Private Payer Roundup, January 2015

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 the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems. Also, visit the TMA Payment Advocacy Services webpage and TMA's Payer page for more resources and information.


Which electronic payment method do you choose? — If you are not yet receiving your UnitedHealthcare (UHC) payments electronically, you’ll need to sign up for electronic funds transfer (EFT) in 2015. If you are already using EFT, you’ll need to specify your preferred method: direct deposit or Virtual Card Payments. 

UHC will send you a reminder about your payment method election deadline date 90 days in advance of the deadline. If your practice doesn’t elect either direct deposit or Virtual Card Payments by your deadline, your election will default to Virtual Card Payments. If your business operations require continued paper payments, contact UHC after April 1 and before your payment election deadline. Learn more about the payment methods in UHC’s January Network Bulletin (PDF) (scroll to page 9). 

Some hysterectomies to require prior authorization — The American Congress of Obstetricians and Gynecologists (ACOG) has identified the preferred method for hysterectomies to be vaginal. To align with ACOG’s recommendation, UHC commercial and Medicare plans will require prior authorization for certain hysterectomy procedures starting April 6, 2015. See the list of affected codes in UHC’s January Network Bulletin (PDF) (scroll to page 5). Vaginal hysterectomies done on an outpatient basis do not need prior authorization. 

HEDIS time — UHC will conduct its annual HEDIS data collection from February to March, as required by the Centers for Medicare & Medicaid Services (CMS). If your office is contacted for information, UHC asks that you respond within five business days. 

Source: UnitedHealthcare Network Bulletin (PDF), January 2015. 


Changes to note

Coding guidelines for obstetrician-gynecologists (OB-Gyns) — Humana covers a well woman visit once every 24 months or once every 12 months for women at high risk and for women of childbearing age who have had an exam that indicated cancer or other abnormalities in the past three years.

These guidelines apply to Humana commercial and Medicare Advantage plan claims:

  • Submit claims for well woman exams with HCPCS codes Q0091 (screening Papanicolaou [Pap] smear; obtaining, preparing and conveyance of cervical or vaginal smear to laboratory) and/or G0101 (cervical or vaginal cancer screening; pelvic and clinical breast examination).
  • An OB-Gyn who functions as a primary care physician may submit a charge for an initial or periodic comprehensive preventive medicine evaluation using a 9938x or 9939x CPT code only when performing all of the components of the annual preventive physical exam. Reserve the 9938x and 9939x CPT codes for reporting annual preventive physical exams; these codes can be billed only once per calendar year.
  • An evaluation and management (E&M) service is not separately reportable unless the visit is unrelated to the well woman exam. If the services are unrelated, you may report the E&M service with a modifier.   

Multiple procedure payment reduction — Humana applies multiple procedure payment reduction (MPPR) for the services below. MPPR is a reduction to a portion of the base allowable amount for a service (or a component of service) when you provide more than one unit or procedure of a particular type to the same patient on the same date of service. MPPR applies only to multiple procedures and multiple units.

  • Diagnostic cardiovascular services — MPPR applied to the technical component.
  • Diagnostic ophthalmology services — MPPR applied to the technical component.
  • Diagnostic imaging (radiology) — MPPR applied to the technical and professional components.
  • Therapy practice expense — For current dates of service, Humana applies a 50-percent MPPR to the practice expense (PE) payment of "always therapy" services.

Visit the Humana website for more information, including a sample calculation of therapy PE MPPR.

Top five coding errors — Humana has identified the following most common coding errors:
  1. Incorrectly using current versus historical. Physicians should avoid using "history of" to describe current or chronic conditions that are still present, active, and ongoing. A medical condition described as "history of" means the condition was in the past and no longer exists. Coders should not code such conditions as current when it is not clear that the condition still exists. Likewise, physicians shouldn't document past conditions that no longer exist as if they are current.
  2. Failing to code to the highest level of specificity. Coders must carefully review the entire medical record with attention to the details of a specific diagnosis description. For example, the coder must look for documentation of the specific location on the body or within a body part; the specific type or stage of the condition; and whether the condition, as documented, is linked to another condition in a cause-and-effect relationship.
  3. Coding uncertain diagnoses as confirmed. Coders should code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.
  4. Misinterpreting of abbreviations/acronyms. Humana recommends spelling out terms in full on first reference within your documentation, followed by the acronym in parentheses. Use the acronym in subsequent references, but spell out the term again on final reference.
  5. Applying a clinical interpretation to a medical record documentation. Coders should avoid reading into or clinically interpreting medical information or assigning a diagnosis that the physician has not documented.

