This notice is to clarify a segment of Wellcare's payment policy language applicable to all Wellcare Medicare markets. Wellcare's payment policies are based on publicly distributed guidelines from established industry sources such as the Centers for Medicare and Medicaid Services (CMS), the American Medical Association (AMA), state health care agencies and medical specialty professional societies.
If you have questions about this information, please contact your Provider Relations representative.
Texas Medicare Claim & Payment Policies
Claim Classifications
| Classification | Policy | Claim Type |
|---|---|---|
| Local Coverage Determinations (LCDs) | Unless a more restrictive Wellcare Clinical Coverage Determination exists, Wellcare relies on guidance published in Local Coverage Determinations, respective to the state in which the service is rendered, to determine coverage requirements. | Facility and Professional |
| Age & Gender Policies | Certain procedure codes, by definition or nature of the procedure, are limited to the treatment of a specific age or age group or gender. Similarly, certain diagnosis codes are age- or gender specific as well. | Professional |
| Bundled Services | There are a number of services and supplies whose payment is bundled into the payment for other related services. A procedure code that has a status indicator of "P" or "B", meaning that per the Medicare Physician Fee Schedule this item or service is incidental or bundled in to another service and will not be separately payable. | Professional |
| Invalid Procedure Codes | Payment is not made for a procedure code that has a status indicator of "I", meaning that per the Medicare Physician Fee Schedule these procedures are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. | Professional |
| Invalid Primary Diagnosis Codes | Payment is not made for claims that contain an invalid primary diagnosis code, based on coding guidelines outlined in the Official ICD-9-CM Guidelines for Coding and Reporting. | Professional |
| Global Surgery | Global surgery includes all necessary services normally furnished by the surgeon before, during and after the surgical procedure. The global surgery period applies only to surgical procedures that have postoperative periods of zero, 10 and 90 days. The global surgery concept applies only to primary surgeons and co-surgeons. | Professional |
| Not Covered Procedure | Payment is not made for a procedure code that has a status indicator of "N", meaning that per the Medicare Physician Fee Schedule these procedures are not covered by Medicare. | Professional |
| New Patient Visits | The AMA defines a new patient as "one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years." Given this definition, if a physician bills a new patient visit, and the same physician or a physician from the same group practice with the same specialty has performed any other evaluation and management code in the previous three years, then the second new patient visit will be denied. | Professional |
| National Correct Coding Initiative (NCCI) Hospital Version | The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. CMS developed its coding policies based on coding conventions defined in the American Medical Association's CPT Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. | Facility |
| Medical Visit on the Same Day as a Procedure | An evaluation and management (E&M) service that is billed on the same day as a surgical procedure (either an "S", significant procedure not discounted, or a "T", significant procedure eligible for discounting) is not normally reimbursed on the same day as a surgery or significant procedure, unless the physician performs additional services at the visit beyond those associated with the procedure, and indicates this with an appropriate modifier. | Facility |
| Modifiers | Most modifiers have descriptions indicating that the procedure applies to a specific anatomic site, the services were performed distinctly from other services or special circumstances surrounded the performance of services. Procedures billed with inappropriate modifiers will be denied as inappropriately coded procedures. | Professional |
| Bilateral Payment Reduction | Medicare payment rules require that a payment reduction be performed whenever the same procedure is performed bilaterally by the same physician during the same operative session or same date of service, on the same patient. Refer to the Bilateral Service Indicator in the Medicare Physician Fee Schedule Database (MPFSDB) for services eligible for bilateral payment. | Professional |
| Assistant/Co/Team Surgeon Reduction | Assistant surgeon (modifiers 80, 81, 82, AS), co-surgeon (modifier 62), team surgeon (modifier 66) claims will be paid at the applicable rate as described in Chapter 12 of the Medicare Claims Processing Manual. | Professional |
| Return to Operating Room Reduction | The Medicare Physician Fee Schedule designates procedures that are appropriate to have the modifier 78 appended and show the percentage that a procedure should be reimbursed. If there is an amount, other than zero, in the intra op field in the Medicare Physician Fee schedule, the modifier 78 is appropriate and the procedure is eligible for a return to operating room reduction. | Professional |
| Endoscopic Payment Reduction | Endoscopic procedures are identified in the Medicare Physician Fee Schedule Database (MPFSDB) with multiple surgery indicator '3'. Endoscopic payment reductions will be applied as described in Chapter 12 of the Medicare Claims Processing Manual. | Professional |
| Multiple Procedure Payment Reduction | Multiple procedures are identified in the Medicare Physician Fee Schedule Database (MPFSDB) with multiple surgery indicator '2'. Multiple procedure payment reductions will be applied as described in Chapter 12 of the Medicare Claims Processing Manual. | Professional |
| Multiple Therapy Reduction | MA multiple therapy reduction applies to the practice expense (PE) payment of select therapy services. The reduction applies to the HCPCS codes contained on the list of "always therapy" services as described in Chapter 5 of the Medicare Claims Processing Manual. | Professional |
