Participating Provider Reimbursement Guidelines and Coding Edits
Anesthesia Time Designation
The Alliance adheres to guidelines by Centers of Medicare and Medicaid Services (CMS) with respect to 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.
CMS guidelines are followed for purposes of calculating reimbursement rates, where the total units will be the reported time divided by 15 and rounded to the first decimal then added to the base units for the relevant 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 Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes identified by the Centers of Medicare and Medicaid Services (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 to be a component of the overall medical management service.
Category II Codes (Measurement Codes)
Current Procedural Terminology (CPT) Category II codes, often referred to as Measurement Codes, are supplemental tracking codes that can be used for performance measurement.
The use of these codes is optional. These Category II codes are not required for correct coding and may not be used as a 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. Therefore, Category II codes are billed with a $0.00 billable charge amount. The Alliance will reprice 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 is considered to be 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. |
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.
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 payers, 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 | Description | Adjustment Rate |
|---|---|---|
| 22 | Unusual procedural service | 125% of Contract Rate (For CPT Codes 1XXXX – 6XXXX) |
| 50 | Bilateral procedure | 150% of Contract Rate |
| 51 | Multiple procedure | 50% of Contract Rate |
| 52 | Reduced services | 50% of Contract Rate |
| 53 | Discontinued procedure | 50% of Contract Rate |
| 54 | Surgical procedure only | 80% of Contract Rate |
| 55 | Postoperative management only | 20% of Contract Rate |
| 56 | Preoperative management only | 10% of Contract Rate |
| 62 | Two surgeons | 62.5% of Contract Rate |
| 63 | Procedure performed on infants less than 4 kg. | 125% of Contract Rate |
| 73 | Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia | 50% of Contract Rate |
| 78 | Unplanned return to OR during post-op period | 70% of Contract Rate |
| 80 | Assistant surgeon | 20% of Contract Rate |
| 81 | Minimum assistant surgeon | 10% of Contract Rate |
| 82 | Assistant surgeon | 20% of Contract Rate |
| AA | Administered by anesthesiologist | 100% of Contract Rate |
| AD | Medical supervision—more than 4 concurrent anesthesia procedures | 100% of Contract Rate |
| AS | Assistant at surgery: physician assistant, nurse practitioner or clinical nurse specialist | 14% of Contract Rate for practitioner level |
| NU | Purchased durable medical equipment | Contract Rate |
| QK | Medical direction of two, three or four concurrent anesthesia procedures | 50% of Contract Rate |
| QX | Administered by CRNA with medical direction | 50% of Contract Rate |
| QY | Anesthesiologist medically directs one CRNA | 50% of Contract Rate |
| QZ | Administered by CRNA without medical direction | 100% of Contract Rate |
| P1 | Healthy patient | No additional units allowed |
| P2 | Patient with mild systemic disease | No additional units allowed |
| P3 | Patient with severe systemic disease | One additional unit |
| P4 | Patient with severe systemic disease that is a constant threat to life | Two additional units |
| P5 | A morbid patient who is not expected to survive without the operation | Three additional units |
| P6 | A declared brain-dead patient whose organs are being removed for donor purposes | No additional units allowed |
| 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.
