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March-April 2014 In This Issue  Testing for ICD-10


 Payment Policy Updates (NEW)

 Always Use Current Codes (REPEAT)

 Modifiers –33 and –PT (REPEAT)

 Dosimetry Calculations and Treatment Devices (NEW)

 Documentation Required for Appeals (NEW)

 Pharmacist-Managed ACC (NEW)  Correction to Previous Connections Article (NEW)  CPT Codes 88342 and 88343 No Longer Recog-nized by PHP (NEW)

 PHP Clinical Editing Ex-planation Codes

 What To Do If You Have Questions

 Payment Rules

 Electronic Contract Deliv-ery



In conjunction with the Centers for Medicare and Medi-caid Services (CMS), Providence Health Plan (PHP) and all major payers will convert from International Classifi-cation of Diseases, Ninth Revision (ICD-9), to Interna-tional Classification of Diseases, Tenth Revision (ICD-10), on October 1, 2014.

All PHP applications will be ready for end-to-end (i.e., start to finish) formal testing by the summer of 2014. PHP will be testing with the clearinghouses and trading partners with which it does business and with all provid-ers who submit claims to those clearinghouses and trad-ing partners starttrad-ing this summer. Specifically, PHP will be processing electronically submitted claims (known as Electronic Data Interchange or EDI 837) sent from the clearinghouses and will be providing Electron-ic Remittance AdvElectron-ice (ERA) 835 to those same clear-inghouses. PHP will be implementing beta testing the first half of the year with select providers.

For additional information on the transition to ICD-10, visit the CMS websites: index.html?redirect=/icd10/


PHP completed its annual review of payment policies, and the updated policies have been published on ProvLink. The following policies have changes:

Payment Policy 09.0 (Anesthesia): Added a statement saying claims billed with modifier AD will pend for medical review. Added instructions for reporting injec-tions given for postoperative pain control.

Payment Policy 13.0 (Bundled or Adjunct Services): Added codes 99446-99449 (telephone consultation services), which also have a bundled status on the Medi-care Physician Fee Schedule. Added HCPCS codes G9001-G9140, which are designated as “Coordinated Care” or “Demonstration Project,” codes and should not be used by providers not involved in a Medicare demonstration project. Payment Policy 51.0 (Modifier -47): Anesthesia provided by the surgeon is not paid separately by PHP. The wording previously said no additional payment would be made for anesthesia provided by the surgeon and the modifier was con-sidered “informational only.” Wording was changed to show that surgery codes billed with modifier -47 will be denied. To report provision of anesthesia by the surgeon, one surgery code may be reported with modifier -47 and one without modifier -47, and only the code without the modifier will be paid.

Payment Policy 52.0 (Medical Visits): Added wording to clarify that providers of the same specialty within the same group practice may not report multiple E&M services on the same day. This is not a change in policy but a clarification of current policy.

Payment Policy 53.0 (E-Visits): Changed policy to show only providers who may report E&M services may bill E-visits.

Payment Policy 67.0 (Telehealth Services): Transitional care management codes (99495 and 99496) added to the policy.

Payment Policy 87.0 (Wellness Visits for Medicare Advantage): Added instruc-tions for billing “Wellness Plus Visit” (code S0250).

Payment Policy 90.0 (Chemotherapy Administration): Code Q2050 added to the policy.

Payment Policy 91.0 (Pharmacist Managed Anticoagulation Clinic): This policy was published October 1, 2013. See related article in this issue.




Providers may use only the most current code sets for billing PHP. PHP Payment Policy 19.0 (Service Code Policy) states, “Providence Health Plan will use the most current pub-lished service codes for coverage issues and pricing. These service codes are pubpub-lished in the Current Procedural Terminology (CPT), International Classification of Diseases (ICD), HCPCS (National Level II codes) and Diagnostic Related Groupings (DRG) books. System-atic implementation of approved service codes and rates is effective January 1. Per HIPAA guidelines, the most current code sets must be used for billing services.”

