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.
American Medical Association (AMA). CPT® 2018 Professional Edition: Spiralbound.
Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 12: Physicians/Nonphysician Practitioners. §40.8. pg. 95-97. [CMS Web site]. 01/26/07. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf.
Centers for Medicare & Medicare Services (CMS). PFS Relative Value Files http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html
Optum 360. Understanding Modifiers. West Valley City, UT. Optum 360; 2018
Policy: 00.10.18l:Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS
Policy: 11.00.10w:Multiple Surgery Payment Reduction