Staywell is committed to continually improving its claims review and payment processes. That is why we support our provider partners with quality incentive programs, quicker claims payments and dedicated market support.
Effective 5/31/2019, we will introduce new Coding Integrity Reimbursement Guidelines. These coding rules are published within the Medicare Claims Processing Manual, Current Procedural Terminology (CPT®) by the American Medical Association (AMA) and ICD-10-CM guidelines governed by Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). These same rules are used by most healthcare claims payers and enforced by the Centers for Medicare and Medicaid Services.
Also, to ensure claims process and pay accurately, Staywell may deny a claim and ask for pertinent medical documentation from the provider or supplier who submitted the claim. The medical record request is coordinated with a third-party vendor. Providers should submit adequate medical record documentation that supports the claim (services) billed. Once medical records are received, medical review professionals will review the documentation to determine whether the claim is supported as submitted and pay or deny accordingly. Please note that the submission of medical records is not a guarantee of payment.
Determinations as to whether services are reasonable and necessary for an individual patient should be made on the same basis as all other such determinations: with reference to accepted standards of medical practice and the medical circumstances of the individual case.
The following table outlines the new coding guidelines.
| Coding Policy | Description |
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| Modifier Policies | Anatomical Modifiers
Claims may deny when a procedure defined as requiring an anatomical modifier is billed without an associated anatomical modifier. Unrelated Procedure/Service by the Same Physician During the Post-op Period, Modifier 79 Claims may deny for procedures billed with modifier 79 when the same or different 0-, 10- or 90-day procedure code has not been billed on the same date of service.
Alternatively, CPT XXXXX has been billed in the previous 10 days for a CPT code with a 10-day post-operative period, or in the previous 90 days for a code with a 90-day post-operative period by the same provider. |
| Diagnosis Code Guideline Policy | ICD-10-CM Excludes 1 Notes Policy
Claims may deny when reported with mutually exclusive code combinations according to the ICD-10-CM “Excludes 1 Notes” guideline policy. ICD-10-CM Laterality Policy "Laterality" (side of the body affected) is a coding convention added to relevant ICD-10 codes to increase specificity. Designated codes for conditions such as fractures, burns, ulcers and certain neoplasms require documentation of the side/region of the body where the condition occurs.
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| Diagnosis-Evaluation and Management Over-coding Policy | E&M services CPT 99201-99215
In general, the more complex the visit, the higher the E&M level of code you may bill within the appropriate category. To bill any code, the services furnished must meet the definition of the code. Providers must ensure that the E&M CPT codes selected reflect the services furnished. The three key components when selecting the appropriate level of E&M services provided are history, examination, and medical decision-making.
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| Maximum Units Policy: Surgical Pathology and Microscopic Examination | Diagnosis of malignancies and inflammatory conditions frequently requires numerous biopsies of a particular organ or suspicious site. CPT Code 88305 (Level IV – Surgical pathology, gross and microscopic examination) includes different types of biopsies.
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| Evaluation and Management Services Policies | Multiple Inpatient Admission or Consultation Services
According to the AMA CPT Manual and our policy, an initial inpatient admission (CPT 99221-99223) is allowed once every seven days.
Auditory Screening with Preventive Medicine Visits
Observation Services Based on reimbursement guidelines it is not appropriate for providers to bill inpatient Evaluation and Management (E/M) services while the patient is in an observation status.
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| Radiology Policy: Intracranial and Extracranial Imaging (Duplex, CT, CTA, MRA, MRI) for Simple Syncope | According to the American College of Emergency Physicians, the American Heart Association and the American College of Cardiology Foundation, CT, CTA, MRA, MRI should not be performed routinely for evaluation of syncope in the absence of related neurologic signs and symptoms. The likelihood of a central nervous system (CNS) cause of the event is extremely low, and patient outcomes are not improved with brain imaging studies.
In addition, duplex scan of extracranial arteries, computed tomographic angiography (CTA) of the neck and magnetic resonance angiography (MRA) of the neck are not medically necessary for evaluation of syncope in patients with no suggestion of seizure and no report of other neurologic symptoms or signs. The American College of Emergency Physicians (ACEP) also indicates that it is not appropriate to perform screening with advanced imaging for syncope patients, however be guided by the patient’s history and physical exam findings. A standard 12-lead electrocardiogram should be obtained first for patients with a diagnosis of syncope and collapse before performing advanced imaging procedures. Claims may be denied if the only reported diagnosis is syncope and collapse when any of the listed diagnostic head, brain, carotid artery or neck imaging procedures are billed. Claims may be denied if an advanced imaging procedure is billed with a diagnosis of syncope and there is no history of a 12-lead EKG being performed/billed the same date or in the previous 90 days.
