Payment Policy Changes for 1/1/21
Date: 12/14/20
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.
Visit mhsindiana.com to find the Payment Policies. The effective date for the below policy revisions is January 1, 2021.
Policy Name | Description | Non-adherence Consequence | Products Impacted |
CP.MP.121 Homocysteine Testing
| During the May 2020 annual review of homocysteine testing, it was determined to change the policy regarding the borderline B12 deficiency and idiopathic VTE/thromboembolism indications from medically necessary to investigational. Removed from the list of ICD-10 codes supporting coverage criteria: D51.0-D51.9, E53.8, I26.01-I26.99, I81, I82.0-I82.91, Z86.711, Z86.718. | EX Code: xE Procedure code is disallowed with this diagnosis code(s) per plan policy | Medicaid, |
CP.MP.124 Attention Deficit Hyperactivity Disorder Assessment and Treatment | During the May 2020 ADHD annual review, it was determined to change the policy to add 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): 78803, 81171, 81172, 92547, 95705, 95706, 95707, 95708, 95709, 95710, 95711, 95712, 95713, 95714, 95715, 95716, 95717, 95718, 95719, 95720, 95721, 95722, 95723, 95724, 95725, 95726, 96121, 97129, 97130 Remove 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): 78607, 95827, 97127 Add the following HCPCS code as not payable when billed with only a diagnosis of ADHD (F90.0, F90.1, F90.2, F90.8, F90.9):G0176 | EX Code: yw | Medicaid, Medicare (Allwell), |
CP.MP.157 Vitamin D Testing in Children
| A global consensus statement recommends against universal screening for vitamin D deficiency in healthy children as there is insufficient evidence that the potential benefits of testing outweigh the potential harms. Policy/Criteria I. It is the policy of health plans affiliated with Centene Corporation® that 25-hydroxyvitamin D testing in healthy, including obese but otherwise healthy, children (age ≥ 1 and ≤ 18) is not medically necessary because these tests have not been demonstrated to have a clear clinical benefit. | EX Code: yw | Medicare (Allwell) |
CP.MP.50 Outpatient Testing for Drugs of Abuse | 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. Consider G0482 and G0483 as not medically necessary instead of being on prior authorization for members over the age of 6. | EX Code: wW | Marketplace (Ambetter) |
CP.MP.139 Low-Frequency Ultrasound Wound Therapy | Low-frequency ultrasound debridement is a noncontact debridement method that provides simultaneous cleansing and debridement of wounds. It is generally performed at a 5 mm - 15mm distance from the wound surface. A device uses ultrasound technology to atomize saline, delivering a continuous mist to the treatment site. Multiple passes over the wound are made with the treatment head of the device for a predetermined treatment session. This can accelerate the wound healing process by removing the necrotic tissue, fibrosis, exudate, and bacteria with minimum bleeding and pain. It is the policy of health plans affiliated with Centene Corporation® that low-frequency ultrasound wound therapy is considered investigational. This treatment continues to be evaluated in clinical studies. However, current peer reviewed literature is inconclusive at this time. | EX Code: yw | Medicaid, |
CP.MP.154 Thyroid Testing in Pediatrics | Numerous essential metabolic functions are mitigated by hormones produced by, and affecting the thyroid, e.g., thyroid stimulating hormone [TSH] and thyroxine [T4], as well as by insulin. This policy discusses the medical necessity requirements for the testing of these hormones. | EX Code: yw | Medicare (Allwell) |
CC.PP.065 Multiple Diagnostic Cardiovascular Payment Reduction | This policy is based on CMS reimbursement methodologies for MPPR and applies a multiple diagnostic cardiovascular procedure reimbursement reduction (MDCR) to procedures assigned a multiple procedure indicator (MPI) of 6 on the CMS National Physician Fee Schedule (NPFS). When this occurs, only the highest-valued procedure is reimbursed at the full payment allowance (100%) and payment for subsequent procedures/units is reimbursed at 75% of the allowance. | EX Code: yl Reduction Applied For Multiple Procedures Per Payment Policy | Marketplace (Ambetter) |
CC.PP.011 Cotiviti 8 | The purpose of this policy is to serve as a reference guide for general coding and claims editing information. Cotiviti 8 is a correct coding edit of ICD-10 diagnosis codes. Source: ICD-10 CM Diagnosis Code Manual | EX Code: wd Diagnosis Code Incorrectly Coded Per ICD10 Manual | Medicaid, |
CP.MP.125 DNA Analysis of Stool | Cologuard is a noninvasive screening test for colon cancer. This test comprises a multi-target screen for several aberrant DNA markers of colon cancer, as well as a hemoglobin immunoassay. This policy describes the medical necessity requirements for DNA analysis of stool with Cologuard. 8/12/20 email revision: Policy being revised and becoming more lenient to add ICD-10-CM code Z12.12 as payable when billed with CPT 81528. | EX Code: yt Incorrect Procedure Or Dx Code For Member Age Or Gender Per CMS/AMA/PLAN or EX Code: ya | Medicare (Allwell |