cms requires the kx modifier to signify requirements

Notification of medical claim payment policy and code-editing updates for facility practitioners

Effective Date: Nov. 9, 2015 Notification Date: Aug. 7, 2015

GCHJEHMEN 2074ALL0715-G

Special announcements: International Classification of Diseases, 10th Revision (ICD-10) implementation The health care industry is required to migrate from the ICD-9 code set to ICD-10 starting Oct. 1, 2015. Humana will not accept ICD-9 coded claims with dates of service after Sept. 30, 2015. Humana’s claims systems will accept only ICD-10 coded claims with dates of service on or after Oct. 1, 2015. Humana will accept authorizations with ICD-10 codes beginning July 1, 2015. Additionally, Humana will no longer accept ICD-9 coded retroactive authorizations as of Sept. 30, 2016. In order to prepare for a smooth transition, the Centers for Medicare & Medicaid Services (CMS) recommends following its guidelines and preparation recommendations. Find out more about ICD-10 by visiting Humana’s ICD-10 website located at https://www.humana.com/provider/medical-providers/education/claims/icd-10/. The website includes ICD-10 training guides, checklists, FAQs and resources.

General reminders: Edits associated with new or revised AMA Current Procedural Terminology (CPT®), International Classification of

Diseases, Ninth Revision (ICD-9), modifier and Healthcare Common Procedure Coding System (HCPCS) codes will be added.

Edits for CPT, ICD-9, ICD-10, modifier and HCPCS codes deleted by the AMA and/or CMS will be removed.

Procedures that are submitted in a manner that is not consistent with their definitions will not be reimbursed. For example, cesarean delivery only (59514) or cesarean delivery only including postpartum care (59515) will not be

https://www.humana.com/provider/medical-providers/education/claims/icd-10/


reimbursed when billed with routine obstetric care including antepartum care, cesarean delivery and postpartum care (59510). Based on the definition of 59510, it would not be appropriate to also bill 59514 or 59515, as the services represented by those codes are already included in 59510.

Services will be reimbursed only when all diagnosis codes submitted on the claim are coded to the highest level of specificity.

As noted in the AMA CPT manual, procedure codes that are designated add-on codes are intended to report additional service beyond the related primary code. The add-on code must be reported in conjunction with a related primary code. Therefore, add-on codes will not be reimbursed when the primary code is absent or has been denied for other reasons.

Humana is committed to remaining consistent with CMS claims processing guidelines. To further that effort, as Medicare payment policies change, Humana continuously updates code-editing logic on all Humana Medicare Advantage (MA) products. Health care providers must follow applicable claim submission guidelines, including local coverage determinations (LCDs) and national coverage determinations (NCDs), to facilitate accurate claims processing results.

As supported by Section 1815(a) and Section 1833(e) of the Social Security Act, Section 422.214(a)(2) of Title 42 of the Code of Federal Regulations, provider manual and other relevant guidance, Humana reserves the right to request itemized bills in order to confirm proper billing, prior to payment, when necessary. Any improper billing may result in payment reduction or denial for specific charges.

Per Humana’s provider contract language, claims shall include the physician’s national provider identifier (NPI) and the valid taxonomy code that most accurately describes the health care services reported on the claim. Submitting this information on claims will allow more accurate and timely processing of claims through Humana’s systems.

Humana does not reimburse for noncovered services (experimental and investigational, cosmetic, etc.) billed on facility claims. Noncovered services are listed in Limitations and Exclusions.

Humana implements incidental/bundling editing continuously, with updates to its editing systems based on direction from the AMA CPT, National Correct Coding Initiative (NCCI) and other applicable coding standards.

Claim edits do not supersede the necessity to obtain preauthorization. Preauthorization requirements are still applicable. *Note: These and all edits previously published or posted on Humana.com/providers for fully insured commercial Humana members may be applied to self-funded members when requested by the self-funded group.


