2006 2006 CODINg GUIDELINES Coding AND POLICY UPDATE Guidelines COMPENDIUM www.amerihealth.com and Important Note: TABLE OF CONTENTS The medical policies referenced in this document apply to all Policy HMO, POS, and PPO products of AmeriHealth, including its affiliates, Introduction .........................................3 Class Action Settlement Update ..........35 as well as to traditional indemnity products to the extent the applicable About the Coding Guidelines and Enhancements to Claim Payment covered services are underwritten by AmeriHealth or its affiliates. Policy Update (CGPU) Compendium ....3 Policy, Processing and Payment Update This document was developed to Disclosure, and an Appeals Process assist AmeriHealth in administering What are the Primary Reasons that the provisions of its benefits programs for Class Action Settlement and does not constitute medical AmeriHealth Develops Claim advice. Professional providers are Providers ...........................................36 responsible for providing medical Payment and Medical Policies? ...........3 Compendium advice and treatment. Even thoughwww.amerihealth.com Assistant Surgery Modifiers this document may conclude that a Physician Volunteers Needed to particular service or item is medically 80, 81, 82 ...........................................36 necessary, such conclusion is NOT Assist in Developing Medical based upon the terms of a particular member’s benefit plan. Members must Policies ................................................3 Co-Surgery Modifier 62 ...................37 refer to their specific benefit program for the terms, conditions, limitations and exclusions of coverage. Medical Policies Covered: According to Medical Code Updates ........................39 Please note that the Policy Bulletins Certain Criteria ....................................5 which are referenced herein describe CPT® Codes ....................................40 the status of a specific topic at the time the Policy Bulletin was created. HCPCS Codes .................................62 Policy Bulletins are updated biennially Medical Policies Not Covered: Considered and when new medical evidence Experimental/Investigational ................21 becomes available, therefore, they are ICD-9 CM Codes ............................90 subject to change. Please be aware that the actual Policy Claim Payment Policies .......................27 Bulletins which are discussed herein are used as a guide only. Coverage decisions are made on a case-by-case 2006 Articles .......................................31 basis by applying Policy Bulletin criteria to the member’s medical history, condition, and proposed course ICD-9 CM Diagnosis Codes of treatment as well as the member’s benefit program. Providers should Change for Routine Gynecological review Policy Bulletins with Members as treatment options are discussed, Exams ...............................................32 as the Policy Bulletins are designed to be used by our professional staff Billing for Neonatal Hearing in making coverage determinations and can be highly technical. Screening Should be Directed Information contained in this to Facility ..........................................32 document and the actual Policy Bulletin does not constitute an offer of coverage, medical advice, or Anesthesia Claims Update ................32 guarantee of payment. Please note that, if there is a conflict between Gardasil® Approved by the FDA .....32 the Policy Bulletin and a member’s benefit program, the terms of the Clarifications to the Intensity benefit program will govern. Please note that providers who opted Modulated Radiation Therapy out of the class action settlement may not be entitled to certain claim Policy ................................................33 payment policy changes. Therefore, any payments made pursuant to such policy changes to providers who opted out of the class action settlement are View Full Policies Online subject to retroactive adjustments. Full descriptions of these policies are available online: www.amerihealth.com/medpolicy. C C O MMUNIC A P H I ATIO GR NS ® UNION LABEL 526-M I N T E O N R N AT I O N A L U N I AmeriHealth HMO, Inc. • QCC Insurance Company, d/b/a AmeriHealth Insurance Company • AmeriHealth Insurance Company of New Jersey INTRODUCTION About the Coding Guidelines and What Are the Primary Reasons That Policy Update (CGPU) Compendium AmeriHealth Develops Claim Payment and Medical Policies? Over the past year, AmeriHealth has published four Coding Guidelines and Policy Update (CGPU) newsletters. Some of the primary reasons that AmeriHealth develops claim payment and medical policy are to: This 2006 Coding Guidelines and Policy Update Compendium is a collection of relevant