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ANTHEM BLUE CROSS REIMBURSEMENT POLICIES AND MCKESSON CLAIMSXTEN RULES

Overview This document provides all new, revised and existing Reimbursement Policies and all new, revised and existing claims editing rules administered by ClaimsXtenTM that are effective January 1, 2018. Claims submitted in a CMS-1500 format will be subject to the editing rules. This document is organized into two sections: McKesson ClaimsXtenTM Rules: The enclosed grid includes all claims editing rules in. This grid

lists all claims editing rules (new, revised and existing). Reimbursement Policies: Copies of all Reimbursement Policies are enclosed, which includes all

new, revised and existing reimbursement policies, including the following which are new or updated policies that are effective January 1, 2018:

Policy # 0008: Bundled Services and Supplies We have updated the Bundled Services and Supplies Section 1 code list to reflect that transitional care codes 99495 and 99496 are eligible for separate reimbursement. Medical decision making and the date of the first face-to-face visit are used to select and report the appropriate Transitional Care Management (TCM) code. For 99496, the face-to-face visit must occur within 7 calendar days of the date of discharge and medical decision making must be high complexity. For 99495, the face-to-face visit must occur within 14 calendar days of the date of discharge and medical decision making must be of at least moderate complexity. Only one provider may report these services and only once per patient within 30 days of discharge.

Policy # 0016: Frequency Editing HCPCS code A9276 (sensor; invasive, disposable, for use with interstitial continuous glucose monitoring system, 1 unit = 1 day supply) will have a unit limit of 1 per three (3) days of service for claims processed on and after January 1, 2018. Modifiers will not override this frequency limit edit. Policy # 0026: Evaluation and Management Services and Related Modifiers -25 & -57 Beginning with claims processed on and after January 1, 2018, Evaluation and Management Services that are eligible for separate reimbursement when reported by the same provider on the same day as a minor surgery (0 or 10 day global period) will be reduced by 50%. Policy # 0029: Laboratory and Venipuncture Services For claims processed on and after January 1, 2018, when routine venipuncture CPT code 36415 is reported with Evaluation and Management (E/M) office visit codes (99201-99205 and 99211-99215), it is included in the reimbursement for office visit E/M services and is not eligible for separate reimbursement. CPT code 36415 is eligible for separate reimbursement when reported with a laboratory service. Modifiers will not override the edit. Policy # 0038: Drug Screen Testing Beginning with claims processed on and after January 1, 2018, G0480, G0481, G0482, or G0483 (definitive drug testing) will not be eligible for separate reimbursement when reported on the same date of service as 80307 (presumptive drug testing by instrumented chemistry analyzers) for the same patient by an independent clinical laboratory. In addition, to be considered for reimbursement, additional documentation must be provided specifying the rationale for the drug classes being tested for to support performing the higher level definitive drug testing codes G0482 (15-21 drug classes) and G0483 (22 or more drug classes).

Policy # 0055: Acupuncture When Billed with Evaluation and Management A new policy titled Acupuncture when billed with Evaluation and Management Services will be effective for claims processed on and after [January 1, 2018]. E&M services performed by a physician or other health care professional and billed with Acupuncture services will not be eligible for reimbursement. Claims must be submitted in accordance with the reporting guidelines and instructions contained in the American Medical Association (AMA) CPT Manual, CPT Assistant, and HCPCS publications. Providers

are responsible for accurately reporting the medical, surgical, diagnostic, and therapeutic services rendered to a member with the correct CPT and/or HCPCS codes, and for appending the applicable modifiers, when appropriate. Updates to claims editing rules may be implemented from time to time to reflect the addition of new/revised CPT/HCPCS codes and their associated edits, Correct Coding Initiative (CCI) revisions, and changes identified through regular review or inquiry. In addition to updates that are implemented from time to time to reflect the addition of new/revised CPT/HCPCS codes and their associated edits, CCI revisions, and changes identified through regular review or inquiry, we will be updating the rules as outlined below.

ANTHEMBLUECROSSCLAIMSXTENTMRULES10/1/2016Update

Rule RelatedAnthemProfessionalReimbursementPolicy/Policies

New,Existing,orRevisedPolicy

Edit EditLogic EffectiveProcessDate(willaffectanydateofserviceprocessedonorafterdatelisted)orDateofService(DOSonorafterdatelisted)

Documentationpolicy DocumentationGuidelinesforAdaptiveBehaviorAssessmentsandTreatmentforAutismSpectrumDisorder#0052

new Noeditsinvolved;thisisadocumentationsguidelinespolicy. N/A Dateofservice10/01/2016

Frequency/MaximumOccurances OnceperLifetimeProcedures#0049

new When the Health Plan identifies a once per lifetime procedure on the current claim andalso identifies a historical claim with the same or different procedure code that includesthe current procedure in the description (code grouping), the current procedure will notbe eligible for reimbursement. This will include those once per lifetime proceduresprocessed and approved either by a previous carrier or with another Anthem, Inc.affiliatedhealthplan.

HealthPlanPolicy DateofService10/01/2016

Frequency/MaximumOccurrences UnitsFrequencyMaximumforDrugsandBiologicSubstances#0048

new CodeDescription

J0180Injection,agalsidasebeta,1mg(Fabrazyme)J0490Injection,belimumab,10mg(Benlysta)J1602Injection,golimumab,1mg(Simponi)J1745Injectioninfliximab,10mg(Remicade)J2796Injection,romiplostim,10mcg(Nplate)J9035Injection,bevacizumab,10mg(Avastin)J9041Injection,bortezomib,0.1mg(Velcade)J9055Injection,cetuximab,10mg(Erbitux)J9171Injectiondocetaxel1mg(Docetaxel)J9206Injectionirinotecan20mg(Camptosar)J9228Injection,ipilimumab,1mg(Yervoy)J9263Injection,oxaliplatin,0.5mg(Eloxatin/Oxaliplatin)J9305Injectionpemetrexed10mg(Alimta)J9310Injection,rituximab,100mg(Rituxan)

HealthPlanPolicy

Specialtypharmacyreview

Seepolicyforrationalesandmaximumunitsforeachdrug.

DateofService10/01/2016

Paypercentmultiplediagnosticcardiology

MultipleDiagnosticCardiology#0051

new Newpolicywewillapplyamultipleprocedurepaymentreduction(MPPR)of25%tothetechnicalcomponentofdiagnosticcardiologyservicesthathaveamultipleprocedureindicator(MPI)ofsix(6)inthemultipleprocedurecolumnoftheCMSNationalPhysicianFeeSchedule(NPFS).

HealthPlanPolicy

BasedonCMS

Dateofservice10/17/2016

Paypercentmultiplediagnosticophthalmology

MultipleDiagnosticOphthalmology#0050

new Newpolicywewillapplyamultipleprocedurepaymentreduction(MPPR)of20%tothetechnicalcomponentofdiagnosticophthalmologyservicesthathaveamultipleprocedureindicator(MPI)ofseven(7)inthemultipleprocedurecolumnoftheCMSNationalPhysicianFeeSchedule(NPFS).

