WELLCARE CLAIM PAYMENT POLICIES

Evaluation and Management (E&M) Services

New Patient Visits:

The AMA defines a new patient as “one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years.” Given this definition, if a physician bills a new patient visit, and the same physician or a physician from the same group practice with the same specialty has performed any other evaluation and management code in the previous three years, then the second new patient visit will be denied.

Multiple E&M Services on the Same Day:

Only one E&M code is allowed for a single date of service for the same provider group and specialty, regardless of place of service. Payment recommendation will be made for the E&M code with the highest average Medicare-allowed amount and all other E&M codes will be denied. Should an E&M service with a lower average Medicare-allowed amount have been previously processed, the second E&M service will be denied even if the average Medicare-allowed amount is higher than that of the first E&M service processed.

Multiple Inpatient Admission or Consultation Services:

If a provider bills an inpatient admission or consultation service and if another inpatient admission or consultation service has been billed in the previous seven days by the same provider then the second inpatient admission or consultation service will be denied. The exception is if an inpatient discharge service has been billed during the seven-day period.

Global Surgery

Global surgery includes all necessary services normally furnished by the surgeon before, during and after the surgical procedure. The global surgery period applies only to surgical procedures that have postoperative periods of zero, 10 and 90 days. The global surgery concept applies only to primary surgeons and co-surgeons.

Minor surgical procedures:

These are relatively small procedures that include various intraoperative and post-operative services. Procedures with a zero- and 10-day postoperative period are classified as minor procedures. The services included in the minor surgery period are: evaluation and management visits rendered on the same day as the minor procedure are not payable separately; all intra-operative services (same-day services) that are normally part of the surgical procedure and for 10-day global surgery procedures: postoperative visits and related procedures rendered within 10 days of the surgery.

Major surgical procedures:

These are relatively extensive surgical procedures that include various pre-operative, intra-operative and post-operative services. Procedures with a 90-day postoperative period are classified as major procedures. The services included in the major surgery fee are: Preoperative visits rendered 1 day (24 hours) prior to the surgery, all intraoperative services (same day services) that are normally part of the surgical procedure and postoperative visits and related procedures rendered within 90 days after the surgery.

Please visit http://codingahead.blogspot.com/2009/10/global-period.html for more information on Global period.

Obstetrical Care

Global Obstetrical Package:

Separate reimbursement for those services that are included in the global obstetrical package for uncomplicated maternity cases is not allowed.

Global Obstetrical Delivery Post-Operative Care:

Evaluation and management services and postpartum care billed for a date of service within a 42-day time frame will be bundled into the global delivery service when billed by the same provider that performed the delivery, except when the E&M was unrelated to the obstetrical care..

Antepartum Care:

It is not appropriate for a single provider to bill more than one 59425 or 59426 in any combination during the antepartum period. Therefore if more than one of these codes billed by the same provider in a 240-day period, the subsequent billed codes will be denied.

Professional, Technical and Global Policies

Diagnostic Tests and Radiology Services Performed Outside the Office Setting:

Procedures with professional, technical and global components should be submitted with an appropriate procedure code modifier that is consistent with the place the service was rendered. It is not appropriate for a provider to bill the global or technical component in a place of service outside their office as the technical component will be billed by the facility in which the service took place.

Global Payment to the Same Provider: A provider will not be reimbursed more than the global component amount. If a provider splits components among different claims, then the claims received subsequent to the first claim will be adjusted based on the payment of the first claim.

Technical Component-Only Procedures:

Technical component-only services are stand-alone procedure codes that describe only the technical component (e.g., staff and equipment costs only) of a given procedure for which there is either an associated code that describes the professional component of the diagnostic test only or for which there is accompanying professional component. Payment to physicians for these services is limited to the office place of service as the facility will bill for these services when rendered in a non-office setting. It is also inappropriate for a provider to bill these procedures with either modifier 26 (professional component) or TC (technical component) as neither of these modifiers is applicable to this group of procedure codes.

Add-On Codes

When an add-on code is submitted and the primary procedure has not been identified on either the same or previous claim, then the add-on code will be denied as an inappropriately coded procedure. If the primary procedure is denied because of some other logic (e.g. Correct Coding Initiative), then the add-on code will also be denied.

An add-on code billed with a -51 modifier will be denied as the allowance for these procedures already reflects the reduced service associated to it.

Providers should bill the appropriate add-on codes and not bill a primary service/procedure with a quantity greater than one.