Provider Reimbursement Guidelines and Coding Edits
Anesthesia Time Designation
The Alliance adheres to Centers of Medicare and Medicaid Services (CMS) guidelines for anesthesia services for relevant ASA codes published in the Current Procedural Terminology (CPT) manual (00100-01999). The total anesthesia time should be reported on the claim in the units of service field, where one unit equals one minute. All services for the same operative session should be submitted on the same claim.
Reimbursement rates are calculated using CMS guidelines, dividing reported time by 15, rounding to the first decimal, and adding to the base units for the CPT code (00100-01999). Any relevant modifier adjustments will be applied to the reimbursement rates (see Modifier Reference Guide).
Bundled Services
We will not separately reimburse for certain CPT and Healthcare Common Procedure Coding System (HCPCS) codes identified by the CMS National Physician Fee Schedule (NPFS) Relative Value File with designated status indicator of “B” for bundled service.
Bundled Codes are not reimbursable services, regardless of whether they are billed alone or in conjunction with other services on the same date. If these services are covered, allowance for them is subsumed by the allowance for the services to which they are incidental. (An example is a telephone call from a hospital nurse regarding care of a patient.) Services without direct face-to-face contact are considered a part of the overall medical management service.
Category II Codes (Measurement Codes)
CPT Category II codes, often called Measurement Codes, are supplemental tracking codes for performance measurement. The use of these codes is optional. Category II codes are not
necessary for correct coding and cannot substitute for Category I codes.
Category II codes are billed in the procedure code field, just as CPT Category I codes are billed. Category II codes describe clinical components usually included in evaluation and management of clinical services and are not associated with any relative value. Category II codes are billed with a $0.00 billable charge amount. The Alliance reprices contracted participating providers billing Category II codes at $0.00 and these services are not separately reimbursable.
Coding Edits
The Alliance applies industry edits to provide consistency in reimbursement by the benefit plan.The Alliance addresses coding relationships through code pair edits from the Centers for
Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI).Providers must report services correctly, according to CMS’s NCCI. Medical and surgical procedures are to be reported with the Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes that most comprehensively describe the
services performed.
When the same provider submits two or more procedure codes for the same member on the same date of service, the codes will be compared. If any of the codes are considered a component of or mutually exclusive of the other code, only the most comprehensive procedure code will be reimbursed.
These edits are based on CMS’s NCCI (or CCI) code pair edits, which are intended to promote consistent and correct coding and reduce inappropriate reimbursement. Under certain circumstances, codes may be reimbursed when appended with the proper modifier if the criteria are met as indicated by CMS and OPTUM’s Resource Based Relative Value System (RBRVS).
View Modifiers
Modifiers include (when appropriately indicated):
| Modifier 25 | Significant, Separately Identifiable Evaluation and Management (E/M) Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service. |
| Modifier 59 | Distinct Procedural Service. |
| Modifier XE | Separate Encounter. A service that is distinct because it occurred during a separate encounter. |
| Modifier XP | Separate Practitioner. A service that is distinct because it was performed by a different practitioner. |
| Modifier XS | Separate Structure. A service that is distinct because it was performed on a separate organ/structure. |
| Modifier XU | Unusual Non-overlapping Service. The use of a service that is distinct because it does not overlap usual components of the main service. |
Commodities
An outpatient reimbursement methodology that applies to specific charge codes and categories. It references either:
- Medicare’ Hospital Outpatient Prospective Payment System (OPPS): Specifically, the Ambulatory Payment Classification (APC) fee schedule is used, relying on geographically unadjusted rates or
- Resource-Based Relative Value Scale (RBRVS): This fee schedule uses geographically unadjusted values for facility-related services.
Outpatient Commodities will be updated annually with new and terminated Charge Codes.
Hospital Inpatient MS-DRG Methodology
The Alliance participating providers whose contract is based on MS-DRG reimbursement methodology for inpatient care will process relevant annual adjustments to the MS-DRG conversion factor, then round to the nearest dollar to arrive at the final conversion factor amount.
The Alliance updates the Hospital Inpatient MS-DRG weights when Medicare releases the updates, typically October 1.
For inpatient stays that span over a period with two different reimbursement rate methodologies, The Alliance processes the inpatient claim based on the reimbursement rate methodology that was in place on the admission date.
