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Provider and Facility Reference Manual

Section 13A - Additional Claims and Billing Information

Lesions

The CPT4 codes for lesion treatments include specific verbiage that needs to be considered in determining whether more than one unit of service or line of service can be billed for a code and if any other codes can be billed with it.

Listed below are the CPT4 codes and the maximum number of units that should be reported on a claim for a date of service.

Code Verbiage Maximum Units
11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion 01
11056  Two to four lesions 01
11057  More than four lesions 01
17000 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curretement), premalignant lesions (e.g., actinic keratoses); first lesion 01
17003  Second through14th lesion, each (list separately in addition to code for first lesion) 13
17004  Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curretement), premalignant lesions (e.g., actinic keratoses), 15 or more lesions  01
17110  Destruction by any method of flat warts, molluscum contagiosum, or milia; up to 14 lesions 01
17111  15 or more lesions
  • No more than one of the following codes can be reported for an encounter:11055, 11056, 11057
  • 17003 can only be billed with 17000.  Do not report 17004 in conjunction with codes 17000 or 17003
  • Code 17111 cannot be reported with 17110
01

Mammography

Please be sure to use the appropriate CPT codes when billing mammography to differentiate diagnostic from screening.

Diagnostic codes should be used when the procedure is ordered because of a suspicion of breast disease (due to symptoms or clinical findings), patient history of breast cancer or biopsy proven breast disease.


Screening Mammography

A screening code should be used when the procedure is done as a baseline or on a routine basis.

Multiple, Bilateral, and Multiple Bilateral Procedures

Surgical:
In accordance with Current Procedural Terminology (CPT) guidelines, bilateral procedures should be billed on one line only, utilizing the modifier 50; enter one as 01 in the units field and bill your total bilateral charge.

Bilateral Billing Examples

  • Bilateral breast reconstruction – report as code 19357 with modifier 50 on one claim line with 01 in the units field.
  • Bilateral lower and upper blepharoplasties – report as:
    •  15820 with modifier 50 on the first claim line with 01 units
    • 15822 with modifier 50 on the second claim line with 01 units

Note: For bilateral services, do not bill modifier LT/RT or any other site-specific modifier other than 50.

Multiple Procedures
Separate billing is allowed for multiple procedures performed on the same day that add significant time or complexity and are not incidental or an integral part of the primary procedure. The primary procedure is reimbursed at the fee schedule amount; eligible secondary procedures are reimbursed at 50 percent.

Multiple procedures that involve the same service performed more than once (such as CPT code 26100, arthrotomy of each carpometacarpal joint of the left hand), should be billed as five separate lines on the claim form along with the modifier 59 or the HCPCS individual digit modifiers on lines two through five in order to clarify that the additional lines are definitely separate services.

Procedure code descriptions including more than one unit of service provided, (such as code 95117, professional services for allergy immunotherapy, two or more injections, or code 96406, intralesional injections, more than seven lesions), are reported on one line with only one (01) unit.

Final reimbursement is also determined after applying usual edits such as (but not limited to) preauthorization, cosmetic coverage and bundling. In addition, the member’s contract must be active at the time the service is rendered.

Physician/Provider Exceptions (Does not apply to Hospital category reimbursement)

When the CPT code description includes: "each additional" (for example, code 63048, laminectomy, each additional cervical, thoracic, or lumbar segment), report the code on one line with the number of additional segments indicated in the units field.

When the CPT code states: "specify number of tests, doses" (such as code 95024, intradermal tests with allergenic extracts), report the code on one line with the number of tests, doses, etc., indicated in the units field.

Code & Comment

The Code & Comment section on our provider website is an extremely valuable tool that, among other things, can help you determine if a surgical code is bilateral. The Code & Comment tool provides procedure code coverage information including preauthorization requirements and potential medical policies/ protocols that may apply. Code & Comment is available as a "Quick Link" on our secure website. Once selected, a pop-up window will appear. Once you type in a procedure code and select a code type, the coverage information will be returned. A key is also available to explain the abbreviations used in the results. The key also describes some of the fields found in the tool and provides further explanation. The key should be consulted frequently as information can change.

Non-Ionic Low Osmolality Contrast Media

Contrast media will not be considered for separate payment and cannot be billed to the patient. Reimbursement for contrast media is included in the allowance for the radiology service. To maintain accurate records of the use of non-ionic contrast media, use the appropriate CPT/HCPCS code.

 

Sleep Studies

Modifier 26 (for the physician component/CMS 1500 or 837P claim) and modifier TC (for the hospital or technical services/UB04 or 837I claim) must be used when a sleep study is performed at a hospital or affiliated clinic.