HealthPlanPolicy

BasedonCMS

Dateofservice10/17/2016

1





AlwaysBundledServicesandSupplies BundledServicesandSupplies#0008

Revised ThiseditdeniescodesforwhichAnthemdoesnotreimbursewhenreportedaloneorwithanyotherprocedure

Revisions:Reimbursementisnotprovidedforthefollowingcodes:G0151G0164,Q5001Q5002andQ5009(skilledservicesprovidedinthehomeorhospicesettings)

HealthPlanPolicy

ThiseditdeniescodesforwhichAnthemdoesnotreimbursewhenreportedaloneorwithanyotherprocedure





Revisions:Reimbursementisnotprovidedforthefollowingcodes:G0299G0300,G9473G9479

HealthPlanPolicy





Revised Reimbursementisnotprovidedforthefollowingcode:S9484,S9485,S9990andS9992 HealthPlanPolicy

Revisions:Reimbursementisnotprovidedforthefollowingcode:S9484,S9485,S9990andS9993

HealthPlannonapproveddrugs,programs,services,andsuppliesidentifiedbycertainHealthcareCommonProceduralCodingSystem(HCPCSLevelII)Scodesincluding,butnotlimitedto,diseasemanagementprograms,orwhenanothercurrentCurrentProceduralTerminology(CPT)orHCPCScodeexists




Revisions:Reimbursementisnotprovidedforthefollowingcode:8030080304,8032080377and83992




BundledServiceandSupplies BundledServicesandSupplies#0008

Modifiers59andXE,XP,XS,&XU(DistinctProcedural/Separate/UnusualService)

Revised ThiseditwilldenyA4648(tissuemarker)whenreportedwith1908119101(breastbiopsy)or1928119288(placementofbreastlocalizationdevice(s)).Modifierswillnotoverridethisedit.

HealthPlanPolicy

RVUsforthebreastbiopsyandclipplacementcodesincludethecostoftheclip(tissuemarker).


2





BundledServiceandSupplies Modifier59#0023 Revised Procedure29875denieswhenreportedwithotherarthroscopickneeprocedurecodes(29880,29881,29882and29883)performedonthesameknee;modifiers59,XE,XP,XSorXUwillnotoverridetheedit.


BundledServicesandSupplies BundledServicesandSupplies#0008

Modifier 59 #0023

Revised Denyvaliditytesting(82570and83986)whenreportedwithlabtoxicologycodes(8030080377,83992,G0477G0483);modifierswillnotoverridethisedit

Denyvaliditytesting(82570and83986)whenreportedwithlabtoxicologycodes(8030080377,83992,G0477G0483);modifierswillnotoverridethisedit



Modifier 59 #0023

Revised Deny95940asmutuallyexclusivewhenreportedwith95941(intraoperativeneurophysiologicmonitoringprocedures)bythesameprovider,forthesamemember,onthesamedateofservice.Modifierswillnotoverridethisedit.


BundledServicesandSupplies ObstetricsServices#0011

Revised Thiseditwilldenyprocedures7680176802,76805,76810or7681576817whenreportedwithanICD10RoutineDiagnosisCode[onlytakenfromtheroutineObstetricsservicespolicy]

Thiseditwilldenyprocedures7680176802,76805,76810or7681576817whenreportedwithanICD10RoutineDiagnosisCode[onlytakenfromtheroutineObstetricsservicespolicy]


Frequency/MaximumOccurances FrequencyEditing#0016

revised Limitprocedurecode86160(COMPLEMENT;ANTIGEN,EACHCOMPONENT)to4unitsperdaywithnomodifieroverride.

HealthPlanPolicy

BasedonCMSMUEs

ProcessDate08/22/2016

Frequency/MaximumOccurrences FrequencyEditing#0016

Revised Thiswilladdalimitofoneunitperdateofservicefor87529(herpessimplexvirus,amplifiedprobetechnique).

Thiswilladdalimitofoneunitperdateofservicefor87529(herpessimplexvirus,amplifiedprobetechnique).

10/1/2016


Revised Thiswilladdalimitof1unitperdateofserviceforJ9031(Theracys/TiceBCG). HealthPlanPolicy




Revised Thiswilladdalimitof10unitsperdateofserviceforJ2649(Aloxi,25mcg). HealthPlanPolicy




Revised Thiswilladdalimitof10unitsperdateofserviceforJ9217(LupronDepot,Eligard,7.5mg).

HealthPlanPolicy

Specialtypharmacyreview.



Revised Thiswilladdalimitof600unitsperdateofserviceforJ0585(Botox/BotoxCosmetic)and400unitsperdateofserviceforJ0717(Cimzia).

HealthPlanPolicy




Revised Thiswilladdalimitof200unitsperdateofserviceforJ0586(Dysport). HealthPlanPolicy




Revised Thiswilladdalimitof20unitsperdateofserviceforJ9395(Faslodex)andalimitof20unitsperdateofserviceforJ1750(Dextran).

HealthPlanPolicy



3






Revised Thiswilladdalimitof8unitsperdateofserviceforJ2507(Krystexxa). HealthPlanPolicy




Revised Thiswilladdalimitof60unitsperdateofserviceforJ9047(Kyprolis). HealthPlanPolicy




Revised Thiswilladdalimitof100unitsperdateofserviceforJ0129(Orencia). HealthPlanPolicy




Revised Thiswilladdalimitof120unitsperdateofserviceforJ0897(Prolia/Xgeva). HealthPlanPolicy




Revised Thiswilladdalimitof40unitsperdateofserviceforJ2353(Sandostatin,Depot). HealthPlanPolicy




Revised Thiswilladdalimitof150unitsperdateofserviceforJ1453(Emend). HealthPlanPolicy




Revised Thiswilladdalimitof3unitsperdateofserviceforJ9202(Zoladex). HealthPlanPolicy




Revised Thiswilladdalimitof5unitsperdateofserviceforJ3489(ZoledronicAcid). HealthPlanPolicy




Revised Thiswilladdalimitof96unitsperdateofserviceforJ7325(Synvisc/Synviscone). HealthPlanPolicy




Revised Thiswilladdalimitof90unitsperevery28daysforJ3357(Stelara,1mg). HealthPlanPolicy




Revised Thiswilladdalimitofoneunitperevery60daysfor11720(debridementforonetofivenails)andalimitofoneunitperevery60daysfor11721(debridementforsixormorenails).

HealthPlanPolicy

BasedonCMS

Thiswilladdalimitofoneunitperevery60daysfor11720(debridementforonetofivenails)andalimitofoneunitperevery60daysfor11721(debridementforsixormorenails).



Revised Thiswilladdalimitof90unitsperevery14daysforJ2357(Xolair,5mg). HealthPlanPolicy



4






Revised Thiswilladdalimitof14unitsperevery90daysforJ7312(Ozurdex). HealthPlanPolicy




Revised Thiswilladdalimitofoneunitfor96401withtheadministrationofXolairandadiagnosisofidiopathicurticaria.

HealthPlanPolicy

Limitis1injectionperdrug;thisdrugadministrationcodeisfortheadministrationofadrug,notthenumberofinjectionsneededtoadministerthecorrectdosageofthedrug.



Revised Thiswilladdalimitof18unitsperevery365daysfor8032080377and83992(confirmationtestingcodes)forparticipatingproviders.

Thiswilladdalimitof18unitsperevery365daysfor8032080377and83992(confirmationtestingcodes)forparticipatingproviders.


ModifiertoProcedureValidation DurableMedicalEquipment#0022

Revised Thiseditdeniescodeswhenreportedwithinappropriatemodifiers.

Revisions:Reimbursementwhenreportedwithpurchasemodifiersisnotprovidedforthefollowingcodes,whichareclassifiedasRenttoPurchaseitemsandarenoteligibleforupfrontpurchase:E0601,E0470,E0471,E0561,E0562(BiPAP,CPAP,humidifiers)whensubmittedwithpurchasemodifiersNR,NU,andUE

HealthPlanPolicy

Reimbursementwhenreportedwithpurchasemodifiersisnotprovidedforthefollowingcodes,whichareclassifiedasRenttoPurchaseitemsandarenoteligibleforupfrontpurchase:E0601,E0470,E0471,E0561,E0562(BiPAP,CPAP,humidifiers)whensubmittedwithpurchasemodifiersNR,NU,andUE


ModifiertoProcedureValidation ModifierRules#0017 Revised Thisdeniescodeswhenreportedwithinappropriatemodifiers.

