Frequency of Care Coordination Services and ESRD Procedures

Reimbursement Policy:
Frequency of Care Coordination Services and ESRD Procedures

Effective Date:
February 25, 2019

Purpose:
Provides guidelines for the reimbursement of Care Coordination Services rendered during the same service period of ESRD procedures (90951-90962, 90963-90966) when appropriately billed by professional providers.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • ITS Home In-Network
  • FEP
  • SHBP non MA

All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included.

ASO accounts will be included as an Opt-In option for additional claims editing on an account-by-account basis.

Policy:
In accordance with AMA CPT Manual guidelines, Horizon BCBSNJ shall not consider for separate reimbursement care plan oversight services (99375 or G0181) or transitional care services (99495-99496) when billed during the same calendar month as a monthly ESRD services code.

Care plan oversight activities and care coordination services, including transitional care services, are included in the monthly capitation payment (MCP) for monthly ESRD services (90951-90962, 90963-90966). The care plan oversight activity includes assessment of the patient’s dialysis regimen, prescriptions, and response to and complications from the dialysis treatment. Periodic review and update of the patient’s short-term and long-term care plans with staff, as well as coordination and direction of the care of patients by other professional staff, such as dieticians and social workers, are also included.

The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
Horizon BCBSNJ shall deny care plan oversight activities, care coordination services, including transitional care services, when billed within the same calendar month of a monthly ESRD services code.

In instances where the provider is participating, no member liability shall apply.

In instances where the provider is not participating, member liability shall be up to the provider’s charge.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
10/25/2017: Policy Approved

CPT® is a registered trademark of the American Medical Association.

Policy 106_v1.0_10252017