Claim payment policy and code-editing updates Effective Nov. 9, 2015, the following changes apply to outpatient facility and ambulatory surgery center (ASC) claims submitted for Humana commercial fully insured, including health maintenance organization exchange (HMOx) and select self-funded* members, Medicaid and Medicare Advantage (MA) health maintenance organization (HMO), preferred provider organization (PPO) and private fee-for-service (PFFS) members:

Category Topic Policy Statement Impacted Products

Cardiology Cardiac rehabilitation

What is changing? Physician services for outpatient cardiac rehabilitation or intensive cardiac rehabilitation, with or without continuous ECG monitoring, without exercise, per session, will be eligible for reimbursement only when billed with a covered diagnosis as indicated in Chapter 32 of the Medicare Claims Processing Manual. Why is Humana implementing this change? According to Chapter 32 of the Medicare Claims Processing Manual, outpatient cardiac rehabilitation or intensive cardiac rehabilitation services are covered for patients who have experienced one or more of the following: • Acute myocardial infarction within the preceding 12 months • Coronary artery bypass surgery • Current stable angina pectoris • Heart valve repair/replacement • Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting • Heart or heart-lung transplant • Stable, chronic heart failure defined as patients with left ventricular ejection

fraction of 35 percent or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least six weeks

Commercial fully insured products

Select self-funded* products

All Medicare Advantage products




Cardiology Cardiac stress tests

What is changing? Stress test and echocardiography/cardiac nuclear imaging procedure will not be eligible for reimbursement when billed on the same date or within six months of another echocardiography/cardiac nuclear imaging procedure, unless a coronary intervention has also been billed on the same date of service or within the previous six months. Why is Humana implementing this change? According to Humana policy, a physician should bill a noncomplex or complex stress test only once within a six-month period, unless there is a significant change in the patient's condition that would be determined by a coronary intervention.




Cardiology Cardiovascular nuclear imaging

What is changing? Myocardial perfusion imaging, single study, will not be eligible for reimbursement when billed more than once on the same claim for the same or the previous date of service. Why is Humana implementing this change? According to the American College of Cardiology Guide to CPT, when performing more than one myocardial perfusion study over a two-day period, the appropriate procedure to use is myocardial perfusion imaging, multiple studies.







Cardiology Cardiovascular nuclear imaging

What is changing? Cardiac nuclear imaging procedures will be eligible for reimbursement only when billed with a CMS place of service code of 11 (office), 21 (inpatient hospital), 22 (outpatient hospital), 23 (emergency room), 24 (ambulatory surgical center) or 49 (independent clinic). Why is Humana implementing this change? According to Humana policy, cardiac nuclear imaging procedures must be performed in the office, inpatient hospital, outpatient hospital, emergency room, ambulatory surgical center or independent clinic setting.




Cardiology Electro-cardiograms (ECGs)

What is changing? Electrocardiogram, routine ECG with at least 12 leads, with interpretation and report, will not be eligible for reimbursement when billed in the office setting for a patient age 18 or older with a general medical exam diagnosis or a cardiovascular screening diagnosis, unless an appropriate additional diagnosis is present on the claim. Why is Humana implementing this change? According to the U.S. Preventive Services Task Force, it is not appropriate to screen for coronary disease in asymptomatic adult patients. Therefore, when an ECG is billed in the office setting for a patient age 18 or older with a general medical exam diagnosis or a cardiovascular screening diagnosis, the ECG will not be eligible for reimbursement.







Cardiology Noninvasive vascular diagnostic studies

What is changing? Arterial studies will not be eligible for reimbursement when venous studies have been allowed for the same date of service. Why is Humana implementing this change? Based on Humana’s internal review and supported by LCDs, it would be necessary only rarely to perform extremity venous studies and arterial studies at the same session. If arterial studies are submitted and venous studies have already been allowed for the same date of service, the arterial studies would not be eligible for reimbursement.