Revisions:ReimbursementisnotprovidedforsurgeriesreportedwithmodifierSA

Thisdeniescodeswhenreportedwithinappropriatemodifiers.



Paypercentradiology ModifierRules#0017 Revised Wewillapplya5%reductionfordatesofservicebeginningOctober1,2016throughDecember31,2016anda15%reductionfordatesofserviceonorafterJanuary1,2017tothetechnicalcomponentofdiagnosticcomputedtomographyservicesforthehead/brain,abdomen,pelvis,upperextremity,lowerextremity,etc.inthefollowingcoderangesandanysucceedingcodes:7045070498,7125071275,7212572133,7219172194,7320073206,7370073706,7415074178,7426174263,and7557175574.

HealthPlanPolicy

BasedonCMSguidelineComputedtomographyservicesthatarefurnishedonnonNEMAStandardXR292013compliantCTequipmentmustincludemodifierCT


5

ANTHEMBLUECROSSCLAIMSXTENRULES10/1/2016Update







HealthPlanPolicy







HealthPlanPolicy





Revised Reimbursementisnotprovidedforthefollowingcode:S9484,S9485,S9990andS9992 HealthPlanPolicy

Revisions:Reimbursementisnotprovidedforthefollowingcode:S9484,S9485,S9990andS9993

HealthPlannonapproveddrugs,programs,services,andsuppliesidentifiedbycertainHealthcareCommonProceduralCodingSystem(HCPCSLevelII)Scodesincluding,butnotlimitedto,diseasemanagementprograms,orwhenanothercurrentCurrentProceduralTerminology(CPT)orHCPCScodeexists








BundledServiceandSupplies BundledServicesandSupplies#0008

Modifiers59andXE,XP,XS,&XU(DistinctProcedural/Separate/UnusualService)

Revised ThiseditwilldenyA4648(tissuemarker)whenreportedwith1908119101(breastbiopsy)or1928119288(placementofbreastlocalizationdevice(s)).Modifierswillnotoverridethisedit.

HealthPlanPolicy

RVUsforthebreastbiopsyandclipplacementcodesincludethecostoftheclip(tissuemarker).


2





BundledServiceandSupplies Modifier59#0023 Revised Procedure29875denieswhenreportedwithotherarthroscopickneeprocedurecodes(29880,29881,29882and29883)performedonthesameknee;modifiers59,XE,XP,XSorXUwillnotoverridetheedit.



Modifier 59 #0023

Revised Denyvaliditytesting(82570and83986)whenreportedwithlabtoxicologycodes(8030080377,83992,G0477G0483);modifierswillnotoverridethisedit

Denyvaliditytesting(82570and83986)whenreportedwithlabtoxicologycodes(8030080377,83992,G0477G0483);modifierswillnotoverridethisedit



Modifier 59 #0023

Revised Deny95940asmutuallyexclusivewhenreportedwith95941(intraoperativeneurophysiologicmonitoringprocedures)bythesameprovider,forthesamemember,onthesamedateofservice.Modifierswillnotoverridethisedit.


BundledServicesandSupplies ObstetricsServices#0011

Revised Thiseditwilldenyprocedures7680176802,76805,76810or7681576817whenreportedwithanICD10RoutineDiagnosisCode[onlytakenfromtheroutineObstetricsservicespolicy]

Thiseditwilldenyprocedures7680176802,76805,76810or7681576817whenreportedwithanICD10RoutineDiagnosisCode[onlytakenfromtheroutineObstetricsservicespolicy]


Frequency/MaximumOccurances FrequencyEditing#0016

revised Limitprocedurecode86160(COMPLEMENT;ANTIGEN,EACHCOMPONENT)to4unitsperdaywithnomodifieroverride.

HealthPlanPolicy

BasedonCMSMUEs

ProcessDate08/22/2016


Revised Thiswilladdalimitofoneunitperdateofservicefor87529(herpessimplexvirus,amplifiedprobetechnique).

Thiswilladdalimitofoneunitperdateofservicefor87529(herpessimplexvirus,amplifiedprobetechnique).

10/1/2016


Revised Thiswilladdalimitof1unitperdateofserviceforJ9031(Theracys/TiceBCG). HealthPlanPolicy




Revised Thiswilladdalimitof10unitsperdateofserviceforJ2649(Aloxi,25mcg). HealthPlanPolicy




Revised Thiswilladdalimitof10unitsperdateofserviceforJ9217(LupronDepot,Eligard,7.5mg).

HealthPlanPolicy




Revised Thiswilladdalimitof600unitsperdateofserviceforJ0585(Botox/BotoxCosmetic)and400unitsperdateofserviceforJ0717(Cimzia).

HealthPlanPolicy




Revised Thiswilladdalimitof200unitsperdateofserviceforJ0586(Dysport). HealthPlanPolicy




Revised Thiswilladdalimitof20unitsperdateofserviceforJ9395(Faslodex)andalimitof20unitsperdateofserviceforJ1750(Dextran).

HealthPlanPolicy



3






Revised Thiswilladdalimitof8unitsperdateofserviceforJ2507(Krystexxa). HealthPlanPolicy




Revised Thiswilladdalimitof60unitsperdateofserviceforJ9047(Kyprolis). HealthPlanPolicy




Revised Thiswilladdalimitof100unitsperdateofserviceforJ0129(Orencia). HealthPlanPolicy




Revised Thiswilladdalimitof120unitsperdateofserviceforJ0897(Prolia/Xgeva). HealthPlanPolicy




Revised Thiswilladdalimitof40unitsperdateofserviceforJ2353(Sandostatin,Depot). HealthPlanPolicy




Revised Thiswilladdalimitof150unitsperdateofserviceforJ1453(Emend). HealthPlanPolicy




Revised Thiswilladdalimitof3unitsperdateofserviceforJ9202(Zoladex). HealthPlanPolicy




Revised Thiswilladdalimitof5unitsperdateofserviceforJ3489(ZoledronicAcid). HealthPlanPolicy




Revised Thiswilladdalimitof96unitsperdateofserviceforJ7325(Synvisc/Synviscone). HealthPlanPolicy




Revised Thiswilladdalimitof90unitsperevery28daysforJ3357(Stelara,1mg). HealthPlanPolicy




Revised Thiswilladdalimitofoneunitperevery60daysfor11720(debridementforonetofivenails)andalimitofoneunitperevery60daysfor11721(debridementforsixormorenails).

HealthPlanPolicy

BasedonCMS

Thiswilladdalimitofoneunitperevery60daysfor11720(debridementforonetofivenails)andalimitofoneunitperevery60daysfor11721(debridementforsixormorenails).



Revised Thiswilladdalimitof90unitsperevery14daysforJ2357(Xolair,5mg). HealthPlanPolicy



4






Revised Thiswilladdalimitof14unitsperevery90daysforJ7312(Ozurdex). HealthPlanPolicy




Revised Thiswilladdalimitofoneunitfor96401withtheadministrationofXolairandadiagnosisofidiopathicurticaria.

HealthPlanPolicy

Limitis1injectionperdrug;thisdrugadministrationcodeisfortheadministrationofadrug,notthenumberofinjectionsneededtoadministerthecorrectdosageofthedrug.



Revised Thiswilladdalimitof18unitsperevery365daysfor8032080377and83992(confirmationtestingcodes)forparticipatingproviders.

Thiswilladdalimitof18unitsperevery365daysfor8032080377and83992(confirmationtestingcodes)forparticipatingproviders.


ModifiertoProcedureValidation DurableMedicalEquipment#0022

Revised Thiseditdeniescodeswhenreportedwithinappropriatemodifiers.

