Policy Number

Policy Name

Policy Description

Line of Business

CC.PP.052

Problem Oriented Visits Billed with Surgical Procedures

Under modifier -25 correct coding principles, a patient may be seen by the physician for a problem-oriented evaluation and management (E&M) service on the same day of a procedure with a 0-, 10- or 90- day global surgical period if the physician indicates that the service is a significant and separately identifiable E&M service that is above and beyond the usual pre- and post-operative work associated with the procedure. The purpose of this policy is to prevent duplicate payments that occur when a provider is reimbursed for resources not directly consumed during the provision of a service. Furthermore, to define payment criteria for problem-oriented visits when billed on the same day as a surgical procedure with a 0-, 10- or 90- day global period when making payment decisions and administering benefits.

Marketplace

CC.PP.055

Physician’s Office Lab Testing

To ensure higher quality laboratory tests are performed in the correct setting, the health plan will limit the performance of in-office laboratory testing to the CPT® and HCPCS codes listed in the Short Turnaround Time (STAT) laboratory (lab) code list included in this policy. The purpose of this policy is to define payment criteria for in-office laboratory procedures to be used in making payment decisions and administering benefits. Furthermore, to encourage the specialization of independent labs to ensure higher quality laboratory tests are performed in the appropriate setting.

Marketplace

CC.PP.057

Problem Oriented Visits Billed with Preventative Visits

Under modifier -25 correct coding principles, a patient may be seen by the physician for both a preventative evaluation and management (E&M) service and a problem-oriented E&M service during the same patient encounter. Duplicate payments occur when a provider is reimbursed for resources not directly consumed during the provision of a service. The purpose of this policy is to define payment criteria for problem-oriented visits when billed with preventative visits in making payment decisions and administering benefits.

Marketplace

CC.PP.071

E&M Services Billed with Treatment Room Revenue Codes

Treatment Room and Specialty Services revenue codes characterize services performed in a facility setting that are represented by a specific procedure reportable in a treatment room setting.

The patient receiving these services must be registered through the hospital business office for outpatient services on a hospital campus. Treatment room services are outpatient services, furnished on hospital premises, which require the use of a bed, and periodic monitoring for a relatively brief episode of time to carry out certain procedures. The use of the treatment room is an expected part of a minor procedure and replaces the charge for the operating room and recovery room as patients can also recover in the treatment room. Operating rooms are procedure rooms within a sterile corridor and are used for open or major surgical procedures usually involving general anesthesia.

Marketplace

CP.MP.181

Polymerase Chain Reaction Respiratory Viral Panel Testing

Medical necessity criteria for multiplex respiratory polymerase chain reaction (PCR) testing.

Note: For criteria applicable to Medicare plans, please see MC.CP.MP.181 Polymerase Chain Reaction Respiratory Viral Panel Testing.

Marketplace

CP.MP.38

Ultrasound in Pregnancy

This policy outlines the medical necessity criteria for ultrasound use in pregnancy. Ultrasound is the most common fetal imaging tool used today. Ultrasound is accurate at determining gestational age, fetal number, viability, and placental location and is necessary for many diagnostic purposes in obstetrics. The determination of the time and type of ultrasound should allow for a specific clinical question(s) to be answered. Ultrasound exams should be conducted only when indicated and must be appropriately documented.

Marketplace

CP.MP.50

Drugs of Abuse Definitive Testing

Urine drug testing is a key diagnostic and therapeutic tool that is useful for patient care and monitoring of adherence to a controlled substance treatment regimen (e.g., for chronic non-cancer pain) and to identify drug misuse or addiction prior to starting or during treatment with controlled substances.

Marketplace