Participating Provider Reimbursement Guidelines and Coding Edits 

Cloud
Compare
Cloud
Clouds

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. 

Bundled Service List

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. 

Category II Codes List

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.

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

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 reprice at $0.00 for service codes valued at 0 (zero) on their respective contracted methodology and these services are not separately reimbursable. 

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. 

OPTUM Zero Valued Codes (Gap Codes)

Clouds
Contact Us

Want to learn more about provider reimbursement rates?

Clouds
Plant
logo