Revisions:Reimbursementwhenreportedwithpurchasemodifiersisnotprovidedforthefollowingcodes,whichareclassifiedasRenttoPurchaseitemsandarenoteligibleforupfrontpurchase:E0601,E0470,E0471,E0561,E0562(BiPAP,CPAP,humidifiers)whensubmittedwithpurchasemodifiersNR,NU,andUE

HealthPlanPolicy

Reimbursementwhenreportedwithpurchasemodifiersisnotprovidedforthefollowingcodes,whichareclassifiedasRenttoPurchaseitemsandarenoteligibleforupfrontpurchase:E0601,E0470,E0471,E0561,E0562(BiPAP,CPAP,humidifiers)whensubmittedwithpurchasemodifiersNR,NU,andUE


ModifiertoProcedureValidation ModifierRules#0017 Revised Thisdeniescodeswhenreportedwithinappropriatemodifiers.


Thisdeniescodeswhenreportedwithinappropriatemodifiers.



Paypercentradiology ModifierRules#0017 Revised Wewillapplya5%reductionfordatesofservicebeginningOctober1,2016throughDecember31,2016anda15%reductionfordatesofserviceonorafterJanuary1,2017tothetechnicalcomponentofdiagnosticcomputedtomographyservicesforthehead/brain,abdomen,pelvis,upperextremity,lowerextremity,etc.inthefollowingcoderangesandanysucceedingcodes:7045070498,7125071275,7212572133,7219172194,7320073206,7370073706,7415074178,7426174263,and7557175574.

HealthPlanPolicy

BasedonCMSguidelineComputedtomographyservicesthatarefurnishedonnonNEMAStandardXR292013compliantCTequipmentmustincludemodifierCT


5

SUMMARY OF ANTHEM BLUE CROSS PROFESSIONAL REIMBURSEMENT POLICIES

Anthem Blue Cross is updating its PPO professional reimbursement policies by adopting the following new policy and updating several other existing policies as of January 1, 2018

NOTE: For ease of searching for policies of most interest, the policies are referenced below in alpha order by policy name. The actual policies that follow are in order of the Anthem Blue Cross Policy number (format: Policy: CA - 00##).

New Policies Acupuncture When Billed with Evaluation and Management Services (Policy: CA - 0055)

Updated Policies effective 1/1/18: Bundled Services and Supplies --------------------------------------------- (Policy: CA - 0008) Frequency Editing ----------------------------------------------------------- (Policy: CA - 0016) Evaluation and management Services Related Modifiers -25 & -57 (Policy: CA - 0026) Laboratory and Venipuncture Services -------------------------------- (Policy: CA - 0029) Drug Screen Testing -------------------------------------------------------- (Policy: CA - 0038)

Full list of Policies

Acupuncture When Billed with Evaluation and Management (Policy: CA - 0055) After Hours, Emergency, and Miscellaneous E/M Services (Policy: CA - 0001) Anesthesia Services ----------------------------------------------------- (Policy: CA - 0020) Assistant Surgeon Services -------------------------------------------- (Policy: CA - 0009) Bundled Services and Supplies -------------------------------------- (Policy: CA - 0008) Cancer Treatment Planning and Care Coordination------------- (Policy: CA - 0043) Claims Editing Overview ---------------------------------------------- (Policy: CA - 0027) Co-Surgeon/Team Surgeon Services -------------------------------- (Policy: CA - 0006)

Documentation and Reporting Guidelinesfor Consultations ------------------------------------------------------ (Policy: CA - 0030)

Documentation and Reporting Guidelinesfor Evaluation and Management Services ------------------------- (Policy: CA - 0024)

Documentation Guidelines for Central NervousSystem Assessments and Tests--------------------------------------------- (Policy: CA - 0046)

Documentation Guidelines for Psychotherapy Services-------------- (Policy: CA - 0047) Drug Screen Testing ----------------------------------------------------- (Policy: CA - 0038) Duplicate Reporting of Diagnostic Services) --------------------------- (Policy: CA - 0045) Durable Medical Equipment ------------------------------------------- (Policy: CA - 0022) Evaluation and Management Services and

Related Modifiers -25 & -57 ------------------------------------------- (Policy: CA - 0026) Frequency Editing ------------------------------------------------------- (Policy: CA - 0016) Global Surgery ----------------------------------------------------------- (Policy: CA - 0012) Health and Behavior Assessment/Intervention --------------------- (Policy: CA - 0033) Incident To Services --------------------------------------------------- (Policy: CA - 0032) Injectable Substances with Related Injection Services---------------- (Policy: CA - 0039) Injection and Infusion Administration

and Related Services and Supplies ----------------------------------- (Policy: CA - 0015) Laboratory and Venipuncture Services ---------------------------- (Policy: CA - 0029) Moderate Sedation ----------------------------------------------------- (Policy: CA - 0014)

Page 1of 2

SUMMARY OF ANTHEM BLUE CROSS PROFESSIONAL REIMBURSEMENT POLICIES Full List of Policies (continued) Modifier Rules ---------------------------------------------------------- (Policy: CA - 0017) Modifier 22 (Increased Procedural Services) ---------------------- (Policy: CA - 0037) Modifier 59 and XE, XP, XS &XU (Distinct

Procedural/Separate/Unusual Service) ----------------------------- (Policy: CA - 0023) Overhead Expense For Office Based Surgery and Diagnostic Testing -------------------------------------------------- (Policy: CA - 0041) Multiple Diagnostic Imaging Procedures---------------------------- (Policy: CA - 0034) Multiple and Bilateral Surgery Processing ------------------------ (Policy: CA - 0010) Office Place of Service --------------------------------------------------- (Policy: CA - 0042) Pharmaceutical Waste --------------------------------------------------- (Policy: CA - 0031) Physical and Manipulative Maintenance Services ----------------- (Policy: CA - 0035) Place of Service ---------------------------------------------------------- (Policy: CA - 0018) Prolonged Services ------------------------------------------------------ (Policy: CA - 0019) Routine Obstetric Services -------------------------------------------- (Policy: CA - 0011) Rule of Eight Reporting Guidelines for Physical

Medicine and Rehabilitation Services -------------------------------- (Policy: CA - 0005) Screening Services with Related Evaluation and Management Services ---------------------------------------------------- (Policy: CA - 0036) Sleep Studies and Related Bundled Services & Supplies --------- (Policy: CA - 0028) Standby Services ----------------------------------------------------------- (Policy: CA - 0021) Surgical Pathology and Related Prostate Needle Biopsy------------ (Policy: CA - 0044) Telehealth Services ------------------------------------------------------- (Policy: CA - 0007) Three-Dimensional (3D) Radiology Services) ------------------------ (Policy: CA - 0040) Urgent Care (Coding and Bundled Supplies) ------------------------ (Policy: CA - 0025) Please note that the following policies first effective 11/7/2009 have been archived and replaced with the policies referenced: CA 0002 Modifier 52 (Refer to Policy: CA 0017 - Modifier Rules) CA 0003 Modifier 53 (Refer to Policy: CA 0017 - Modifier Rules) CA 0004 Lab Combo (Refer to Policy: CA 0029 - Laboratory and Venipuncture Services) CA 0013Venipuncture (Refer to Policy: CA 0029 - Laboratory and Venipuncture Services) Page 2 of 2

Anthem Blue Cross Commercial Professional Reimbursement Policy

Subject: After Hours, Emergency, and Miscellaneous E/M Services

Policy: CA - 0001 Effective: 10/01/2016 Coverage is subject to the terms, conditions, and limitations of an individual members programs or products and policy criteria listed below. DESCRIPTION Current Procedural Terminology (CPT) indicates that codes within the range of 99050-99060 describe special circumstances under which the basic service was rendered and are sometimes referred to as adjunct services. The applicable adjunctive code is reported in addition to the associated basic service. This policy documents the Health Plans reimbursement and reporting requirements for these adjunct after hours, emergency, and miscellaneous evaluation and management (E/M) services.

