Pulmonary Diagnostic Procedures when billed with E&M Codes

Reimbursement Policy:
Pulmonary Diagnostic Procedures when billed with E&M Codes

Effective Date:
February 25, 2019

Purpose:
Provide guidelines for the reimbursement of pulmonary diagnostic procedures (CPT® 94010-94799) when billed with an Evaluation and Management (E&M) code (99201-99215, 99241-99245, 99281-99285, 99304-99318, 99324-99337, 99341-99350). This policy applies to 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 CMS guidelines, Horizon BCBSNJ shall not consider for reimbursement an E&M code billed with a pulmonary diagnostic procedure on the same date by the same provider unless there is a modifier 25 appended to the E&M code to indicate a significant separately identifiable service was performed which is unrelated to the pulmonary diagnostic procedure.

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 an E&M service when billed with 94010-94799 (Pulmonary function testing) unless reported with modifier 25 indicating the E&M is a significant separately identifiable evaluation and management service.

No additional reimbursement shall be made if the provider is capitated or the reimbursement structure for that provider is a global fee.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible 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 109_v1.0_10252017