Policy No: 129
Originally Created: 03/01/2017
Section: Administrative
Last Reviewed: 07/01/2024
Last Revised: 07/01/2023
Approved: 07/11/2024
Effective: 08/01/2024
Policy Applies to: Group and Individual & Medicare Advantage
This policy applies to all physicians, dental providers, other health care professionals, hospitals, and other facilities.
Current Dental Terminology (CDT®)
A dental code set maintained by the American Dental Association (ADA) that is used to report dental procedures and services by dental providers.
Current Procedural Terminology (CPT®)
A medical code set maintained by the American Medical Association (AMA) that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations. CPT is included in Level I Healthcare Common Procedure Coding System (HCPCS).
HCPCS Level II
A standardized coding system that is used primarily to identify medical supplies, durable medical equipment, non-physician services, and services not represented in the Level I code set CPT.
National Correct Coding Initiative (NCCI or CCI)
The Centers for Medicare & Medicaid Services (CMS) developed these edits to promote consistent, correct coding and appropriate payment. These coding edits are developed based on the AMA CPT code set and the HCPCS code set, as well as analysis of standard medical and surgical practice and input from various groups, including specialty societies, other national healthcare organizations, Medicare contractors, providers, and consultants.
The National Uniform Billing Committee (NUBC) and the state uniform billing committees (SUBC)
Committees responsible for the revenue code definitions and requirements for use.
Uniform Billing Editor (UBE)
A reference tool utilized by facilities to manage the constant changes to Medicare billing and reimbursement processes. The UBE provides detailed, accurate, and timely information about Medicare and UB-04 billing rules and requirements.
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)
A morbidity classification system for classifying diagnoses and reason for visits in all health care settings for the purpose of coding and reporting.
Revenue Codes (Rev Codes)
Revenue codes are 4-digit numbers that are used on hospital bills to identify where a member was located in a facility when they received treatment or services, or what service a member received as a patient.
Providers are required to submit accurate and complete claims for all medical and surgical services, supplies and items rendered to members using industry standard coding guidelines. Coding guidelines include, but are not limited to, AMA, CPT, HCPCS, CMS Coding Initiatives, UBE and ICD-10.
Any medical or surgical service, supply, or item, either inpatient or outpatient, reported by any code, must be clearly documented in an appropriate medical record. Our health plan will not allow reimbursement for undocumented professional, inpatient or outpatient medical and surgical services, supplies and items.
This includes but is not limited to reimbursement of multiple intravenous (IV) bags for the same product, when only an IV drip rate change or drip rate check has occurred. Charges for bag changes that conflict with the drip rate for the drug administered, will be considered as a drip rate change. Documentation indicating a new bag scanned and/or administered will not be sufficient to indicate a new bag, if in conflict with the drip rate for the drug administered.
The services must also be within the scope of practice for the relevant type of provider in the State in which they are furnished and within provider's credentials/training (e.g., board certification).
Hospitals and facilities must report all services, supplies and items using accurate revenue codes.
Our health plan will not allow reimbursement for incorrectly reported codes and modifiers, including revenue codes, for medical and surgical services and supplies and items, for professional, inpatient or outpatient facility claims.
Centers for Medicare & Medicaid Services (CMS), ICD-10-CM Official Guidelines for Coding and Reporting
Centers for Medicare & Medicaid Services (CMS), Medicare Claims Processing Manual, Chapter 23 - Fee Schedule Administration and Coding Requirements
Noridian Medicare Revenue Codes
Centers for Medicare & Medicaid Services (CMS), National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services
Centers for Medicare & Medicaid Services (CMS), Medicare Learning Network, Proper Use of Modifiers 59 & X
National Uniform Billing Committee (NUBC)
Centers for Medicare & Medicaid Services (CMS), Medicare Learning Network Evaluation and Management Services guide; E/M Service Providers
American Medical Association. Current Procedural Terminology. AMA Press
Centers for Medicare & Medicaid Services (CMS), HCPCS
American Academy of Professional Coders (AAPC). HCPCS Level II Expert Codebook
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.