POLICY The Health Plan defines After-Hours as services rendered between 5:00 p.m. and 8:00 a.m. on weekdays, and anytime on weekends. The Health Plan does not designate a special status in this policy to holidays. If a holiday falls on a weekday, then services rendered between 5:00 p.m. and 8:00 a.m. on that day are eligible for after hours reimbursement. Also, if a holiday falls on a weekend, then services rendered anytime on that weekend are eligible for after hours reimbursement. CPT codes 99050 or 99051 (use the most applicable code for the after-hours situation), are eligible for separate reimbursement, in addition to the basic covered service, if the basic service provided meets all of the following criteria:

It is reported with an office (11) or urgent care facility (20) place of service; and It is rendered between 5:00 p.m. and 8:00 a.m. on weekdays, and anytime on weekends; and The basic service time is based on arrival time, not actual time the service commenced.

CPT code 99050 is not eligible for separate reimbursement when it is reported with a preventive diagnosis and/or a preventive service. Adjunctive E/M services described by CPT codes 99053, 99056, 99058, and 99060 are not eligible for separate reimbursement.

Page 1 of [2]

CA 0001 Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.


CODING The following is provided as an informational tool only, to help identify some of the applicable CPT codes that may be utilized in reporting after hour services. The inclusion or exclusion of a specific code does not guarantee reimbursement and/or coverage (e.g., when 99050 is reported with a preventive service as outlined on page 1). Codes eligible for separate reimbursement: Code Description 99050 Services provided in the office at times other than regularly scheduled office

hours, or days when the office is normally closed (e.g., holidays, Saturday and Sunday) in addition to basic service.1

99051 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours in addition to basic service.2

Codes not eligible for separate reimbursement: Code Description 99053 Service(s) provided between 10:00 p.m. and 8:00 a.m. at 24 hour facility, in

addition to basic service.3

99056 Service(s) typically provided in the office, provided out of the office at the request of patient, in addition to basic service.4

99058 Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service.5

99060 Service(s) provided on an emergency basis out of the office, which disrupts other scheduled office services, in addition to basic service.6

1 Current Procedural Terminology, cpt 2016, Professional Edition, pg.662 2Ibid, pg. 662 3Ibid, pg. 662 4Ibid, pg. 662 5Ibid, pg. 662 6Ibid, pg. 662 CPT is a registered trademark of the American Medical Association Use of Reimbursement Policy: This policy is subject to federal and state laws, to the extent applicable, as well as the terms, conditions, and limitations of a members benefits on the date of service. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Anthem Blue Cross.

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Subject: Rule of Eight Reporting Guidelines for Physical Medicine and Rehabilitation Services

Policy: CA 0005 Effective: 10/01/2016 Coverage is subject to the terms, conditions, and limitations of an individual members programs or products and policy criteria listed below. DESCRIPTION The Physical Medicine and Rehabilitation Section of the Current Procedural Terminology (CPT) codebook contains four sections with time-based codes: Modalities (Constant Attendance) Therapeutic Procedures Tests and Measurements Orthotic Management and Prosthetic Management

Modalities: CPT defines a modality as Any physical agent applied to produce therapeutic changes to biologic tissues; includes but not limited to thermal, acoustic, light, mechanical, or electric energy.1 CPT codes within the code range of 97032-97036 are Constant Attendance codes that require direct (one-on-one) patient contact by the provider. These codes contain a time component (15 minutes) and time is recorded based on constant one-on-one attendance. Therapeutic Procedures: CPT defines a therapeutic procedure as A manner of effecting change through the application of clinical skills and/or services that attempt to improve function.2 CPT codes within the code ranges of 97110-97124, 97140, and 97530-97542 require direct (one-on-one) patient contact by the provider. These codes contain a time component (15 minutes) and time is recorded based on constant one-on-one-attendance. Page 1 of [4]



Tests and Measurements: CPT codes 97750 and 97755 require direct (one-on-one) patient contact by the provider. These codes contain a time component (15 minutes) and time is recorded based on constant one-on-one attendance. Orthotic Management and Prosthetic Management: CPT codes 97760-97762 describe orthotic and prosthetic assessment, management, and training services. These codes also contain a 15 minute time component. The Rule of Eight reporting requirements described in the policy section below apply to all of the 15 minute time-based codes listed above under Modalities, Therapeutic Procedures, Tests and Measurements, and Orthotic Management and Prosthetic Management. However, this policy focuses on Constant Attendance Modalities and Therapeutic Procedures.

POLICY I. Rule of Eight

The Health Plan has adopted The Centers for Medicare & Medicaid Services (CMS) reporting guidelines for determining the appropriate number of units to report with respect to physical medicine CPT codes that are subject to a 15-minute time component. The Health Plan refers to this guideline as the Rule of Eight. The Rule of Eight addresses the relationship between the direct (one-on-one) time spent with the patient, and the billing and reimbursement of a unit of service. According to the Rule of Eight, the provider must spend more than one-half (8 minutes or more) of a given 15-minute time component with the patient in order to properly submit that unit to the Health Plan for reimbursement.

II. Reporting Guidelines

The Health Plan requires that the provider maintain visual, verbal, and/or manual contact with the patient throughout the performance of procedures that are reported to Health Plan as direct treatment services.

a. The time reported should be the time actually spent in the delivery of the modality and/or therapeutic procedure. This means that pre and post-delivery services should not be counted in determining the treatment time.

b. The time that the patient spends not being treated, due to resting periods or waiting for a piece of equipment to become available, is not considered treatment time.

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c. All treatment time, including the beginning and ending time of the direct treatment, must be

recorded in the patients medical record, along with the note describing the specific modality or procedure.

III. Determining Units

A. A provider should not report a direct treatment service if only one attended modality or therapeutic procedure is provided in a day, and the procedure is performed for less than 8 minutes.

B. A single 15-minute unit of direct treatment service may be billed when the duration of direct treatment is equal to or greater than 8 minutes, and less than 23 minutes. If the duration of a single modality or procedure is between 23 minutes but less than 38 minutes, then two 15-minute units of direct treatment service may be billed. C. The following table indicates the appropriate protocol for reporting each additional unit:

Number of units billed: Number of minutes provided in treatment: 1 unit 8 minutes to < 23 minutes 2 units 23 minutes to < 38 minutes 3 units 38 minutes to < 53 minutes 4 units 53 minutes to < 68 minutes 5 units 68 minutes to < 83 minutes 6 units 83 minutes to < 98 minutes 7 units 98 minutes to < 113 minutes 8 units 113 minutes to < 128 minutes*

*The pattern remains the same for treatment time in excess of 2 hours.

D. The Health Plan also accepts the following CMS reporting guideline:

If any 15 minute timed service that is performed for 7 minutes or less than 7 minutes on the same day as another 15 minute timed service that was also performed for 7 minutes or less and the total time of the two is 8 minutes or greater than 8 minutes, then bill one unit for the service performed for the most minutes. The same logic is applied when three or more different services are provided for 7 minutes or less than 7 minutes.

For example, if a provider renders: 5 minutes of 97035 (ultrasound), 6 minutes of 97110 (therapeutic procedure), and

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7 minutes of 97140 (manual therapy techniques), then the total minutes of direct treatment is 18 minutes.

Eighteen (18) minutes of direct treatment time for the manual therapy service is eligible for reimbursement as one unit. The patients medical record should document that all three modalities and procedures were rendered and include the direct treatment time for each.

1Current Procedural Terminiology cpt 2015 Professional Edition, pg. 627-628 2Ibid, pg. 628-629 CPT is a registered trademark of the American Medical Association Use of Reimbursement Policy: This policy is subject to federal and state laws, to the extent applicable, as well as the terms, conditions, and limitations of a members benefits on the date of service. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Anthem Blue Cross.

