Reimbursement Guidelines
Time Span Codes
UnitedHealthcare will reimburse a CPT or HCPCS Level II code that specifies a time period for which it should be reported (e.g., weekly, monthly), once during that time period. The time period is based on sourcing from the AMA or CMS including: the CPT or HCPCS code description, CPT book parentheticals and other coding guidance in the CPT book, other AMA publications or CMS publications.
For example: Within the CPT book, the code description for CPT code 95250 states, “Ambulatory continuous glucose monitoring of interstitial tissue fluid via subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording”. In addition to that code description, there is also a parenthetical that provides further instructions with regard to the frequency the code can be reported. The parenthetical states, “Do not report 95250 more than once per month”. UnitedHealthcare will reimburse CPT Code 95250 only once per month for the same member, for services provided by the Same Group Physician and/or Other Qualified Health Care Professional.
CPT coding guidelines specify for physicians or other qualified health care professionals to select the name of the procedure or service that accurately identifies the services performed
Calendar-Year Versus 12-Month Monitoring Cycle
Some IHCP service limitations are monitored via a rolling 12-month period, and some are monitored on a calendar-year basis. During claim processing, CoreMMIS reviews the claim history to ensure services do not exceed established limitations. CoreMMIS compares the service date for a particular claim with service dates that are already paid. CoreMMIS looks back at service dates within the particular code’s established service limitation. If the number of services or dollars has been exceeded for a specific benefit limit, prior authorization (PA) may be required based on medical necessity. If PA is not obtained, CoreMMIS rejects the claim. In summary, CoreMMIS generally rolls back 1 year from the service date and counts the number of units or dollars used. CoreMMIS calculates benefit limits on a service-date-specific basis for paid claims.
Example 1: This example illustrates a calendar-year monitoring cycle. IHCP members are authorized office visits at 30 per calendar year. A member became eligible on February 1, 2019, and with four office visits per month (to a physician, chiropractor, podiatrist, and mental health provider), reaches the 30-office-visit limitation in September 2019. Without PA, the member is not authorized for another office visit until January 1, 2020 (the beginning of a new calendar year), at which point the restriction of 30 visits per calendar year is restored.
Example 2: This example illustrates a rolling 12-month monitoring cycle. The IHCP limits coverage of mental health services provided in an outpatient or office setting to 20 units per member, per provider, per rolling 12-month period without prior authorization. A member became eligible on February 1, 2019, and received four units of outpatient mental health services on the first day of eligibility. On September 1, 2019, the member reached the 20-unit limitation. Without PA, the member is not authorized for another outpatient mental health service until February 1, 2020. In this example of a 12-month limitation, the system restores the four units depleted on September 1, 2019, 12 months (or 365 days) after the date they were used. In this illustration, if the member does not use another outpatient mental health service until all 20 units are restored, the full complement of 20 units per rolling 12-month period would be totally restored in September 2020.
The following are examples of services that are limited on a calendar-year basis:
• Office visits
• Inpatient rehabilitation
• Durable medical equipment (DME) and home medical equipment (HME)
• Chiropractic
• Vision
The following are examples of services that are limited on a rolling 12-month basis:
• Mental health visits
• Transportation
• Incontinence supplies
Time Span Comprehensive and Component Codes
When related Time Span Codes which share a common portion of a code description are both reported during the same time span period by the Same Group Physician and/or Other Qualified Health Care Professional for the same patient, the code with the most comprehensive description is the reimbursable service. The other code is considered inclusive and is not a separately reimbursable service. No modifiers will override this denial.
CPT codes 93270, 93271, and 93272 are indented and each share a common component of their code description with CPT code 93268.
When CPT code 93270, 93271, or93272 are ported with CPT 93268 during the same 30-day period by the Same Group Physician and/or Other Qualified Health Care Professional for the same patient, only CPT code 93268 is the reimbursable service.
The Time Span Code Comprehensive and Component Codes list includes applicable comprehensive and related component Time Span Codes
Q:How does UnitedHealthcare determine the “time span” for codes with a description of calendar month, per month or monthly?
A:UnitedHealthcare determines the “time span” for codes with a description of Calendar Month, per month or monthly by an individually named month of the year, e.g., January, February etc. Example: A member can get a calendar month, per month or monthly supply on December 31 for December and then again on January 1 for January. If a code description says 30 days, the code can be submitted for consideration of reimbursement again on the 30thday from the date of service on the previous submission
Policy from BCBS
Blue Cross Blue Shield North Carolina (Blue Cross NC) will not reimburse claims with units that exceed the assigned maximum for that service. The total number of units will be adjusted to the maximum and the excess units will be denied.
Reimbursement of:
•Ocular photography of an eye segment will be limited to no more than twice per year.
•Whole body integumentary photography is only reimbursable for high-risk members, and will be limited to no more than once per year.
•Chiropractic manipulative treatment (CPT®98940-98942) will be limited to one unit per day.
•Percutaneous implantation of a peripheral nerve neuro stimulator will be limited to two units per year.
•Psychiatric diagnostic evaluations (CPT®90791 and 90792 or any combination thereof) are limited to no more than three units per year.
•Home health agency recertification code will be limited to no more than once every 60 days.
Diagnostic and therapeutic paravertebral facet joint injections are limited to eight times per region in a year.
•Diagnostic and therapeutic epidural or subarachnoid injections are limited to six times a year.
•Up to eight transforaminal epidural injection sessions per region may be performed in a year upto two diagnostic and up to six therapeutic.