As it does every year, PHP began accepting the current codes on the first of January. The 2014 CPT codes may be used for dates of service on or after January 1, 2014. Codes that are new this year will be retrofitted for contracts that use the previous year’s relative value sched-ule for setting payment rates.


–33 AND –PT

Modifier 33 is used to identify a service that was originally intended to be preventive, but the focus changed to an illness-related visit or procedure due to abnormal findings during the preventive service. Modifier 33 was developed to identify services that should be paid as pre-ventive according to government mandates for payment of prepre-ventive services.

Modifier PT is used to identify a colorectal cancer screening test that was converted to diag-nostic test or other procedure due to abnormal findings on the screening exam. PHP accepts either modifier 33 or modifier PT to identify colorectal cancer screening tests that are con-verted to a diagnostic test or other procedure.

Modifier 33 should not be used on codes that are specifically identified as preventive. For example, modifier 33 would not be appended to CPT code 99395, as this code is already identified as a preventive service. However, if the patient presents for an annual exam, and during the course of performing the annual exam the physician finds a medical problem that needs to be addressed, the physician may elect to report CPT code 99215 instead of CPT code 99395. In this case, the provider would append modifier 33 to CPT code 99215 to iden-tify the original intent of the visit as a preventive service. The preventive and problem-focused services would both be performed and billed with one code, i.e., 99215-33.




CPT code 77300 is used to report, “Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose.” PHP allows payment for one unit of CPT code 77330 for each treatment port (each gantry angle for IMRT) per course of therapy, with additional calcula-tions allowed if medically indicated, to a maximum of ten units total (combined for all ports or gantry angles) per course of therapy. Code 77300 may only be reported when the plan is verified. The documentation must show the date of verification and must be signed by the provider who performed the verifica-tion. The date of service is the date the plan is verified.

PHP allows payment for one set of treatment devices (CPT code 77332, 77333, or 77334) for each port (each gantry angle for IMRT), with additional units allowed if medically indicated, to a maximum of ten units total (combined for all ports or gantry angles) per course of therapy. A pair of devices for opposing ports (e.g., left and right lateral, AP and PA) constructed from a single film is considered one port for billing purposes. The date of service is the plan print date.

PHP allows up to six units of 77300 and six units of 77332, 77333, or 77334 to be paid without review. When more than six units of 77300 or more than six units of 77332, 77333, or 77334 are needed during the course of therapy, the provider may submit an appeal with chart notes supporting all the units billed. When do-simetry calculations and/or treatment devices are billed across multiple dates of service, chart notes will be required for all dates of service. If medically indicated and supported by the documentation, PHP may allow up to ten units of code 77300 and up to ten units total of 77332, 77333, or 77334 per course of therapy. Documentation must show the actual dose calculations (as outlined in the CPT code description) approved and signed by the provider to support reporting code 77300. Documentation must show a description of the treatment devices (as out-lined in the CPT code description) to support reporting codes 77332, 77333, and/ or 77334.




Providers are required to submit the final, signed draft of any medical records sent to PHP for review. If the provider’s signature is missing from the note, or if the signature is illegible, the documentation will not be considered for review. A refund may be requested for services already paid.

An electronic signature is acceptable if it is added to statements such as

“authenticated by” or “reviewed by.” It must be clear to the reviewer that this is an electronically generated statement. A typed name alone is not valid and would need to have a handwritten signature authenticating the entry. Providers are ad-vised to review PHP Payment Policy 58.0 (Documentation Guidelines for Medi-cal Services), which is available on ProvLink, for complete information on what documentation is required to support services billed to PHP.

To avoid delays when submitting records to appeal denied services, submit signed records for ALL services billed on that date. It is not sufficient to send documen-tation supporting only the denied code. If documendocumen-tation is not submitted for all services billed on claim, the appeal may be returned to the provider requesting additional notes. Include documentation to support all lab tests, x-rays, surgical or diagnostic procedures, and E&M services billed.

PHP allows payment for face-to-face visits and/or telephone visits provided by a pharmacist in a medical clinic or an outpatient hospital setting where the pharma-cist regulates anticoagulation therapy using physician-approved protocols as au-thorized by ORS collaborative drug therapy rules and in accordance with the Ore-gon State Board of Pharmacy.