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Anthem Blue Cross

Commercial Professional Reimbursement Policy

Subject: Co-Surgeon/Team Surgeon Services

Policy: CA - 0006 Effective: 10/01/2016 Coverage is subject to the terms, conditions, and limitations of an individual members programs or products and policy criteria listed below. DESCRIPTION Co-surgery occurs when one surgeon is not able to perform a surgical procedure without using the skills of a second surgeon, usually of a different specialty. The term co-surgeon may also apply to two surgeons of like training performing parts of the procedure simultaneously. A co-surgeon performs a distinct portion of a procedure, and is not acting as an assistant. Co-surgeon services are identified by appending modifier 62 to the applicable Current Procedural Terminology (CPT) code(s). CPT defines Modifier 62 as: Two Surgeons: When 2 surgeons work together as primary surgeons performing distinct

part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on codes(s) for that procedure as long as both surgeons continue to work together as primary surgeons.1

Team surgery takes place when highly complex procedures are performed which require the accompanying services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel and various types of complex equipment. Surgical Team services are identified by appending the modifier 66 to the designated CPT code(s). CPT defines Modifier 66 as: Surgical Team: Under some circumstances, highly complex procedures (requiring the

concomitant services of several physicians or other qualified health care professionals, often of different specialties, plus other highly skilled, specially trained personnel, various types of complex equipment) are carried out under the surgical team concept.2

POLICY Co-surgery/surgical team surgery is medically indicated for procedures when different skills are needed to perform a specific procedure(s) or when simultaneous surgery minimizes anesthesia time or complications. For co-surgery services, a combination of the type of specialty of each surgeon, along with CPT guidelines, and the specific operative report from each surgeon are used to make a coverage determination of eligibility for co-surgeon reimbursement.

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Anthem Blue Cross


It is not considered co-surgery when two surgeons are performing separate procedures on different anatomical sites during the same operative session. Each surgeon is considered the primary surgeon for that specific procedure and will be reimbursed up to 100% of the fee schedule allowance. (e.g., a total knee replacement done bilaterally, with one surgeon operating solely on the right knee and the other surgeon operating solely on the left knee.) For co-Surgery services, 63% of the fee schedule allowance is reimbursed for each of the two operating surgeons for an eligible CPT code with the appended 62 modifier. Codes reported with modifier 62 are subject to the multiple surgical reimbursement rules if applicable. Procedures reported with a 66 modifier, which meet the definition of Surgical Team, are subject to the multiple surgical reimbursement rules if applicable. When multiple procedures are performed during one surgical session, and a co-surgeon for one part of the surgery acts as an assistant in the performance of an additional procedure(s) during the same operative session, then that particular service should be reported using the 80, 81, or 82 modifier, as appropriate. Co-surgery services rendered by a surgeon who is acting as an assistant should not be reported with modifier 62 and are not eligible for reimbursement as co-surgery. The Health Plan follows CPT parenthetical guidelines which state that co-surgery should not be reported with bone graft or spinal instrumentation codes. Therefore, ClaimsXten will deny a claim line item if modifier 62 is appended to one of the codes listed in the coding section below.

CODING The following table lists the codes that are not eligible for reimbursement if they are reported with modifier 62.

1Current Procedural Terminology CPT 2015 Professional Edition, pg. 680 2Ibid, pg. 681 CPT is a registered trademark of the American Medical Association Use of Reimbursement Policy: This policy is subject to federal and state laws, to the extent applicable, as well as the terms, conditions, and limitations of a members benefits on the date of service. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Anthem Blue Cross.

20900 20922 20936 22842 22847 20902 20924 20937 22843 22848 20910 20926 20938 22844 22850 20912 20930 22840 22845 22851 20920 20931 22841 22846 22852

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Anthem Blue Cross


Subject: Telehealth Services

Policy: CA - 0007 Effective: 10/01/2016 Coverage is subject to the terms, conditions, and limitations of an individual members programs or products and policy criteria listed below. DESCRIPTION Telehealth services are described as the delivery of healthcare services through the use of interactive audio - video, or other interactive electronic media for the purpose of diagnosis, consultation, and/or treatment of a patient in a location separate from the servicing provider. Telehealth services do not include the use of audio-only telephone, facsimile machine, or electronic mail. Telehealth services may also include ancillary preventive, educational, and nonclinical or curative services. Telehealth services are used to support health care when the provider and patient are physically separated. Typically, the patient communicates with the provider via interactive means that is sufficient to establish the necessary link to the provider who is working at a different location from the patient. The presentation/origination site is the place where the patient is located at the time of the telehealth

service. The provider site is the place where the provider is located at the time the service is provided.

This policy documents the Health Plans position on services identified as telehealth services. POLICY Reimbursement for telehealth services may be available when interactive services occur between the patient and the remote provider and:

1. the telehealth services are provided through a Health Plan approved telehealth program (e.g., LiveHealth Online)

or 2. the telehealth services are mandated by state or federal law

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Anthem Blue Cross


CODING The following is provided as an informational tool only, to help identify some of the applicable Current Procedural Terminology (CPT) codes/code ranges and Healthcare Common Procedure Coding System (HCPCS Level II) codes/modifiers that may be utilized in reporting telehealth services. The inclusion or exclusion of a specific code does not indicate eligibility for reimbursement and/or coverage in all situations. Telehealth services are identified by appending HCPCS modifiers GQ or GT to CPT or HCPCS codes that ordinarily describe face-to-face services, including, but not limited to, office or other outpatient visits, inpatient visits, or individual psychotherapy services. GQ (via asynchronous telecommunications system) GT (via interactive audio and video telecommunication systems)

The following CPT and HCPCS codes are specific to telehealth services and do not require the use of modifiers GQ or GT:

Code Description 99444 Online evaluation and management service provided by a physician or other

qualified health care professional who may report an evaluation and management service provided to an established patient or guardian, not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network

98969

Online assessment and management service provided by a qualified nonphysician health care professional to an established patient or guardian, not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network

0188T Remote real-time interactive video-conferenced critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes

+0189T Remote real-time interactive video-conferenced critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service.)

G0406 Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth

G0407 Follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth

G0408 Follow-up inpatient consultation, complex, physicians typically spend 35 minutes or more communicating with the patient via telehealth

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G0425 Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth

G0426 Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via telehealth

G0427 Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth

G0459 Inpatient telehealth pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy

Q3014 Telehealth originating site facility fee T1014 Telehealth transmission, per minute, professional services bill separately

CPT is a registered trademark of the American Medical Association Use of Reimbursement Policy: This policy is subject to federal and state laws, to the extent applicable, as well as the terms, conditions, and limitations of a members benefits on the date of service. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Anthem Blue Cross.

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Anthem Blue Cross

Professional Reimbursement Policy

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Subject: Bundled Services and Supplies

Policy: CA - 0008 Effective: 01/01/2018 Coverage is subject to the terms, conditions, and limitations of an individual members programs or products and policy criteria listed below. This reimbursement policy also applies to Employer Group Retiree Medicare Advantage programs.

Description The Health Plan considers certain services and supplies to be ineligible for separate reimbursement when reported by a professional provider. These services and/or supplies may be reported with a primary service or as a stand-alone service. This policy is divided into 3 sections:

Section 1 provides a description and a list of examples of Current Procedural Terminology (CPT) and Healthcare Common Procedural Coding System (HCPCS Level II) codes for those services and supplies not eligible for reimbursement, whether they are reported with another service or as a stand-alone service.

Section 2 provides a description and the code pair relationship for a number of procedures that are not eligible for separate reimbursement when performed with another specific service or item. (See also our Modifiers 59 and XE, XP, XS, & XU Reimbursement Policy for additional information.)