More information, including examples, is on the Humana website.

 Source: Humana's YourPractice, December 2014


Drug formulary changes affect insulin — As of Jan. 1, 2015, Blue Cross and Blue Shield of Texas (BCBSTX) has changed its formulary to make Novo Nordisk  insulin products the preferred brands for members with prescription drug benefits administered through Prime Therapeutics. Additionally, a new insulin agents prior authorization (PA) program began.

Lantus and Levemir also are preferred brands, which process at the patient's preferred brand copay. Insulin manufactured by Eli Lilly and Company (Humulin and Humalog) are nonpreferred brands, and in most cases, will require prior authorization and will cost the patient more than the preferred drugs. Source: BCBSTX

To submit a PA request, consider using the electronic prior authorization tool CoverMyMeds, a time-saving online PA service.

Prescription drug benefit changes — The BCBSTX prescription drug benefit no longer covers nonsedating antihistamines and compound medications. Your patients may have received a letter from BCBSTX about pharmacy benefit changes starting Jan. 1, 2015, that affect them. The letter encourages them to talk with their physician about their affected prescribed medications. Source: BCBSTX

New coding edits — Beginning on or after March 23, 2015, BCBSTX will add the CMS Correct Coding Initiative rule into its claim-processing system. The purpose of this new rule is to identify claims containing code pairs found to be unbundled according to the CMS National Correct Coding Initiative (NCCI). BCBSTX will continue with the modifier 59 exempt program, which is based on the CMS NCCI. Source: BCBSTX 

 File one-carrier claims correctly — BCBSTX continues to report receiving thousands of claims each month that require unnecessary review for coordination of benefits. Here are some tips to help prevent claim-processing delays when there is only one insurance carrier:

  • CMS-1500, box 11-d - If there is no secondary insurance carrier, mark the "No" box.
  • Do not place anything in box 9, a through d - This area is reserved for member information for a secondary insurance payer. 

Pass-through billing — BCBSTX does not permit pass-through billing (occurs when the ordering physician requests and bills for a service, but someone else provides the service). The performing physician or other medical professional should bill for these services unless otherwise approved by BCBSTX. BCBSTX does not consider the following scenarios to be pass-through billing:

  • Dr. A performs the service at the place of service of Dr. B, the ordering physician, and Dr. B bills for the service.
  • A midlevel practitioner employed by the ordering physician performs the service, and the physician bills for the service. 

Supervising physicians should use the following modifiers when billing for services rendered by a physician assistant (PA), advanced practice nurse (APN) or certified registered nurse first assistant (CRNFA):

  • Use modifier AS when billing on behalf of a PA, APN or CRNFA for services provided when these midlevel practitioners are acting as an assistant during surgery. (Modifier AS is to be used only if they assist at surgery.)
  • Use modifier SA when billing on behalf of a PA, APN or CRNFA for nonsurgical services. (Modifier SA is used when the PA, APN, or CRNFA is assisting with any other procedure that does not include surgery.)

Source: Blue Review (PDF), December 2014


Changes to the No Government Pay List

Urine drug screening codes 80100 and 80101 were added to the No Government Pay (NGP) list in October 2014. You must use the Medicare drug screening codes G0431 and G0434 by encounter and no longer by drug class. Screenings that laboratories processed for TRICARE patients must now use the G codes.

These two flu vaccine codes were on the NGP list but became covered preventive flu vaccines for TRICARE patients for 2014:

  • Code 90787 for children 6-35 months of age, and
  • Code 90688 for individuals 3 years of age and older.

Your PGBA claims processor for TRICARE will reprocess claims for these flu vaccine codes, as appropriate, early in 2015.

Source: Humana Military

Published Jan. 27, 2015

TMA Practice E-Tips main page


Last Updated On

April 27, 2018

Originally Published On

January 27, 2015