delete Date indicates either the date the code becomes invalid and/or the date the code is no longer eligible for reimbursement above capitation.
  • PA PCPs are eligible to receive payment above capitation for codes listed in the injectable drug and vaccine fee schedules. Injectable drug and vaccine codes are not included in the code list below.
  • PA PCPs are eligible to receive payment above capitation for select Durable Medical Equipment and Supplies, such as cast/splints, crutches, and canes. Durable Medical Equipment and Supplies are not included in the code list below.
SERVICES ELIGIBLE FOR PAYMENT ABOVE CAPITATION FOR PENNSYLVANIA PCPs
Code
Effective
Date
Delete
Date
0403T
01/01/2016
10060
12/01/08
10061
01/01/10
10080
12/01/08
10140
12/01/08
10160
12/01/08
11200
03/01/03
11201
01/01/09
11400
03/01/03
11401
03/01/03
11402
03/01/03
11403
03/01/03
11404
03/01/03
11406
03/01/03
11420
01/01/10
11421
01/01/10
11422
01/01/10
11423
01/01/10
11424
01/01/10
11426
01/01/10
11440
01/01/10
11441
01/01/10
11442
01/01/10
11443
01/01/10
11444
01/01/10
11446
01/01/10
11600
01/01/10
11601
01/01/10
11602
01/01/10
11603
01/01/10
11604
01/01/10
11606
01/01/10
11620
01/01/10
11621
01/01/10
11622
01/01/10
11623
01/01/10
11624
01/01/10
11626
01/01/10
11640
01/01/10
11641
01/01/10
11975
08/04/00
12/31/11
11976
08/04/00
11977
08/04/00
12/31/11
12001
03/01/03
12002
03/01/03
12004
03/01/03
12005
03/01/03
12006
03/01/03
12007
03/01/03
12011
03/01/03
12013
03/01/03
12014
03/01/03
12015
03/01/03
12016
03/01/03
12017
03/01/03
12018
03/01/03
12020
03/01/03
12021
03/01/03
17000
03/01/03
17003
03/01/03
17004
03/01/03
17110
01/01/08
17111
01/01/08
20550
03/01/03
20600
12/01/08
20604
01/01/15
20605
12/01/08
20606
01/01/15
20610
12/01/08
20611
01/01/15
31500
02/10/97
32421
01/01/08
01/01/13
36510
02/10/97
36620
02/10/97
36660
02/10/97
45330
03/01/03
45331
03/01/03
46916
03/01/03
46924
03/01/03
51100
01/01/08
51701
04/18/05
51702
04/18/05
51703
04/18/05
54000
08/01/01
54001
08/01/01
54056
03/01/03
54150
02/10/97
54160
02/10/97
56501
03/01/03
56515
03/01/03
57061
03/01/03
57065
03/01/03
57452
03/01/03
57454
03/01/03
57511
03/01/03
58100
03/01/03
58300
08/04/00
58301
08/04/00
86580
01/01/2016
86710
11/01/01
87275
08/19/2019
87276
08/19/2019
87400
08/19/2019
87501
08/19/2019
87502
08/19/2019
87503
08/19/2019
87804
01/01/02
87880
06/01/07
87899
11/01/01
90460
01/01/11
90461
01/01/11
90465
01/01/07
01/01/11
90466
01/01/07
01/01/11
90467
01/01/07
01/01/11
90468
01/01/07
01/01/11
90470
09/28/09
09/22/10
90471
01/01/07
90472
01/01/07
90473
01/01/07
90474
01/01/07


92227
10/01/17
92550
01/01/10
92567
03/01/03
92570
01/01/10
92585
01/01/02
92586
01/01/02
92587
01/01/02
92588
01/01/02
94010
08/01/12
94640
03/01/03
94664
03/01/03
95145
02/10/97
95146
08/01/01
95147
08/01/01
95148
08/01/01
95149
08/01/01
95165
02/10/97
95170
02/10/97
96127
01/01/15
97802
07/01/07
97803
07/01/07
97804
07/01/07
98960
08/01/08
98961
08/01/08
98962
08/01/08

