DISCLAIMER

Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

Highmark Health Options may provide coverage under medical surgical benefits of the Company’s Medicaid products for medically necessary. Refer to the Noncovered Services policy for more information.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the West Virginia Department of Health and Human Resources (DHHR) and all applicable state and federal regulations.

Purpose 

This medical policy outlines Highmark Health Options services for ambulatory service centers.

Definitions

Highmark Health Options (HHO)- Managed care organization serving vulnerable populations that have complex needs and qualify for Medicaid. Highmark Health Options members include individuals and families with low income, expecting mothers, children, and people with disabilities. Members pay nothing to very little for their health coverage. Highmark Health Options currently services WV Mountain Health Trust (MHT) and West Virginia Health Bridge (WVHB) including an expansion plan (WVHB ABP Alternative Benefit Plan) and WVCHIP members.

Ambulatory Surgical Center (ASC)- Any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization, as well as private practitioners.

Free-Standing Surgical Center (FSSC)- A facility licensed as a free standing or ambulatory surgical center; which is operated solely for the purpose of providing outpatient surgical care.

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool

https://wv.highmarkhealthoptions.com/providers/prior-authorization-code-lookup.html

Procedures

Covered Services

The WV Medicaid Program covers medically necessary services provided by an ASC to eligible members within coverage/benefit limitations in effect on the date of service. Coverage and benefit limitations are subject to change as Federal regulations and State policies dictate. WV Medicaid uses the Medicare Approved ASC Covered Surgical Procedures list and the Surgical Procedures Excluded from Payment in ASCs list as resources. The services provided by ASCs are those surgical procedures which may safely be performed in the ASC setting. The ASC is authorized by Federal and State law and regulation to perform these services.

The following services are included under the benefit:

·       Nursing, technicians, and related services

·       Use of the facilities where surgical procedures are performed; drugs, biologicals, surgical dressings, splints, casts, appliances, and                             equipment directly related to the provision of the surgical procedure;

·       diagnostic or therapeutic services or items directly related to the provision of a surgical procedure.

·       Materials for anesthesia.

·       Any laboratory testing performed under a Clinical Laboratory Improvement Amendments of 1988 (CLIA) certificate of waiver;

·       Drugs and biologicals for which separate payment is not allowed under the hospital outpatient prospective payment system (OPPS).

·       Equipment.

·       Surgical dressings.

·       Implanted prosthetic devices, including intraocular lenses (IOLs), and

·       related accessories and supplies not on pass-through status.

·       Implanted DME and related accessories and supplies not on passthrough status

·       Splints, casts and related devices.

·       Radiology services for which separate payment is not allowed

·       The OPPS, and other diagnostic tests or interpretive services that are integral to a surgical procedure.

·       Administrative, recordkeeping and housekeeping items and services.

·       Supervision of the services of an anesthetist by the operating surgeon.

 

Provider Requirements

To participate in WV Medicaid, providers must be approved through BMS’ fiscal agent contractor enrollment process prior to billing for any services.

CMS-1500 Billing

ASC and FSSC claims must be billed on a CMS-1500 claim, or if billing electronically, the 837 Professional claim using appropriate surgical CPT-4 codes. Providers must use National Place of Service Code 24 to specify that the service(s) were rendered at an ASC or FSSC facility.

Coordination of Benefits

For individuals who have other health insurance, that insurance must be billed first, and the provider must attach the primary insurer’s explanation of benefits to the claim sent to HHO for reimbursement. HHO considers all payments for the service and compares the amounts covered by other insurers to the HHO maximum fee for the service. If HHO’s fee has been met or exceeded by payments from the other insurer, no payment will be made, and the member may not be billed.

Non-Par ASC Reimbursement

All out-of-network and out-of-state ASCs and FSSCs are not covered.

Rendering and Performing Providers

All ASCs and FSSCs are required to submit both rendering and performing provider information on all claims. ASCs and FSSCs rendering and performing providers are required for the encounter to successfully pass through for state encounter submission.

The following modifiers should be used appropriately when billing the claim: 

 

Modifier	Description
TC	Technical component of a test only (no interpretation performed).
FB	Item provided without cost to provider, supplier, or practitioner, or credit received for replacement device; examples include, but not limited to covered under warranty, replaced due to defect, free samples.
FC	Partial credit received for replaced device.

CPT Level 1 Modifier	Description
25	Significant, Separately Identifiable E&M Same Phy & Day
27	Multiple Outpatient Hospital E/M Same Date
33	Preventive Services: When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services
50	Bilateral Procedure
52	Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances the service divided can be identified
58	Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
59	Distinct Procedural Service
73	Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia
74	Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia
76	Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional
77	Repeat Procedure by Another Physician or Other Qualified Health Care Professional
78	Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period
79	Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
91	Repeat Clinical Diagnostic Laboratory Test
GG	Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day
GH	Diagnostic mammogram converted from screening mammogram on same day
LC	Left circumflex coronary artery
LD	Left anterior descending coronary artery
LM	Left main coronary artery
QM	Ambulance service provided under arrangement by a provider of services
QN	Ambulance service furnished directly by a provider of services
RC	Right coronary artery
TA	Left foot, great toe
T1	Left foot, second digit
T2	Left foot, third digit
T3	Left foot, fourth digit
T4	Left foot, fifth digit
T5	Right foot, great toe
T6	Right foot, second digit
T7	Right foot, third digit
T8	Right foot, fourth digit
T9	Right foot, fifth digit

 

Level II Modifier	Description
LT	Left side
RT	Right side
E1	Upper left eyelid
E2	Lower left eyelid
E3	Upper right eyelid
E4	Lower right eyelid
F1	Left hand, second digit
F2	Left hand, third digit
F3	Left hand, fourth digit
F4	Left hand, fifth digit
F5	Right hand, thumb
F6	Right hand, second digit
F7	Right hand, third digit
F8	Right hand, fourth digit
F9	Right hand, fifth digit

 

 

 

 

 

 

 

 

 

 

Per CMS rules has been effective since January 1, 2009, modifier TC on ASC claims, the following must be present:

•         ordering physician name and NPI or

•         referring physician name and NPI

Terminated Procedures

Providers must identify procedures that are terminated prior to inducement of the anesthetic agent due to the onset of medical complications by reporting a modifier of “53,” resulting in one-half reimbursement of the normal rate for the procedure. If the procedure must be terminated after the inducement of the anesthetic agent, providers must report a modifier of “74” and will be reimbursed the full rate of the procedure.

Table 2 – Terminated Procedure Modifier

 

A claim requesting payment for terminated surgery must be accompanied by an operative report that specifies the following:

·                Reason for termination of surgery.

·                Services actually performed.

·                Supplies actually provided.

·                Services not performed that would have been performed if the surgery had not been terminated.

·                Supplies not provided that would have been provided if the surgery had not been terminated.

 

Sterilization and Hysterectomy Procedures

ASCs and FSSCs may be reimbursed for voluntary sterilization and medically necessary hysterectomy procedures for eligible Medicaid clients. A requirement for payment is that each claim must be accompanied by either a consent form when a voluntary or elective sterilization is performed or an awareness form for medically necessary hysterectomy procedures that may result in sterilization.

It is the responsibility of the attending physician to secure a properly executed form when a voluntary sterilization is requested, or a hysterectomy is required. For billing purposes, the ASC and FSSC must secure the appropriate form from the operating surgeon.

Corneal Tissue Acquisition

When billing for corneal tissue acquisition, use the appropriate HCPCS procedure code and attach the invoice from the supplying eye bank showing the actual cost incurred.