News

Five New Policies Implemented

Date: 03/14/18

California Health & Wellness (CHWP) is implementing five new policies, effective May 16, 2018. Four of the policies outline acceptable billing practices and reimbursement methodologies for certain procedures and services. The fifth policy defines the medically necessary procedures for the diagnosis and treatment of Attention Deficit Hyperactivity disorder (ADHD).

The new billing/reimbursement policies follow the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) guidelines and will impact providers who are coding outside of fair and appropriate use.

These policies were developed based on medical literature and research, and industry standards and guidelines as published and defined by the American Medical Association’s CPT^®, CMS, and public domain specialty society guidance, unless specifically addressed in the Medi-Cal fee-for-service provider manual published by California.

The information included in these policies will help providers bill claims accurately, therefore reducing unnecessary denials and delays in claims processing and payments. These policies include information on:

Coding inaccuracies
Diagnosis to procedure code mismatch
Inappropriately modified procedures
Unbundling of services
Incidental procedures
Duplication of services
Medical necessity requirements
Health plan-specific payment rules for procedures and services

Application of Claims Policies
CHWP will apply these policies as medical claims reimbursement edits within our claims adjudication system, in addition to all other reimbursement processes CHWP currently employs.

CHWP Clinical & Payment policies can be accessed online here.

Relevant sections of CHWP’s provider operations manual will be revised to reflect the information contained in this update as applicable. Providers are encouraged to access CHWP’s provider portal online.

If you have questions regarding the information contained in this update, contact your Provider Services Representative or call 1-877-658-0305.

Policy Reference Number	Policy Name	Description
CC.PP.053	Non-Emergent Emergency Room Services	The purpose of this policy is to define payment criteria for non-emergent emergency room services. When a hospital, free-standing emergency center or physician bills a level 4 (99284) or level 5 (99285) emergency room service with a non-emergent diagnosis, CHWP will reimburse the provider at a level 3 (99283) contracted reimbursement rate.
CC.PP.054	Physician’s Consultation Services	The purpose of this policy is to define payment criteria for consultation services. CHWP will reimburse consultation codes at the corresponding evaluation and management (E&M) visit level. The provider should bill the E&M code (other than the consultation code) that describes the service provided. CHWP will identify consultation codes 99241-99255 and crosswalk them to the more appropriate level of office visit, established patient or subsequent hospital care procedure code (see actual policy for codes). The provider will be paid according to the fee schedule for the equivalent procedure code.
CC.PP.057	Problem-Oriented Visits with Preventative Visits	The purpose of this policy is to define payment criteria for problem-oriented visits when billed with preventative visits. Under modifier -25 correct coding principles, a patient may be seen by the physician for both a preventative E&M service and a problem-oriented E&M service during the same patient encounter. Providers do not incur duplicate indirect expenses with the original E&M (preventative service) when there is a problem-oriented visit on the same date of service. For example, obtaining vital signs, scheduling the visits, staffing, lighting, and supplying the examination room costs are not incurred twice by the provider. CHWP will reimburse the preventative medicine code plus 50 percent of the problem-oriented E&M code.
CC.PP.052	Problem-Oriented Visits with Surgical Procedures	The purpose of this policy is to define payment criteria for problem-oriented visits when billed on the same day as a surgical procedure. Under modifier -25 correct coding principles, a patient may be seen by the physician for a problem-oriented E&M service on the same day of a procedure with a 0-, 10- or 90-day global surgical period. Providers do not incur duplicate indirect expenses with the problem-oriented E&M service when there is a surgical procedure on the same date of service. For example, obtaining vital signs, scheduling the visits, staffing, lighting, and supplying the examination room costs are not incurred twice by the provider. CHWP will reimburse the surgical procedure plus 50 percent of the problem-oriented E&M code.
CP.MP.124	Attention Deficit Hyperactivity Disorder Assessment and Treatment	The purpose of this policy is to define the medically necessary procedures for the diagnosis and treatment of Attention Deficit Hyperactivity disorder (ADHD).