SERVICES ELIGIBLE FOR PAYMENT ABOVE CAPITATION FOR PENNSYLVANIA PCPs
Code
Diagnosis Code
Effective
Date
Delete
Date
99078
08/01/08
99170
08/01/01
99188
01/01/15
99217
01/01/09
99218
01/01/09
99219
01/01/09
99220
01/01/09
99221
06/01/06
99222
06/01/06
99223
06/01/06
99224
01/01/11
99225
01/01/11
99226
01/01/11
99231
06/01/07
99232
06/01/07
99233
06/01/07
99234
01/01/09
99235
01/01/09
99236
01/01/09
99238
06/01/06
99239
06/01/06
99291
08/01/01
99292
08/01/01
99295
02/10/97
12/31/08
99296
02/10/97
12/31/08
99297
02/10/97
12/31/03
99301
08/01/01
12/31/05
99302
08/01/01
12/31/05
99303
08/01/01
12/31/05
99304
01/01/06
99305
01/01/06
99306
01/01/06
99307
01/01/06
99308
01/01/06
99309
01/01/06
99310
01/01/06
99311
08/01/01
12/31/05
99312
08/01/01
12/31/05
99313
08/01/01
12/31/05
99315
01/01/06
99316
01/01/06
99318
01/01/06
99321
08/01/01
12/31/05
99322
08/01/01
12/31/05
99323
08/01/01
12/31/05
99324
01/01/06
99325
01/01/06
99326
01/01/06
99327
01/01/06
99328
01/01/06
99331
08/01/01
12/31/05
99332
08/01/01
12/31/05
99333
08/01/01
12/31/05
99334
01/01/06
99335
01/01/06
99336
01/01/06
99337
01/01/06
99341
10/01/94
99342
10/01/94
99343
10/01/94
99344
08/01/01
99345
08/01/01
99347
10/01/94
99348
10/01/94
99349
10/01/94
99350
08/01/01
99384
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99385
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99386
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99387
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99394
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99395
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99396
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99397
Eligible when reported with ICD-10 code Z01.411, Z01.419, Z01.42. When reported with any other ICD-10, the service is included in capitation
10/01/04
99431
02/10/97
12/31/08
99436
02/10/97
12/31/08
99440
08/01/01
12/31/08
99460
01/01/09
99461
01/01/09
99462
01/01/09
99463
01/01/09
99464
01/01/09
99465
01/01/09
99468
01/01/09
99469
01/01/09

SERVICES ELIGIBLE FOR PAYMENT ABOVE CAPITATION FOR PENNSYLVANIA PCPs
Code
Effective
Date
Delete
Date
A4310
04/18/05
A4311
04/18/05
A4312
04/18/05
A4313
04/18/05
A4314
04/18/05
A4315
04/18/05
A4316
04/18/05
A4326
08/01/08
A4327
08/01/08
A4328
08/01/08
A4333
04/18/05
A4334
04/18/05
A4336
01/01/10
A4337
01/01/2016
A4338
04/18/05
A4340
04/18/05
A4344
04/18/05
A4346
04/18/05
A4348
04/18/05
01/01/07
A4349
04/18/05
A4351
04/18/05
A4352
04/18/05
A4353
04/18/05
A4354
04/18/05
A4357
04/18/05
A4358
04/18/05
A4359
04/18/05
01/01/07
A4360
01/01/10
A5056
01/01/12
A5057
01/01/12
A5102
04/18/05
A5105
04/18/05
A5112
04/18/05
A5113
04/18/05
A5114
04/18/05
A5200
04/18/05
G0008
01/01/07
G0009
01/01/07
G0010
01/01/07
G0108
08/01/08
G0109
08/01/08
G0270
07/01/07
G0271
07/01/07
G9141
09/15/09
09/22/10
S0610
07/01/03
S0612
07/01/03
S8930
01/01/19
S9140
08/01/08
S9141
08/01/08
S9449
07/01/07
S9452
07/01/07
S9455
08/01/08
S9460
08/01/08
S9465
08/01/08
S9470
07/01/07



Version Effective Date: 08/19/2019
Version Issued Date: 08/19/2019
Version Reissued Date: N/A

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