RCM eNews – September 2024

From CMS:
Part B payment allowance limits for seasonal influenza (flu) vaccines (that is, the vaccine product) are 95% of the Average Wholesale Price (AWP). In hospital outpatient departments, payment is based on reasonable cost.

Part B deductible and coinsurance amounts don’t apply for flu vaccine products or their administration. With respect to the vaccine product, all providers and suppliers must accept assignment on the claim.

The annual flu vaccine season is August 1–July 31 of the following year.

Get more information on frequency & coverage, billing, and coding.

Effective June 27, 2024, with an implementation date of November 25, 2024, CMS has updated the coverage requirements for pneumococcal vaccinations to align with the Advisory Committee on Immunization Practices (ACIP) recommendations for pneumococcal vaccination coverage.

ACIP recommends that adults aged 65 or older who haven’t previously got a Pneumococcal Conjugate Vaccine (PCV) or whose previous vaccine history is unknown should get 1 dose of PCV (either PCV21, PCV20, or PCV15). When you use PCV15, follow it with a dose of 23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23).

For the complete update and to review the clinical guidelines, click here.

From United Healthcare:
Effective Nov. 1, 2024, we will require prior authorization for the following outpatient radiation therapies for UnitedHealthcare Community Plan members in New York:

• Intensity-modulated radiation therapy (IMRT)
• Proton beam therapy (PBT)
• Stereotactic body radiation therapy (SBRT), including stereotactic radiosurgery (SRS)
• Image-guided radiation therapy (IGRT)
• Special and associated services (Special Plan & Services — Special Services — SPS) (e.g., dosimetry and special physics consults)
• Hypofractionation (aka fractionation) using IMRT, PBT and standard 2D/3D radiation therapy for prostate, breast, lung and bone metastatic cancers
• Selective internal radiation therapy (SIRT), Yttrium-90 (Y90) and implantable beta-emitting microspheres for treatment of malignant tumors

…As part of the new prior authorization requirement, we are also changing the way we manage requests.

Starting Nov. 1, 2024, Optum®, a UnitedHealthcare affiliate, will manage prior authorization requests for the above-noted outpatient radiation therapies and existing prior authorization requirement for PBT. This change should not impact your process for submitting prior authorization requests.
For further details, click here.

From United Healthcare:
Beginning Feb. 1, 2025, we’re adding the following GA modifier requirement for UnitedHealthcare commercial plans claims to our Charging members for non-covered services protocol. This requirement should help improve health care transparency by helping to ensure patients were made aware of their potential cost-sharing liability.

The new requirement
In addition to the consent requirements in the Protocol, if you know or have reason to suspect that a commercial member’s benefits do not cover the service (as described further in the Protocol), a GA modifier must be submitted on the claim if you want to bill our member for the non-covered service. You will use the GA modifier to document when the enhanced content requirements of the consent were met. The aim of requiring use of the GA modifier is to improve health care transparency by helping ensure members were made aware of their potential liability in advance of any procedure or bill they may receive for services. If you didn’t meet all of the consent requirements in the Protocol, it is not appropriate to submit the GA modifier on the claim and you cannot bill our member.

What you need to do
If you obtain written consent from a commercial member for a service you know or suspect is not covered by their benefits, and the consent met all the requirements in the Protocol, you must include the GA modifier on your claim for the non-covered service. Including the GA modifier on your claim for the non-covered service helps ensure it is adjudicated as member liability where appropriate.

A new add-on code +99459 was created by the Centers for Medicare & Medicaid Services (CMS) in January 2024, that is used to report pelvic exams in a non-facility setting. This applies to Commercial, Medicare and Safety Net lines of business.

According to the American College of Obstetricians and Gynecologists (ACOG), CMS created this code to assist with the cost of pelvic examination packs, such as speculums, and in-room chaperones for patients receiving female pelvic examinations during an outpatient evaluation and management visit.

Guidance for Reporting +99459
Report +99459 with one of the following evaluation and management codes:

• Office or other outpatient visit for the evaluation and management of a new patient codes (99202-99205)
• Office or other outpatient visit for the evaluation and management of an established patient codes (99212-99215)
• Preventive visit code (99383-99387, 99393-99397)

Note: If the claim is for a Medicare patient preventive visit, use one of the following HCPCS codes:

• G0402 (Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment)
• G0438 (Annual wellness visit; includes a personalized prevention plan of service, initial visit)
• G0439 (subsequent visit)
• G0468 (Federally qualified health center visit, a FQHC visit that includes an initial preventive physical examination (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV)

Helpful Tips

• When a Medicare patient receives a screening pelvic exam, the codes G0101 for the pelvic exam and Q0091 for the collection work can be reported along with one of these preventive services. Both codes include practice expense relative values specifically addressing the costs of performing the exam; therefore, it is unlikely that +99459 would be billed on your claim.
• If a patient does not have a pelvic exam during the visit, CPT code +99459 should not appear anywhere on the claim.

News release for OB/GYNs, Midwives, Family Practice Providers, and Outpatient Clinics that provide OB/GYN services

The New York State Department of Health (NYSDOH) has mandated, effective July 1, 2024, that providers submit a claim with a Category II CPT code for each prenatal/postpartum service provided to a NYS Medicaid member when the provider is billing using the global bill codes or a bundled bill.

These Category II CPT code claims must be submitted in addition to the global or bundled code claims. Claims for NYS Medicaid FFS members must be submitted directly to NYS Medicaid. Claims for Medicaid Managed Care (MMC) and Health and Recovery Plan enrollees must be submitted to the Managed Care Plan of the enrollee. The codes that must be used are as follows:

Prenatal Bundled Services:

• CPT: 59400, 59425-59426, 59610, 59618
• CPT II: 0500F-0502F (must document the prenatal date of service)

Postpartum Bundled Services:

• CPT: 59400, 59410, 59510, 59515, 59610, 59614, 59618, 59622
• CPT II: 0503F (must document the postpartum date of service)

Click here to view the program update on the New York State Medicaid website.

Effective September 1, 2024, Optum Clinical Support Program is implementing a new protocol for all providers that specialize in in Physical Therapy, Occupational Therapy, Speech Therapy and Chiropractic services for certain United Healthcare and AARP Medicare Advantage members.

These provider types must fill out a PSF (Patient Summary Form) within 10 days from the initial date of service for claims to be processed. The PSF is not required for the initial evaluation however, it is required for all subsequent treatment visits. The top portion of the PSF is to be completed by the provider and the bottom portion is completed by the patient.

Please review the details in the Clinical Support Program guide in the Optum Provider Operations Manual that can be accessed here.

The PSF can be found here.

The quarterly edition of Office Link Updates from Aetna has been released. This edition features some state specific guidance including New Jersey and North Carolina as well as Payment and Coding updates.

Beginning December 1, 2024, you may see new claim edits for commercial, Medicare and Student Health members. For coding changes, go to Aetna Payer Space > Resources > Expanded Claim Edits.

Click here to read the entire news release.