Private Payer Round-Up, January 2013

In case you missed these — here is a roundup of useful items from health care payment plans’ newsletters and updates, compiled by TMA’s reimbursement specialists.

If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call TMA Knowledge Center at (800) 880-7955. Having trouble appealing a claim dealing with a health plan? Report your problem to the TMAHassle Factor Log, and TMA will help you resolve it.


After-hours access is required — Blue Cross and Blue Shield of Texas (BCBSTX) requires physicians to provide urgent care and emergency care or coverage for care 24 hours a day, seven days a week. You must have a verifiable mechanism in place for immediate response that directs patients to alternative after-hours care based on the urgency of the patient’s need. 

Acceptable after-hours access mechanisms may include: 

  • An answering service that offers to call or page the physician or on-call physician;
  • A recorded message that directs the patient to call the answering service and gives the phone number; or
  • A recorded message that directs the patient to call or page the physician or on-call physician and gives the phone number.

For more detail, refer to the BlueChoice® Physician and Other Professional Provider Manual (Section B) and the HMO Blue® Texas Physician and Other Professional Provider Manual (Section B), available on the BCBSTX website. Click on the Education & Reference tab, then click on “Manuals” and enter the password.

Be sure to complete items 21 and 24E on the CMS-1500 properly — BCBSTX reports frequent adjustments needed for claims for routine exams, such as annual physicals, and offers this reminder: The primary reason for the patient’s visit indicates the primary diagnosis code pointer to use on the claim. Diagnosis code pointers indicate the order of importance in relation to the service being performed. The first pointer designates the primary diagnosis for the service line. Remaining diagnosis pointers indicate declining level of importance to the service line.

The following is excerpted from the CMS-1500 claim form instructions from the National Uniform Claim Committee.

Item Number 21 
Title: Diagnosis or Nature of Illness or Injury (relate items 1, 2, 3, or 4 to 24E by line)|
Instructions: Enter the patient’s diagnosis/condition. List no more than four ICD-9-CM diagnosis codes. Relate lines 1, 2, 3, 4 to the lines of service in 24E by line number. Use the highest level of specificity. Do not provide narrative description in this field. When entering the number, include a space (accommodated by the period) between the two sets of numbers. If entering a code with more than 3 beginning digits (e.g., E codes), enter the fourth digit above the period.
Description: The “Diagnosis or Nature of Illness or Injury” refers to the sign, symptom, complaint, or condition of the patient relating to the service(s) on the claim.
Field Specification: This field allows for the entry of 3 characters prior to the period, 1 character above the period, and 4 characters after the period in each of the four line areas.

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate Items 1, 2, 3 or 4 to Item 24E by Line)

  1. 998.59
  2. 780.6
  3. V18.0
  4. E878.8

Item Number 24E 
Title: Diagnosis Pointer [lines 1-6]
Instructions: Enter numbers left justified in the field. Do not use commas between the numbers.
Description: The "Diagnosis Pointer" refers to the line number from Item Number 21 that relates to the reason the service(s) was performed.
Field Specification: This field allows for the entry of 4 characters in the unshaded area.

Source: BCBSTX


Precertification changes — on Feb. 18, 2013, Cigna will update its list of existing CPT and HCPCS codes to include 47 additional codes that will require precertification and to remove 56 codes from the precertification list.

 You can view the updated precertification list on the Cigna for Health Care Professionals (CignaforHCP) website (log-in required) by clicking on “Precertification Policies” under Popular Links.

Codes that will be added to the precertification list on Feb. 18, 2013  

Codes that will no longer require precertification beginning Feb. 18, 2013  

15272, 15274, 15276, 15278, 21325, 33249, 61863, 61867, 61880, 61888, 81210, 81280, 81281, 81282, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301,

81317, 81318, 81319, 81350, 95805, 95806, 95807, 95808, 95810, 95811, E0986, G0398, G0399, J0881, J0885, J0897, J2504, L8680, L8686, L8687, Q4106, S3834, S3890


15170, 15175, 15330, 15331, 15335, 15336, 36515, 55706, 64622, 64623, 64626, 64627, 65770, 77079, 90901, 90911, 92558, 93025, 0042T, 0075T, 0076T, 0100T, 0141T, 0142T,

0143T, 0155T, 0156T, 0157T, 0158T, 0158T, 0166T, 0167T, 0184T, C1818, E0652, E1801, E1806, E1811, E1812, E1818, E1821, G0416, G0417, G0418, G0419, J7184, L7266, L7272,

L7274, Q2040, Q2041, Q2042, S2225, S9090, S9335, S9339

Network News is going all digital — Cigna’s Network News will become an all-digital publication later this year. You will be able to print individual articles or the entire newsletter without any photos or graphics, saving paper and toner.

