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Payment Policy Changes Effective 3/5/2022

Date: 01/05/22

Managed Health Services (MHS) is publishing its Payment Policies to inform providers about acceptable billing practices and reimbursement methodologies for certain procedures and services. MHS believes that publishing this information will help providers to bill claims more efficiently, therefore reducing unnecessary denials and delays in claims processing and payments.

We will apply these policies as medical claims reimbursement edits within our claims adjudication system. This is in addition to all other reimbursement processes that MHS currently employs. These policies are developed based on medical literature and research, industry standards and guidelines as published and defined by the American Medical Association’s Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS), and public domain specialty society guidance, unless specifically addressed in the fee-for-service provider manual published by the state or MHS regulations.

We continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you that the below policies have been revised or changed.

For detailed information about these policies, please refer to our website at mhsindiana.com. For questions about this or any of our payment policies, please don’t hesitate to reach out to our Provider Services team at 1-877-647-4848.

Policy Name

Description/ Changes

Non-adherence Consequence

Products Impacted

CC.PP.071 Evaluation and Management Services Billed with Treatment Rooms - New Policy

Disallows E&M services in treatment rooms as this does not represent a treatment type of service.

Ex Code:

EXJn - Office visits billed on same line as treatment room services.

Marketplace

CP.MP.209 Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing - New Policy

Restricts reimbursement of GI pathogen panels with 12+ targets to only inpatient settings, including inpatient, ED, and outpatient hospitals.

Ex Code:

yN - Deny: Procedure code(s) billed in an inappropriate setting.           

wN - Deny: Procedure code(s) billed in an inappropriate setting.           

Medicaid, Marketplace

CP.MP.97 Testing for Select Genitourinary Conditions - Change to Existing Policy

  • Adds CPT codes 81513 and 81514 codes to list of non-payable codes.
  • Removes all edits applicable to 83986 and 87210.
  • Removes the following ICD-10 codes as payable when billed with CPT 82120, 87480, 87510 and 87905:

A59.01     F11.10      F11.11     F11.120

F11.121   F11.122    F11.129   F11.13

F11.14     F11.150    F11.151   F11.159

F11.181   F11.182    F11.188   F11.19

F11.20     F11.21      F11.220   F11.221

F11.229   F11.23      F11.24     F11.250

F11.251   F11.259    F11.281   F11.282

F11.288   F11.29      F14.10     F14.11

F14.120   F14.121    F14.122   F14.129

F14.13     F14.14      F14.150   F14.151

F14.159   F14.180    F14.181   F14.182

F14.188   F14.19      F14.20     F14.21

F14.220   F14.221    F14.222   F14.229

F14.23     F14.24      F14.250   F14.251

F14.259   F14.280    F14.281   F14.282

F14.288   F14.29      F15.10     F15.11

F15.120   F15.121    F15.122   F15.129

F15.13     F15.14      F15.150   F15.151

F15.159   F15.180    F15.181   F15.182

F15.188   F15.19      F15.20     F15.21

F15.220   F15.221    F15.222   F15.229

F15.23     F15.24      F15.250   F15.251

F15.259   F15.280    F15.281   F15.282

F15.288   F15.29      F18.10     F18.11

F18.120   F18.121    F18.129   F18.14

F18.150   F18.151    F18.159   F18.17

F18.180   F18.188    F18.19     F18.20

F18.21     F18.220    F18.221   F18.229

F18.24     F18.250    F18.251   F18.259

F18.27     F18.280    F18.288   F18.29

F19.10     F19.11      F19.120   F19.121

F19.129   F19.130    F19.131   F19.132

F19.139   F19.14      F19.150   F19.151

F19.159   F19.16      F19.17     F19.180

F19.181   F19.182    F19.188   F19.19

F19.20     F19.21      F19.220   F19.221

F19.222   F19.229    F19.230   F19.231

F19.232   F19.239    F19.24     F19.250

F19.251   F19.259    F19.26     F19.27

F19.280   F19.281    F19.282   F19.288

F19.29     Z11.2        Z11.8       Z13.89

Ex Code:

yw - Not Medically Necessary or Ineligible Service per CMS or Plan Rules.

yC - Not Medically Necessary or Ineligible Service per Centene Policy.

xE - Procedure code is disallowed with this diagnosis code(s) per plan policy.

yE - Procedure code is disallowed with this diagnosis code(s) per plan policy.

wE - Procedure code is disallowed with this diagnosis code(s) per plan policy.

wW - Not medically necessary or ineligible service per plan policy.

 

Medicaid, Marketplace, Medicare

CP.MP.155 EEG for Headache - Change to Existing Policy

  • Adds R51.9 as non-payable when listed as the only diagnosis code, and billed with 95812, 95813, 95816, or 95819.
  • Adds the following ICD-10 codes as non-payable (if listed as the only diagnosis code) when billed with CPT 95822

G43.001        G43.809       G44.051

G43.009        G43.811       G44.059

G43.011        G43.819       G44.091

G43.019        G43.821       G44.099

G43.101        G43.829       G44.1

G43.109        G43.831       G44.201

G43.111        G43.839       G44.209

G43.119        G43.901       G44.211

G43.401        G43.909       G44.219

G43.409        G43.911       G44.221

G43.411        G43.919       G44.229

G43.419        G44.001       G44.301

G43.501        G44.009       G44.309

G43.509        G44.011       G44.311

G43.511        G44.019       G44.319

G43.519        G44.021       G44.321

G43.601        G44.029       G44.329

G43.609        G44.031       G44.40

G43.611        G44.039       G44.41

G43.619        G44.041       G43.701

G44.049        G43.709       G44.53

G43.711        G44.59         G43.719

G44.81          G43.A0    G44.82

G43.A1          G44.83     G43.B0

G44.84          G43.B1    G44.85

G43.C0         G44.89     G43.C1

R51.0            G43.D0     R51.9

G43.D1         G44.51     G43.801

G44.52         

Ex Code:

yw - Not Medically Necessary or Ineligible Service per CMS or Plan Rules.

yC - Not Medically Necessary or Ineligible Service per Centene policy.

Medicaid, Marketplace, Medicare

CP.MP.124 ADHD Testing and Treatment - Change to Existing Policy

  • Adds the following CPT codes as not payable when billed with only a diagnosis of ADHD (F90.0, F90.1, F90.2, F90.8, F90.9):

93000       93005

93010       80061

83718       83719

82721       83722

84475       92650

92651       92652

92653

  • Removes the following CPT codes as not payable when billed with only a diagnosis of ADHD (F90.0, F90.1, F90.2, F90.8, F90.9):

            92585

            92586

Ex Code:

yw - Not Medically Necessary or Ineligible Service per CMS or Plan Rules.

yC - Not Medically Necessary or Ineligible Service per Centene policy.

Medicaid, Marketplace, Medicare



Last Updated: 01/05/2022