Hospital Outpatient APC Fee Schedule Updates
The Alliance updates the Hospital Outpatient APC fee schedule annually on January 1.
Mid-level Practitioner Maximum Reimbursement Rate Fee Schedule
Based on the Agreement between the provider and The Alliance, the following CPT codes may be subject to a maximum reimbursement rate fee schedule that is a percentage of the “Practitioner’s” maximum fee schedule: 10000-69999, 90460 – 90474, 90765-9960. Please refer to the Provider Services Agreement with The Alliance for further information.
Modifier Reference Guide
This is a reference guide to provide information regarding modifier reimbursement practices for The Alliance contracted providers. The Alliance follows industry standards utilized by most payors, including Medicare and OPTUM’s Resource Based Relative Value System (RBRVS) to determine appropriateness of modifier use with CPT/HCPCS codes.
Below is a listing of the most commonly billed modifiers and The Alliance’s corresponding adjustment rate for standard contracts. (NOTE: This is not intended to be an all-inclusive list of CPT/HCPCS modifiers. Rates contained in your Participating Contract with The Alliance supersede rates listed below.)
Commonly Billed Modifiers
| Modifier 22 | Unusual procedural service | 125% of Contract Rate |
| Modifier 50 | Bilateral procedure | 150% of Contract Rate |
| Modifier 51 | Multiple procedure | 50% of Contract Rate |
| Modifier 52 | Reduced services | 50% of Contract Rate |
| Modifier 53 | Discontinued procedure | 50% of Contract Rate |
| Modifier 54 | Surgical procedure only | 80% of Contract Rate |
| Modifier 55 | Postoperative management only | 20% of Contract Rate |
| Modifier 56 | Preoperative management only | 10% of Contract Rate |
| Modifier 62 | Two surgeons | 62.5% of Contract Rate |
| Modifier 78 | Unplanned return to OR during postop period | 70% of Contract Rate |
| Modifier 80 | Assistant surgeon | 20% of Contract Rate |
| Modifier 81 | Minimum assistant surgeon | 10% of Contract Rate |
| Modifier 82 | Assistant surgeon | 20% of Contract Rate |
| Modifier AA | Administered by anesthesiologist | 100% of Contract Rate |
| Modifier AD | Medical supervision—more than 4 concurrent anesthesia procedures | 100% of Contract Rate |
| Modifier AS | Assistant at surgery: physician assistant, nurse practitioner or clinical nurse specialist | 14% of Contract Rate for practitioner level |
| Modifier NU | Purchased durable medical equipment | Contract Rate |
| Modifier QK | Medical direction of two, three or four concurrent anesthesia procedures | 50% of Contract Rate |
| Modifier QX | Administered by CRNA with medical direction | 50% of Contract Rate |
| Modifier QY | Anesthesiologist medically directs one CRNA | 50% of Contract Rate |
| Modifier QZ | Administered by CRNA without medical direction | 100% of Contract Rate |
| Modifier P1 | Healthy patient | No additional units allowed |
| Modifier P2 | Patient with mild systemic disease | No additional units allowed |
| Modifier P3 | Patient with severe systemic disease | One additional unit |
| Modifier P4 | Patient with severe systemic disease that is a constant threat to life | Two additional units |
| Modifier P5 | A morbid patient who is not expected to survive without the operation | Three additional units |
| Modifier P6 | A declared brain-dead patient whose organs are being removed for donor purposes | No additional units allowed |
| Modifier RR | Rental durable medical equipment | Contract Rate |
RBRVS Fee Schedule Updates
The Alliance updates the RBRVS files annually on January 1. If there is a major change to the fee schedule after January 1, The Alliance will update the fee schedule the first of the following month of the release of the updated RBRVS file.
Service Codes with Relative Value of Zero
The Alliance participating providers whose contract is based on reimbursement rates calculated from either OPTUM The Essential RBRVS or OPTUM Relative Values for Physicians shall price service codes with relative values of zero at $0.00.
Service codes with a relative value of zero are considered bundled into another service, whether the code is billed on the same date of service as a primary code or billed alone on a different date or claim. Medicare often refers to these codes as status B codes.
Contracted participating providers whose methodology is OPTUM The Essential RBRVS shall only apply the above guideline when the service code is indicated by OPTUM as a gap code.
