Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

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

Notification Issue Date:

This policy has been identified for the Quarterly Code Update. This version of the policy will become effective 07/01/2020.

The following CPT codes have been deleted from this policy: 0124U, 0125U, 0126U, 0127U, 0128U.

The following CPT codes have been added to this policy: 0172U, 0173U, 0174U, 0175U, 0176U, 0177U, 0178U, 0179U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0202U, 0223U, 0224U, 87426, 77063

The following CPT codes have been revised in this policy: 0165U

Title:

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

Policy #:

00.01.25bk

Policy

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 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 (AHRQ). Vision rehabilitation for elderly individuals with low vision or blindness.
https://www.cms.gov/Medicare/Coverage/InfoExchange/downloads/rtcvisionrehab.pdf. Accessed March 8, 2023.

American Optometric Association. Low vision. https://www.aoa.org/patients-and-public/caring-for-your-vision/low-vision. Accessed March 8, 2023.

Company Provider Contracts.

ICD-10-CM Official Guidelines for Coding and Reporting FY 2019. Low Vision Rehabilitation.
https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2019-ICD10-Coding-Guidelines-.pdf. Accessed March 8, 2023.

Coding

CPT Procedure Code Number(s)

See Attachments.

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

See Attachment D.

HCPCS Level II Code Number(s)

See Attachments.

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

9/25/2023

Version Issued Date:

9/25/2023

Version Reissued Date:

00.01.25

Claim Payment Policy Bulletin

Commercial

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