Section 3 provides the code and description for services that are eligible for reimbursement when reported as a stand-alone service, but are not eligible for separate reimbursement when performed with any other procedure, service, or supply.

This policy documents the Health Plans position on bundled services and supplies for CMS-1500 submitters. Policy Section 1: Services and supplies not eligible for separate reimbursement. In most cases, services rendered without direct (face-to-face) patient contact are considered to be an integral component of the overall medical management service and are not eligible for separate reimbursement. In addition, modifiers 59, XE, XP, XS, & XU will not override the denial for the bundled services and/or supplies listed below. These bundled services and supplies may include, but are not limited to:

1. add-on code to identify services rendered by a hospitalist provider 2. administrative services requiring physician documentation (e.g., recertification, release forms,

physical/camp/school/daycare forms, etc.) 3. all practice overhead costs, such as heat, light, safe access, regulatory compliance including CDC and OSHA

compliance, general supplies (paper, gauze, band aids, etc.), infection control supplies, insurance (including malpractice insurance), collections

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4. application of hot or cold packs 5. bioelectrical impedance analysis whole body composition assessment, supine position, with interpretation

and report 6. Centers for Medicare & Medicaid Services (CMS) Medicare Approved Bundled Payments for Care

Improvement Initiative 7. collection/analysis of digitally/computer stored data 8. compounded drugs that are not a part of Health Plan approved drugs, programs, services, or supplies 9. copies of test results for patient 10. coronary therapeutic services and procedures add-on codes 11. costs to perform participating provider agreement requirements, such as prior authorizations, appeals, notices

of non-coverage 12. definitive drug testing CPT codes (providers must report definitive drug testing by using the HCPCS G

codes in lieu of the CPT codes) 13. delivery, instruction, and/or set up fees for durable medical equipment (DME) 14. determination of venous pressure 15. disease management programs that are not approved by the Health Plan 16. equipment and/or enhanced technology as part of a procedure, test, or treatment (e.g., robotic surgical

systems, radiation oncology treatment tracking systems including Clarity) 17. evaluation of cervicovaginal fluid for specific amniotic fluid protein(s) (eg, placental alpha

microglobulin-1 [PAMG-1], placental protein 12 [PP12], alpha-fetoprotein), qualitative, each specimen (e.g., AmniSure)

18. global fee for urgent care centers 19. handling and/or conveyance fees 20. Health Plan non-approved drugs, programs, services, and supplies identified by certain HCPCS S codes

including, but not limited to, disease management programs, or when another CPT or HCPCS code exists

21. heparin lock flush solution or kit for non-therapeutic use 22. hospital mandated on-call service 23. implantable device for fallopian tube occlusion 24. insertion of a Bakri balloon for treatment of post-partum hemorrhage 25. insertion of a pain pump by the operating physician during a surgical procedure 26. internal spinal fixation by wiring of spinous processes 27. monitoring feature or device, stand-alone or integrated, any type, including all accessories, components

and electronics 28. online assessment and management by a qualified nonphysician health care professional 29. outpatient HCPCS C codes

**exception: C9257 for injection, bevacizumab (Avastin), 0.25 mg 30. patient care planning services the Health Plan considers part of overall care responsibility including, but not

limited to, advanced care planning, care coordination, care management, care planning oversight, education and training for patient self-management, medical home program, comprehensive care coordination and

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planning (initial and maintenance), physician care plan oversight, team conferences, transitional care management/planning, etc.

31. peak expiratory flow rate 32. pharmacy and other dispensing services and/or supply fees, etc. 33. photography 34. physician interpretation and report of molecular pathology procedures 35. placement of an occlusive device into a venous or arterial access site, post op/procedural 36. postoperative follow up visit during the global period for reasons related to the original surgery 37. preparation of fecal microbiota for instillation, including assessment of donor specimen 38. prescriptions, electronic, fax or hard copy, new and renewal, including early renewal 39. programs, services, and supplies identified by certain HCPCS G codes created for CMS use including,

but not limited to, reporting codes (e.g., for functional limitation), Federally Qualified Health Center (FQHC) visits, quality measures, services related to CMS coverage with evidence development (CED) clinical trials, CMS demonstration programs, or when a current CPT or other HCPCS code exists

**exception: report definitive drug testing with HCPCS G codes in lieu of the CPT codes for definitive drug testing

40. prolonged clinical staff service (beyond the typical service time) 41. prolonged physician in-patient service 42. prolonged E/M service before and after direct patient care 43. pulse oximetry 44. Reporting only codes including CPT Category II supplemental tracking codes for performance

measurement 45. review of medical records 46. routine post-surgical services such as dressing changes and suture removal 47. services identified by HCPCS G or Q codes performed in the home or hospice setting when reported on

a CMS-1500 claim form 48. spinal surgery only graft (allograft, morselized; autograft, same incision) 49. standby services 50. stat laboratory request 51. state or federal government agency supplied vaccines 52. sterile water, saline, and/or dextrose, 10 ml 53. surgical/procedural/testing supplies and materials supplied by the provider rendering the primary service

(e.g., surgical trays, syringes, needles, sterile water, etc.) 54. telephone consultations with the patient, family members, or other health care professionals 55. trauma response team associated with hospital critical care service 56. travel allowance for laboratory specimen pick-up 57. 3D rendering of imaging studies

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Coding Section 1: Services and supplies not eligible for separate reimbursement. To reference the listing of code examples the Health Plan has designated as always bundled and not eligible for separate reimbursement please close out of this policy and refer to the separate document under Bundled Services and Supplies titled Bundled Services and Supplies Section 1 Coding. Policy Section 2: Procedures, services, and supplies not eligible for separate reimbursement when reported with another specific procedure, service, or supply. These bundled services and supplies may include, but are not limited to, the services and supplies listed below. See also our Modifiers 59 and XE, XP, XS, & XU and Evaluation and Management Services and Related Modifiers -25 & -57 Reimbursement Policies for those instances when bypass modifiers will not override the denial when reported with a specified service or supply.

1. annual wellness or initial preventive visits when reported with preventive medicine evaluation and management services

2. arthroscopic debridement when reported with same joint arthroscopic surgery of the shoulder or elbow 3. arthrodesis, posterior or posterolateral technique, single level, each additional, reported with arthrodesis,

combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar

4. breast pump replacement supplies when reported on the same date of service as the breast pump 5. cast supplies, special casting materials, and/or impression casting of a foot reported by a practitioner other

than the manufacturer of the orthotic reported with custom foot orthotics 6. cervical or vaginal cancer screening, pelvic and clinical breast examination when reported with

preventive/annual or problem oriented E/M service (See also our Screening Services with Evaluation & Management Services reimbursement policy.)

7. cervical or vaginal cytopathology when reported with a preventive/annual or problem oriented E/M service 8. collection of blood specimen from a completely implantable venous access device or an established venous

central or peripheral catheter when reported with any service (for example E/M services) other than a laboratory service

9. column chromatography, includes mass spectrometry, if performed, non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen when reported with drug screening, confirmatory drug testing, or breath hydrogen or methane test

10. computed tomography guidance for placement of radiation therapy fields when reported with therapeutic radiology simulation-aided field setting procedures

11. continuous intraoperative neurophysiology monitoring in the O/R, one on one, each 15 minutes reported with continuous intraoperative neurophysiology monitoring, outside the O/R or more than one case, per hour

12. daily hospital management of epidural or subarachnoid continuous drug administration for postoperative pain management reported with a therapeutic or diagnostic spinal injection described as without or with imaging

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13. developmental screening when reported with administration and interpretation of health risk assessment instrument

14. diagnostic esophagogastroduodenoscopy (EGD) when reported with laparoscopy, surgical, gastric restrictive procedures

15. digital analysis of electroencephalogram (EEG) when separately reported with EEG recording and interpretation services on the same date of service

16. digital analysis of electroencephalogram (EEG) when separately reported on subsequent dates of service of EEG recording and interpretation services

17. digital rectal exam for prostate cancer screening when reported with a preventive or problem oriented E/M service (See also our Screening Services with Evaluation & Management Services reimbursement policy.)

