Audience
Zip code - drawer
County - drawer

Sign in

Sign in

Policy No: 129

Originally Created: 03/01/2017

Section: Administrative

Last Reviewed:  01/01/2019

Last Revised:  01/01/2019

Approved: 01/17/2019

Effective:  03/01/2019

This policy applies to all physicians, other health care professionals, hospitals and other facilities.

Definitions

Current Procedural Terminology (CPT®)

A medical code set maintained by the American Medical Association (AMA) that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations. CPT is included in Level I Healthcare Common Procedure Coding System (HCPCS).

HCPCS Level II

A standardized coding system that is used primarily to identify medical supplies, durable medical equipment, non-physician services, and services not represented in the Level I code set CPT.

National Correct Coding Initiative (NCCI or CCI)

The Centers for Medicare & Medicaid Services (CMS) developed these edits to promote consistent, correct coding and appropriate payment. These coding edits are developed based on the AMA CPT code set and the HCPCS code set, as well as analysis of standard medical and surgical practice and input from various groups, including specialty societies, other national healthcare organizations, Medicare contractors, providers, and consultants.

The National Uniform Billing Committee (NUBC) and the state uniform billing committees (SUBC)

Committees responsible for the revenue code definitions and requirements for use.

Uniform Billing Editor (UBE)

A reference tool utilized by facilities to manage the constant changes to Medicare billing and reimbursement processes. The UBE provides detailed, accurate, and timely information about Medicare and UB-04 billing rules and requirements.

International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

A morbidity classification system for classifying diagnoses and reason for visits in all health care settings for the purpose of coding and reporting.  Valid for dates of service prior to 10/1/2015.

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

A morbidity classification system for classifying diagnoses and reason for visits in all health care settings for the purpose of coding and reporting. Valid for dates of service on and after 10/1/2015.

Revenue Codes (Rev Codes)

Revenue codes are 4-digit numbers that are used on hospital bills to identify where a member was located in a facility when they received treatment or services, or what service a member received as a patient.

Policy Statement

Providers are required to submit accurate and complete claims for all medical and surgical services, supplies and items rendered to members using industry standard coding guidelines.  Coding guidelines include, but are not limited to, AMA, CPT, HCPCS, CMS Coding Initiatives, UBE, ICD-9 and ICD-10. 

Any medical or surgical service, supply or item, either inpatient or outpatient, reported by any code, must be clearly documented in an appropriate medical record. Our health plan will not allow reimbursement for undocumented professional, inpatient or outpatient medical and surgical services, supplies and items.

Hospitals and facilities must report all services, supplies and items using accurate revenue codes.  

Our health plan will not allow reimbursement for incorrectly reported codes, including revenue codes, for medical and surgical services and supplies and items, for professional, inpatient or outpatient facility claims.

References

ICD-10-CM Official Guidelines for Coding and Reporting 2019 - Centers for Medicare & Medicaid Services

Medicare Claims Processing Manual, Chapter 23 - Fee Schedule Administration and Coding Requirements

Noridian Revenue Codes

National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services

National Uniform Billing Committee (NUBC).

American Medical Association. Current Procedural Terminology: CPT 2019, Professional Edition. AMA Press

American Academy of Professional Coders (AAPC). HCPCS Level II Expert Codebook, 2019. AAPC

Cross References

Facility DRG Validation

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.