 Sign up to receive Network News by email at CignaforHCP. Under Settings and Preferences, review your email address and correct it if needed, and you will automatically receive the publication by email. You also may sign up by emailing NetworkNewsEditor[at]Cigna[dot]com or faxing (646) 467-5697. Include your Cigna provider ID or taxpayer identification number (TIN); email address (can be multiple addresses per ID or TIN); name and job title for each email; practice type (physician, hospital, or ancillary) and primary address, city, state, and ZIP Code. Anyone from your office may receive Network News by email. Or, you can always download and print the latest version of Network News at > Health Care Professionals > Newsletters. Network News is posted the first week of each quarter (January, April, July, and October) at If you prefer to receive NetworkNews each quarter in the mail, use the email and fax contact instructions above to request that. If you have questions, email NetworkNewsEditor[at]Cigna[dot]com.

Coming soon: one website for all Cigna patient information — You’ll soon be able to access one website, CignaforHCP, to complete administrative tasks for all of your Cigna patients, including those who receive care through the GWH-Cigna network (no more logging in to To register, go to CignaforHCP, and click on “Register Now.”

If you or someone in your office is already registered for as a primary administrator, that person can assign website access to others in the office by logging in to and clicking on the Working with Cigna tab. Information about assigning access will be on the left side of the page.

Source: NetworkNews (PDF), January 2013 


Code accurately for assistant surgeon services — Humana offers the following guidelines for use of modifiers when coding for assistant surgeon* services:

  • Modifier 80 — Assistant surgeon (physician)
  • Modifier 81 — Minimum assistant surgeon (physician)
  • Modifier 82 — Assistant surgeon (physician, when resident not available)
  • Modifier AS — Physician assistant, nurse practitioner or clinical nurse specialist services for assist-at-surgery (nonphysician)

For Medicare Advantage billing, use of modifiers 80, 81 and 82 is not limited to physicians. Humana Medicare Advantage policy allows assistant-at-surgery (physician and nonphysician) charges at 16 percent of the contracted rate or Medicare Advantage physician fee schedule (or health care provider’s Medicare Advantage nonphysician practitioner fee schedule) rate (subject to any other applicable reductions) for services considered medically necessary.

Humana commercial and Medicaid policy allows assistant surgeon MD charges at 20 percent and nonphysician charges at 10 percent of the contracted rate or maximum allowable fee for services considered medically necessary.

You can send questions to Humana about Medicare Advantage coding for assistant surgeons on Humana’s provider website (log-in required). Choose the Claims Tools tab, then select “Code Editing Questions” under Associated Links to submit your question.

* The American Medical Association’s Coding with Modifiers defines an assistant surgeon as a health care provider who actively assists an operating surgeon in the performance of a surgical procedure. This is usually necessary because of the complex nature of the procedure(s) or the patient's condition. The assistant surgeon performs medical functions under the direct supervision of the operating physician.

Review inpatient-only procedures before scheduling for outpatient — Humana Medicare Advantage plans follow Centers for Medicare & Medicaid Services (CMS) guidelines as part of its claims payment policies for inpatient services for Medicare patients.

CMS uses an inpatient-only list of CPT and HCPCS codes to define procedures that should be performed on an inpatient basis for these patients due to one or more of the following reasons:

  • Nature of the procedure,
  • Need for at least 24 hours of postoperative care, and/or
  • Underlying physical condition of those patients most often having the particular procedure.

 Medicare — and Humana Medicare Advantage — will not pay for these “inpatient-only” services if performed on an outpatient basis. Be sure to review the list before scheduling any outpatient procedures.

Are you using the correct taxonomy code on your claims? — If you have more than one taxonomy code listed with Humana based on health care services you provide, be sure to use the taxonomy code that most accurately describes the services reported on a claim. This is particularly important if the services are in different contractual arrangements, for example:

  • When a physician bills for services provided in the office setting as an internal medicine physician and also for services provided in the hospital as a hospitalist, or 
  • When a physician provides services in the office as a pediatrician, as well as providing services as a pediatric pulmonary specialist.

Using the correct taxonomy code in these scenarios could determine whether the patient would need to pay the primary care or specialist copayment. If you have questions about correct taxonomy code usage, contact Humana’s Tina Newcomb at (502) 476-5746.

Changes to Humana’s 2013 formularies — Below are links to charts that show some commonly used medications impacted by Humana’s Jan. 1, 2013, commercial and Medicare formulary changes.

Commercial changes:

 Medicare changes:

 High-risk medications (HRMs) (have the potential to be problematic in those 65 years of age or older): Commonly used HRM changes

If you have questions about these changes, call Humana at (800) 457-4708, 8 am to 8 pm, local time, Monday through Friday.

* Click “Drug List Search” and enter the drug name. Choose “Commercial” or “Medicare” as applicable to see the drug’s tier placement in commercial formularies and any restrictions that apply

Source: Humana’s Your Practice (PDF), December 2012

Published Jan. 22, 2013

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Last Updated On

April 19, 2018

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