PHP Payment Policy 91.0 (Pharmacist-Managed Anticoagulation Clinics) was published on ProvLink on October 1, 2013 to give billing and coding information for these services. Please refer to the payment policy for additional information.




An article in the January/February 2014 issue of Connections about updates to PHP Payment Policy 03.0 (Assistant for Surgery) stated in error that an assistant-at-surgery had to bill the same charge for surgery as the surgeon. The same code must be reported, but it is not necessary for both providers to bill the same amount.

PHP Payment Policy 03.0 (Assistant for Surgery) reads: “The assistant surgeon must report the same code reported by the surgeon with the addition of the appro-priate modifier (80, 81, or AS). Reimbursement is based on the assistant sur-geon’s contract and is a percentage of the allowed amount for the surgery as listed below.” Please review PHP Policy 03.0 (Assistant for Surgery) on ProvLink for additional information.

CODES 88342 AND 88343


Effective June 1, 2014, PHP will not recognize CPT codes 88342 or 88343 but will require providers to use HCPCS codes G0461 and G0462 to report immuno-histochemistry tests. Claims billed with codes 88342 and 88343 will receive a denial notice advising providers to “Rebill HCPCS/CPT with appropriate

HCPCS/CPT.” Providers receiving this denial notice may send a corrected claim reporting G0461 and G0462 instead of 88342 and 88343.




EX Code Explanation CDD Duplicate claim

a01 Add-on codes billed without an appropriate parent code a02 Co– or team surgeons not appropriate for code

a03 Charges are included in global OB payment

a04 Postoperative visit included in global surgery payment a05 New patient visit frequency exceeded per CPT guidelines a10 Pharmacy codes currently invalid

a11 Lifetime maximum for procedure exceeded

a13 Bundled/global services, services are never paid separately a14 Chemo admin code not allowed with this drug

a29 Clinical daily maximum exceeded for this service b01 Experimental/investigational procedures not covered b02 Cosmetic procedures not covered

d01 Services not allowed from this provider specialty d02 Services not allowed at this place of service N01 Procedure is incidental to another procedure

N02 Procedure is mutually exclusive to another procedure N04 Postoperative care is included in global surgical payment N05 Preoperative care is included in global surgical payment N06 Assistant surgeon not allowed for this procedure

N14 Invalid gender for procedure

N15 Age does not fit within range described by procedure N51 Rebundle edit occurred with a claim in history

N52 Duplicate unilateral or bilateral procedure

N54 Daily maximum for this procedure has been exceeded

N55 Procedure(s) on current claim combined with procedure(s) on claim in history exceed daily maximum

N58 Mutually exclusive edit with claim in history N58 Incidental edit with claim in history

N91 CCI edit, procedure is incidental to another procedure N92 CCI, current claim denied as incidental to claim in history N93 CCI edit, procedure mutually exclusive to another procedure N94 CCI, current claim denied as mutually exclusive to claim in




Locate the Clinical Edit Fax Inquiry form on ProvLink. Complete the form and send all required documentation as indicated on the form to our dedi-cated inquiry fax line (s).

· A review of the coding applications will be initiated. · Service may be allowed and the claim reprocessed.

· Service denial may be upheld and an explanation of the rationale for the edit will be forwarded to you.


If you do not agree with the edit or payment rule logic, a formal appeal may be submitted in writing. If you are familiar with the edit logic or payment rule and still wish a formal appeal, indicate this to your Provider Relations Representative. Our Medical Coding Administration Department and/or Medical Department will review the appeal and will reply by letter if the denial is upheld.

Edit Reviews




Providence Health Plan offers secure electronic contract delivery.

If you have not already done so, please provide your Providence Health Plan Pro-vider Relations Representative with an E-mail address for the person in your or-ganization who should receive contract negotiation and contract update infor-mation.

Please note that if the contracting contact in your organization changes, it will be important to communicate the new name and E-mail to your Providence Health Plan Provider Relations Representative.






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