18. drug test(s), definitive...qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 or 8-14 or 15-21 or 22 or more drug class(es), including metabolite(s) if performed when reported with drug test(s), definitive...qualitative or quantitative, all sources, includes specimen validity testing, per day, any number of drug classes

19. electrical stimulator supplies with electric stimulation modalities 20. electrodes with services such as electrocardiogram (EKG), electroencephalogram (EEG), stress test, sleep

study, electric stimulation modalities, acupuncture 21. electrodes and lead wires reported with electrical stimulator supplies on the same date of service and/or within

30 days 22. electrodes reported with conductive gel or paste fluoroscopic guidance for needle placement when reported

with spinal injection described as with imaging 23. fluoroscopic guidance for needle placement when reported with spinal injection described as with

imaging 24. home infusion therapy professional pharmacy services, drug administration, equipment, and/or supplies when

reported with any per diem home infusion therapy (HIT) service (e.g., catheter care/maintenance) 25. imaging guidance (fluoroscopic, CT, or MRI) when reported with a therapeutic or diagnostic spinal

injection described as without imaging 26. interpretation and report only of an EKG when reported with an E/M service 27. interpretation and report only of cardiovascular stress test or 64-lead EKG test when reported with an

emergency room (ER) service 28. interpretation of radiology tests when reported with an ER or inpatient E/M service 29. introduction of needle or intracatheter, vein, when reported with injection and infusion services 30. laminectomy, facetectomy and foraminotomy, each additional segment, when reported with arthrodesis,

combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar

31. major arthroscopic knee synovectomy (two or more compartments) when reported with arthroscopic knee surgeries without an approved American Academy of Orthopaedic Surgeons diagnosis

32. moderate (conscious) sedation services when reported by the same provider with the diagnostic or therapeutic codes previously identified in Appendix G of the 2016 CPT codebook.

Anthem Blue Cross


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33. needles when reported with acupuncture services 34. neuromuscular junction testing when reported with continuous intraoperative neurophysiology monitoring 35. nonvascular extremity ultrasound when reported with ultrasonic guidance for needle placement 36. obtaining, preparing, and conveyance of cervical or vaginal PAP smear when reported with a

preventive/annual or problem oriented E/M service (See also our Screening Services with Evaluation & Management Services reimbursement policy.)

37. open capsulectomy when reported with delayed insertion of breast prosthesis 38. preventive medicine counseling when reported with a routine comprehensive preventive medical

examination 39. radiological supervision and interpretation of transcatheter therapy when reported with injection of sclerosing

solution 40. regional or local anesthesia when administered in a physicians office 41. removal of impacted cerumen when reported with audiologic function testing 42. removal of impacted cerumen by irrigation/lavage or by instrumentation when reported with evaluation

and management services 43. replacement soft interface material, with continuous passive motion device 44. syringes and infusion supplies when reported with home infusion/specialty drug administration 45. therapeutic behavioral services, per 15 minutes when reported with therapeutic behavioral services, per

diem 46. therapeutic, prophylactic, and diagnostic injections and infusions when reported with nuclear medicine

testing 47. tissue marker when reported with breast biopsy with placement of breast localization device(s) and/or

percutaneous placement of breast localization device(s) 48. ultrasonic guidance when reported with trigger point injections 49. urine creatinine or urine pH when reported with presumptive and/or definitive drug testing codes to

validate accuracy of test results 50. urine test or reagent strips or tablets when reported with urinalysis 51. vertebral corpectomies when reported with spinal arthrodesis codes unless limited circumstances are

met, such as spinal fracture, spinal infection, or spinal tumor

Coding Section 2: Procedures, services, and supplies not eligible for separate reimbursement when reported with another specific procedure, service, or supply. The following list identifies by code pair some examples of the procedures that are described above. The exclusion of a specific code does not indicate eligibility for reimbursement under all circumstances. These code pair relationships are provided as an informational tool only, to help identify some of the procedures described in Policy Section 2 above. They include, but are not limited to:

1. G0438, G0439, or G0402 with preventive E/M codes 99381-99397 2. 29822 reported with 29819, 29820, 29824, 29825, and 29827; 29823 reported with 29806, 29807, 29819,

29820, 29821, and 29825; 29837 and 29838 reported with 29834, 29835, and 29836 3. 22614 when reported with 22633

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4. A4281, A4282, A4283, A4284, and A4285 when reported with E0602, E0603, and E0604 5. A4580, A4590, and/or S0395 reported with L3000, L3010, L3020, and/or L3030 6. G0101 reported with preventive, problem-oriented E/M, and annual gynecological exam codes such as

99381-99397, S0610, S0612, and 99201-99215 7. 88141-88155, 88164-88167, and 88174-88175 reported with preventive and problem oriented E/M codes

such as 99381-99397,99201-99215, G0101, G0402, G0438, G0439, S0610, and S0612 8. 36591-36592 reported with any service (for example 99201-99215, 99221-99226, 99241-99255) other than a

laboratory service 9. 82542 reported with80305-80307, 8032080377, 83992, G0480-G0483, G0659 or 91065 10. 77014 reported with 77280, 77285, and/or 77290 11. 95940 reported with 95941 12. 01996 reported with 62320, 62321, 62322, 62323, 62324, 62325, 62326, and 62327 13. 96110 reported with 99420 14. 43235 reported with 43770, 43771, 43772, 43773, 43774, and/or 43775 15. 95957 reported with 95951, 95953, 95954 and 95956 on the same date of service 16. 95957 reported on subsequent dates of service of 95950, 95951, 95953, 95954, 95955 and 95956 17. G0102 reported with preventive and problem oriented E/M codes such as 99381-99397 and 99201-99215 18. G0480-G0483 reported with G0659 19. A4595 with 97014 and 97032 20. A4556 reported with services such as 93000, 93015, 95805, 95812, 97014, 97032, 97033, 97813, and 97814 21. A4556 and A4557 reported with A4595 on the same date of service and/or within 30 days 22. A4556 reported with A4558 23. 77002 reported with 62321, 62323, 62325,and 62327 24. A4221, A4222, E0776, E0781, and S9810 reported with any per diem home infusion therapy (HIT) codes

such as S5492-S5502, S9061, S9325-S9379, S9490-S9504, S9537-S9590 25. 76942, 77002, 77003, 77012, and 77021 reported with 62320, 62322, 62324, and 62326 26. 93010, 93042, reported with E/M codes such as 99201-99215, 99221-99233, and 99281-99285 27. 93018 and 0180T reported with ER codes 99281-99285 28. 700XX-788XX, G01XX-G03XX, S8035-S8092, and S9024 (these code ranges include applicable radiology

interpretation codes as well as radiology codes which modifier 26 would be added to identify the professional component only) reported with 99281-99285 and/or 99221-99233

29. 36000 reported with 96360, 96365, 96374, 96375, 96376, 96405, 96406, 96409, 96413, 96416, 96440, 96446, 96450, and/or 96542

30. 63048 reported with 22633 31. 29876 reported with 29879 and 29880-29887 32. 99151, 99152, 99153, 99155, 99156, and 99157 reported by the same provider with codes previously

listed in Appendix G of the 2016 CPT codebook (See our Moderate (Conscious) Sedation reimbursement policy for code list.)

33. A4215 reported with 97810-97814 34. 95937 reported with 95940, 95941, or G0453

Anthem Blue Cross


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CA 0008 Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the

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