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| Radiology Policy: Intracranial and Extracranial Imaging (Duplex, CT, CTA, MRA, MRI) for Migraine | According to the American College of Radiology and the American Academy of Neurology, a CT of the head or brain, CTA of the head, MRA of the head or MRI of the brain should not be performed routinely for patients with a migraine in the absence of related neurologic signs and symptoms.
The changes in the brain that happen during a migraine cannot be seen by the imaging studies since a migraine is caused by a complicated interaction between the brain and the blood vessels in the face and head. Head imaging in the form of CT scans, MRI or MRA is allowed only when the service is medically reasonable and necessary. Claims may deny for a CT head or brain, CTA head, MRA head, MRI brain or CT follow-up when the only diagnosis on the claim is a migraine. Associated CPT Procedure Codes:
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| Radiology Policy: Radiological Examination Chest | According to CMS policy and the American College of Radiology, a chest X-ray (CPT codes 71045, 71046) should not be performed for screening purposes in the absence of pertinent signs, symptoms or diseases.
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| Radiology Policy: Dual-Energy X-Ray Absorptiometry (DXA) Bone Density Screening |
According to the American College of Radiology and the International Society for Clinical Densitometry, dual-energy X-ray absorptiometry (DXA) bone density screening (77080 or 77081) is not indicated for women under age 65 or men under age 70 without risk factors for osteoporosis. Claims may deny when DXA bone density studies (CPT 77080 or 77081) are billed and the only diagnosis on the claim is osteoporosis screening (ICD-10 code Z13.820) for a woman who is under age 65 or for a man who is under age 70. |
| Revenue Code Policy: Revenue Code-HCPCS Code Links | Medicare accepts any National Uniform Billing Committee (NUBC) approved revenue codes. The Medicare Claims Processing Manual and the UB-04 Data Specifications Manual outlines requirements for billing outpatient claims including that (HCPCS) codes are required on outpatient claims (UB-04) with related revenue codes.
Based on these reimbursement guidelines, claims may deny when the following revenue codes are billed without the appropriate HCPCS code: |
| Place of Service Policy: Coding for Physician Services | According to CMS Medicare Claims Processing Manual, Place of Service codes (POS) are used to identify where, i.e., physician office, inpatient hospital, a procedure or service is furnished to a patient. POS codes are required under the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). For example, a claim from a physician provider with place of service 11 (Office) would be considered incorrectly coded when a claim from an outpatient facility (e.g. ambulatory surgical center, outpatient hospital) exists for the same member, same date of service and the same procedure or service. Therefore, physician provider claim would deny. |
| Anesthesia Policy: Anesthesia for Pain Management Injections |
According to the American Society of Anesthesiologists and the International Spine Intervention Society, minor pain procedures such as epidural steroid injections, epidural blood patch, trigger point injections, sacroiliac joint injection, bursal injections, occipital nerve block and facet injections under most routine circumstances, require only local anesthesia. Anesthesia and moderate sedation services billed with pain management services for a patient age 18 or older may deny unless a surgical procedure CPT code range 10021-69990 (other than pain management procedures) is also billed on the claim. An exception will apply for anesthesia services billed with modifiers indicating severe systemic disease (Physical status modifiers P3, P4 or monitored anesthesia care modifier G9). Associated CPT Procedure Codes
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| Neurology Policy: Nerve Conduction Studies (NCS) and Electromyography (EMG) for Radiculopathy |
According to the American Association of Neuromuscular & Electro-Diagnostic Medicine and CMS Policy, nerve conduction studies and a needle electromyography (EMG) must both be performed in order to diagnose radiculopathy (pinched nerve in back or neck). When the nerve conduction study or the needle EMG is performed on its own, the results can be misleading and important diagnoses may be missed. Claims may deny when a nerve conduction study is billed without a needle EMG, or a needle EMG is billed without a Nerve conduction study, and the only diagnosis is radiculopathy (ICD-10 codes M50.1-M50.23, M51.1-M51.27, M51.9, M53.80, M54.10-M54.18, M54.30-M54.42, and M79.2). Associated CPT Procedure Codes
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