  Type of Claim Revenue Codes Bill  Type CPT Codes *Roll-Up/ Reimbursement
1 Ambulatory Surgery 0360-0361, 0490, 0750 & 0790 131

YES          

Valid Category

CPT Code Required

Yes / Category and contract may allow for additional reimbursement of eligible implantable prosthetic devices (revenue codes 274 & 278), pacemakers (revenue code 275).  Eligible secondary procedures pay at 50 Percent.
1a Cancelled Ambulatory Surgery 0360-0361, 0490, 0750 & 0790 131

YES          

Valid Category

CPT Code Required

Bill Claim with Occurrence Code 43.  Reimbursement based on record review or use modifier 53
2 Emergency Room / "Urgent Care" Service within Emergency Department 0450, 0459 13X

YES        

99281-99285

YES/ Case Rate
2a ER Physician Fee 0981 (For hospital employed MD's only) 13X YES NO/ Fee Schedule
3 Observation  0762 13X NO Per diem/Per Case, pays in addition to ER
4 Urgent Care Centers 456

89X

13X

YES

99201-99205

99211-99215

99281-99285       

YES/ All-inclusive case rate (fee schedule)
5 Clinic Must be billed on a HCFA1500/ANSI837 Professional Form. N/A YES NA / Follows physician reimbursement guidelines. 
TC split for Medicare Primary will be accepted on a UB92.
6 Chemotherapy* 0280-0289, 0331, 0332, 0335 13X NO Identified high-cost drugs, labs and diagnostics pay according to your schedule of allowance
7 Radiation Therapy 0330, 0333, 0339  13X YES NA/Services pay according to your schedule of allowance in addition to identified high-cost drugs, labs and diagnostics.
9 Home Infusion Therapy 0640 - 0649 33X              34X YES NO / Schedule of allowance
8 Transfusion* 0390, 0391 13X YES -
391 
36430-36460
NO / Blood Storage & Processing (Rev Code 390 is not payable.  Identified high-cost Injectable drugs, diagnostic services and labs pay according to your schedule of allowance
9 Cast Room* 0700,  0709 131 NO Labs, diagnostic services and durable medical equipment pay according to fee schedule.
10 Infusion Therapy* 0260-0269 131 NO Labs and diagnostic services pay per your schedule of allowance.  Drugs are paid according to guidelines indicated in "High-Cost Drugs" (category #28).
11 Dialysis 0820, 0821, 0830, 0831, 0840, 0841, 0849, 0850, 0851, 0859 13X              72X YES, per contract Ancillaries paid in addition if not included in composite reimbursement.
12 Epogen 0634-0635 13X              72X YES NO/Per Unit. Appropriate HCPCS code should be billed indicating units given in unit field or use value code 68
13 Pre-Admission Testing   13X YES Refer to Guidelines for Diagnostics.  Bill with Occurrence Code 41.  Roll-up to ambulatory surgery/IP stay.
14 False Labor 0720 - 0729 13X NO Per contract, ER  per diem/case rate is paid.  59025 present should pay schedule of allowance
15 Recovery Room 0710 - 0719 13X NO Roll-up to ambulatory surgery, ER or Observation.  Will not pay if billed alone.
16 Ambulance 0540 - 0549 131 N/A Charges (Should not roll up if billed with 450 - ER)
17 Cardiac Rehab 0943 131 YES Schedule of Allowance.  Follow applicable protocol for guidelines and limitations
18 Diagnostic Testing 0300-0309, 0310-0319, 0340-0349, 0350-0359, 0400-0409, 0460-0469, 0470-0479, 0480, 0482, 0489, 0610-0619, 0621-0622, 0720, 0730-0739, 0740-0749, 0920-0929               131 YES Schedule of Allowance
19 Electric Shock                     
Psych / Other
0900, 0901, 0902, 0919 13X YES Schedule of Allowance
20 OP/Alcohol/Drug 0905, 0912, 0914, 0915, 0916, 0944, 0945 13X              89X YES Schedule of Allowance
21 Durable Medical Equipment  (DME) 0290 - 0293, 0299, 0946, 0947 13 YES Schedule of Allowance
21 Therapies                                   
PT, OT, ST
0420-0429, 0430-0439, 0440-0449, 0530-0539, 0940-0941, 0949 13X YES Schedule of Allowance for each per day
22 Fetal Non-Stress 0720 131 YES        
(59025)
Schedule of Allowance
23 Hospice 065X 81X              82X N/A Flat rate per visit; if Medicare eligible and member elects into Hospice Care, Medicare is responsible for all claims
24 Home Health Care 055X , 056X, 057X, 042X, 043X  044X 33X    34X N/A YES/Pays off revenue code per visit except rev code 572 - HHA which pays per hour.
25 Prosthetics and Implantables 0274,  0278, 0275 13X HCPCS Category and contract may allow additional payment for eligible implantables.  Payment equal to invoice cost, subject to post-payment audit.
26 Treatment Room* 0760, 0761 13X YES Pays according to your schedule of allowance
27 Inhalation Therapy 0410 - 0419 131 YES Pays according to your schedule of allowance
28 High-Cost Drugs 0636 131 YES 
(HCPCS)
Pays according to your schedule of allowance
29 Supplies 0270, 0271, 0272, 0273, 0277 & 0279 131 NO These revenue codes will not be paid if billed with unbundled service.
30 Miscellaneous Pharmaceuticals 0250-0259 131 NO These revenue codes will not be paid if billed with unbundled service.
31 Sleep Studies/ Polysomnography 0740, 0920 131 95805-95811 Payable per fee schedule.  
32 Lithotripsy 360, 490, 790 131 YES          
Valid Category CPT Code Required
YES / Secondary procedures pay at 50 percent.

The policies and procedures referenced in this section represent our standard for claims submission, payment, and adjustment. Certain providers may be subject to different guidelines due to contractual limitation or expansions.

*Service could pay up to $50 per day for room charge