Neighborhood Health Plan of Rhode Island

Billing and Reimbursement Guideline: Immunosuppressive Therapy During A Global Period

Billing and Reimbursement Policies

Billing and Reimbursement Policy Name: Billable Drug Testing Services and Limitations Pharmaceutical Supplies

Guideline Publication Date: September 1, 2010

Policy Effective: February 15, 2013

KKey coding, documentation and reimbursement points include:

· Applies to CPT codes 80100, 80101, 80102, 80104, 80154, 80184, 80299*, 82055, 82145, 82520, 83840, 83925, 83992, 82205, 82742, 83805 and HCPCS codes G0431 and G0434.

· As customary, CMS reimbursement policies such as CCI and MUE edits apply. For example, it is inappropriate to bill any combination of 80100, 80101, 80104, G0431 or G0434 together on the same day.

· Limited to five (5) tests/units per date of service, any combination of codes. Only the first five (5) tests/units are reimbursable. Any other test/units are considered inclusive in the allowance of the first five (5).

· The member cannot be balance billed for any test/units exceeding the limit of five (5).

· The global surgical package for transplantation does not include immunosuppressive therapy management.

· Immunosuppressive care is billed with the appropriate Evaluation and Management service and based on the physician’s work performed.

· The attending surgeon should indicate in the medical record that

the visit is for immunosuppressive therapy.

· Modifier 24 may be used to indicate a separately identifiable Evaluation and Management service.

· For patients whose transplant cases are being administered by a Neighborhood contracted transplant vendor, these services may be contractually inclusive in a global case rate.

· This guideline applies to both CMS-1500 and UB-92 claim submissions.This guideline applies to CMS-1500 claim submissions.

· This guideline applies to place of service 11, 20, 22 and 50.

*Miscellaneous code, notes required

Publication date:

12/13/12

Please refer to Neighborhood’s provider website at http://www.nhpri.org for specific

provisions by product line.

This policyguideline is not a guarantee of reimbursement. Plan coverage, eligibility and claim payment edit rules may apply.

Key coding and reimbursement points include:

· All pharmacy supplies should be billed with the appropriate CPT® or HCPC® code and valid NDC number. Please refer to Pharmaceutical Coverage document for list of covered drug codes.

· If the supply is considered a miscellaneous supply, the claim must be billed on paper with a miscellaneous supply code, valid NDC number and an invoice attached for review. Do we need to specify all that is required on an invoice, such as units, etc?

· Any pharmaceutical considered covered under NHPRI’s pharmacy benefit will be denied if billed on a medical claim..

· Only pharmaceuticals that are FDA approved are reimbursable. Any pharmaceutical that is non-FDA approved will be denied.

· No modifier is required.

· This policy applies to all places of service.

and devices or device

Publication date:

09/16/10

Published:

September 1, 2010

Version History

Original Publish Date: September 1, 2010

Revision Date (s):

9/1/2013 Format change, minor edits

Neighborhood Health Plan of Rhode Island

Billing and Reimbursement Guidelines Page 1