Here are the claims-related stories about audits, policies, and programs shared in our newsletters that you may have missed:
EDC Analyzer Expanded to More Members
Starting Oct. 1, 2024, ConnectiCare’s ED Outpatient Facility E/M Coding Reimbursement Policy was expanded to include EmblemHealth’s HMO and PPO (non-City of New York) Commercial, Medicare, and Medicaid plans. This policy now applies to all facilities, including freestanding facilities, that submit emergency department (ED) claims with evaluation and management codes (E/M). See announcement for details.
More Members Added to the Avalon Lab Program
Starting Oct. 1, 2024, EmblemHealth will expand our current Laboratory Benefit Management (LBM) program with Avalon Healthcare Solutions (Avalon) to our HMO and PPO (non-City of New York) Commercial, Medicare, and Medicaid plans. See announcement or details.
Acute Stroke and Sepsis Coding in Outpatient Setting
The Office of Inspector General (OIG) Office of Audit Services has identified acute stroke and sepsis as not supported in an outpatient setting. These conditions are typically treated in an inpatient hospital setting and rarely, if ever, occur in an outpatient setting.
EmblemHealth and ConnectiCare recognize the need for accurate coding and documentation. It’s an important part of patient care. We have taken the OIG Office of Audit Service findings into consideration and are making updates to our claims processing system.
Starting Dec. 6, 2024, we will deny any claims that have a diagnosis of acute stroke (I63.-) or sepsis (A41.-) when billed with the following place of service (POS) codes.
- Office (POS 11).
- Telehealth (Use POS 2 when patient and provider are in a facility; POS 10 for patients at home).
- On Campus - outpatient hospital (POS 22).
- Skilled nursing facility (POS 31).
- Federally Qualified Health Center (POS 50); Off-campus outpatient hospital (POS 19).
The denial reason will be listed as “diagnosis/place of service mismatch.” See coding edits policies:
ConnectiCare: Coding Edits Policy
EmblemHealth: Coding Edits Policy
New and Updated Policies
Formalized Policies
Over the past year, we have continued our efforts to consolidate and document our administrative guidelines into formal policy formats. We are doing this to:
- Help you find the information you need.
- Introduce a Revision History to increase transparency when an update is made. Look to revision histories for the effective dates of updates and what has changed, including codes added and/or removed from the scope of the policy.
Formalized Polices vs. New Policies
Unless a change is specifically indicated in the provider newsletter, when we say a formalized policy has been introduced, we mean that the current policy has been reformatted, but no changes were made to the way we are processing claims or the workflows you need to follow. Once a formalized policy is introduced and added to the Claims Corner, we may remove the same content from other pages on our website to avoid duplication.
New policies will introduce policies that were not previously in existence or may indicate changes to current policies or administrative guidelines. If we introduce a new policy and there are administrative guidelines posted to our website that reflect former or expiring claims payment policies or workflows, we will move the ineffective content to an online archive. That way, you can still view the rules that were in effect when older services were rendered or claims processed.
Payment Integrity Policies
The following is a list of formalized and new Payment Integrity Policies that were introduced or updated in the past year:
- CPT/HCPCS New Code Updates (New).
- Device, Implant, and Skin Substitutes (Facilities) Payment Integrity Policy (Updated).
Reimbursement Policies
The following is a list of formalized and new Reimbursement Policies that were introduced in the past year. Laboratory Benefit Management program policies are noted with “(LBM)”:
- Compression Garments.
- Drugs and Biologicals Reimbursement Policy.
- Facility Fees for Evaluation and Management (E&M) Services on Outpatient Facility Claims (Commercial).
- Habilitative and Rehabilitative Services Reimbursement Policy.
- Pharmacy – Medical Claim Edit.
- Testing of Homocysteine Metabolism (LBM).
Updated Reimbursement Policies
The following Reimbursement Policies were updated. See their revision histories for effective dates and applicable changes:
- Allergen Testing (LBM).
- Anesthesia Billing.
- ASC Grouper 2024
- Biomarker Testing for Autoimmune Rheumatic Disease (LBM).
- Bundled Services Reimbursement Policy (Commercial and Medicare).
- Cervical Cancer Screening (LBM).
- Coding Edit Rules.
- Coronavirus Testing in the Outpatient Setting (LBM).
- Corrected Claim Submission.
- CPT and HCPCS Billing Guidelines (Commercial and Medicaid).
- Diabetes Mellitus Testing (LBM).
- Diagnosis of Idiopathic Environmental Intolerance (LBM).
- Diagnosis of Vaginitis (LBM).
- Diagnostic Testing of Common Sexually Transmitted Infections (LBM).
- Diagnostic Testing of Iron Homeostasis and Metabolism (LBM).
- Drugs and Biologicals.
- Durable Medical Equipment (DME) Rental vs. Purchase (Commercial and Medicare).
- ED Outpatient Facility E/M Coding Reimbursement Policy.
- Evaluation and Management (E&M) Services.
- Evaluation of Dry Eyes (LBM).
- Helicobacter Pylori Testing (LBM).
- Hepatitis Testing (LBM).
- Hospital Readmissions.
- Immunohistochemistry (LBM).
- Intracellular Micronutrient Analysis (LBM).
- Lyme Disease Testing (LBM).
- Modifiers PN and PO for Clinic Visit Services (G0463) (Medicare).
- Multiple & Bilateral Surgical Procedures Policy.
- Multiple Procedure Reduction Cardiology/Ophthalmology.
- Observation Stay – Medicare/Medicaid Policy (Effective Nov.14, 2024).
- Observation Stay – Commercial Policy (Effective Nov.14, 2024).
- Parathyroid Hormone, Phosphorus, Calcium, and Magnesium (LBM).
- Pediatric Preventative Screening (LBM).
- Prescription Medication and Illicit Drug Testing in the Outpatient Setting (LBM).
- Preventive Care/Screening - Commercial.
- Preventive Care/Screening - Medicare.
- Preventive Lists: EmblemHealth – Commercial.
- Prostate Specific Antigen (PSA) Testing (LBM).
- Provider’s Guide to Preventive Health Services (Medicare).
- Radiopharmaceuticals and Contrast Media (Commercial and Medicaid).
- Salivary Hormone Testing (LBM).
- Serum Tumor Markers for Malignancies (LBM).
- Telehealth and Virtual Care Service (Commercial, Medicare and Medicaid)
- Testosterone Testing (LBM).
- Urinary Tumor Markers for Bladder Cancer (LBM).
- Vitamin B12 and Methylmalonic Acid Testing (LBM).
- Vitamin D Testing (LBM).
Reimbursement: Billed Charges vs. Contracted Rates
According to EmblemHealth’s participation agreements, Providers will be reimbursed for, and will accept as payment in full, medically necessary covered services and supplies at the lesser of Provider's billed charges or their contracted reimbursement rates.
See ConnectiCare In 2025 and What You May Have Missed in 2024 to see its new and updated policies.