policy summaries that have been • Comply with legislation (e.g., federal, state, and local published in CGPU during the past year. We are not able to legislative mandates). reproduce all of the CGPU summaries in the Compendium • Correspond to national or local Medicare Carrier because some policies have undergone updates and revisions Coverage Policy. since their initial publication in CGPU; however, these updated policies will appear in future issues of CGPU. We • Allow consistent interpretation and application of encourage you to visit www.amerihealth.com/providers for benefits. expanded, up-to-date versions of each policy. • Respond to requests for new, emerging technology or In addition to the descriptions of policies previously changes in existing technology. published in the CGPU, the Compendium has also expanded • Ensure a relevant and timely scheduled review of the normal CGPU parameters to include articles on coding existing policies. and policy, plus a section detailing new, revised, and deleted • CPT®*, HCPCS, and ICD-9 CM codes. Provide claims submission policies and procedures. This Compendium contains information that you can Physician Volunteers Needed to Assist immediately adopt within your practice to simplify your information retrieval and claims submission processes. in Developing Medical Policies *Current Procedural Terminology (CPT®) is a copyright of the American Medical AmeriHealth is currently recruiting physicians to join our Association (AMA). All Rights Reserved. No fee schedules, basic units, relative Policy Committee Advisory Panel. This panel is responsible values, or related listings are included in the CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to for evaluating the scientific evidence and local standards of government use. CPT® is a trademark of the AMA. care addressed in our medical policies. Medical policies are research-based documents that allow AmeriHealth to evaluate the medical necessity of services, devices, biologics, and procedures for its members. In addition, medical policies provide guidelines for obtaining benefits and reimbursement in accordance with a member’s plan. As a volunteer consultant on the Policy Committee Advisory Panel, you will evaluate proposed medical policies based on your area(s) of expertise. As such, your contributions Visit www.amerihealth.com/medpolicy to get the most current, will significantly impact the care of patients in your region. in-depth and up-to-date information on policies affecting health care in your region. Review and accept the terms & At this time, AmeriHealth is seeking physician consultants in conditions, and you can quickly and easily search all active the following specialties: policies. Bookmark this site and check back regularly for the • Neurosurgery latest information and updates. • Orthopedics • The 2006 CGPU Compendium can be found at Urology • www.amerihealth.com/providers/communications. You Vascular Surgery • can also check the website to find specific billing codes, Physical Medicine and Rehabilitation in-depth descriptions of services, or other policy-related data. • Rheumatology • Cardiology • Gastroenterology www.amerihealth.com/providers/communications • Pain Medicine 3 43034txtAH.indd 3 2/19/07 2:43:02 PM CO D I N G G U I D ELI N ES A N D POLI C Y U pdat E CO mp E nd I um To qualify as a member of the Policy Committee Advisory Panel, you must: • Maintain board certification for each specialty or subspecialty for which you wish to consult. • Maintain an active clinical practice in each specialty or subspecialty for which you wish to consult. • Understand and agree to adhere to our confidentiality statement. • Maintain a high ethical standard, evidenced by the absence of any AmeriHealth investigation into personal or group claims practices. • Complete and sign a Conflict of Interest Statement and Confidentiality Agreement prior to becoming a member of the advisory panel. If you meet the above criteria and have an interest in sharing your expertise as a member of the Policy Committee Advisory Panel, please submit your curriculum vitae to: Gerald W. Peden, M.D., M.A. Senior Medical Director Claim Payment Policy Department AmeriHealth 1901 Market Street Philadelphia, PA 19103-1480 View Full Policies Online Full descriptions of these policies are available online at: www.amerihealth.com/medpolicy. 4 View full policies online at www.amerihealth.com/medpolicy 2006 CGPU Compendium 43034txtAH.indd 4 2/19/07 2:43:02 PM CO D I N G G U I D ELI N ES A N D POLI C Y U pdat E CO mp E nd I um MEDICAL POLICIES COVERED: ACCORDING TO CERTAIN CRITERIA www.amerihealth.com TABLE OF CONTENTS Ambulatory Blood Pressure Monitoring (ABPM) (07.02.09) ................................................................6