Select self-funded*products

Cardiology Noninvasive vascular diagnostic studies

What is changing? Venous studies will not be eligible for reimbursement when arterial studies have been allowed for the same date of service. Why is Humana implementing this change? Based on Humana’s internal review and supported by LCDs, it would be necessary only rarely to perform extremity venous studies and arterial studies at the same session. If venous studies are submitted and arterial studies have already been allowed for the same date of service, the venous studies would not be eligible for reimbursement.



Correct Coding 3-D base What is changing? 3-D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound or other tomographic modality with image post-processing under concurrent supervision (either on an independent work station or not) will not be reimbursed unless submitted with an appropriate base code. Why is Humana implementing this change?







According to the AMA CPT, 3-D rendering services must be billed in conjunction with a code that represents the base imaging procedure.

Correct Coding 3-D rendering with routine pregnancy diagnosis

What is changing? 3-D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound or other tomographic modality with image post-processing under concurrent supervision (either on an independent station or not) will not be reimbursed when submitted with a routine pregnancy diagnosis. Why is Humana implementing this change? According to the Humana coverage policy for noninvasive prenatal screening, 3-D rendering is not covered as a routine pregnancy ultrasound service.



Correct Coding Arthrocentesis What is changing? Arthrocentesis, aspiration and/or injection, major joint or bursa, will be eligible for reimbursement only when submitted with an appropriate ICD diagnosis code. Why is Humana implementing this change? Based on Humana’s internal review and supported by CMS LCDs, arthrocentesis, aspiration and/or injection; major joint or bursa, is eligible for reimbursement when billed with specific diagnoses.




Correct Coding Continuous passive motion (CPM) device

What is changing? A charge for a continuous passive motion (CPM) device must be submitted for a date of service beginning no later than the second day after corrective surgery. Humana will not allow any unit for any day beyond the 21st day after surgery.



All Medicare




Why is Humana implementing this change? CPM devices are covered only when the criteria described in the Humana coverage policy are met. CPM devices are allowed when billed within two days after a surgery and are covered for up to 21 days after the surgery. More information is available at Humana.com/provider. Choose “Medical and Pharmacy Coverage Policies” under “Resources” and search by keyword “CPM devices.”

Advantage products

Correct Coding Diagnosis and procedure consistency

What is changing? Vestibular function tests or audiometry threshold testing will be eligible for reimbursement only when at least one of the ICD codes on the claim line is an appropriate diagnosis procedure combination. Why is Humana implementing this change? Based on Humana’s internal review and supported by CMS LCDs, vestibular function tests or audiometry threshold testing is eligible for reimbursement when billed with specific diagnoses.





What is changing? Computed tomographic (CT) colonography will be eligible for reimbursement only when at least one of the ICD codes on the claim line is an appropriate diagnosis procedure combination. Why is Humana implementing this change? Based on Humana’s internal review and supported by CMS LCDs, CT colonography is eligible for reimbursement when billed with specific diagnoses.








What is changing? Excision, destruction and other procedures of dentoalveolar structures will be eligible for reimbursement only when at least one of the ICD codes on the claim line is an appropriate diagnosis procedure combination. Why is Humana implementing this change? Based on Humana’s internal review and supported by CMS LCDs, excision, destruction and other procedures of dentoalveolar structures is eligible for reimbursement when billed with specific diagnoses.





What is changing? Health and behavior assessment/intervention will be eligible for reimbursement only when at least one of the ICD codes on the claim line is an appropriate diagnosis procedure combination. Why is Humana implementing this change? Based on Humana’s internal review and supported by CMS LCDs, health and behavior assessment/intervention is eligible for reimbursement when billed with specific diagnoses.





What is changing? Pulmonary diagnostic testing will be eligible for reimbursement only when at least one of the ICD codes on the claim line is an appropriate diagnosis procedure combination. Why is Humana implementing this change? Based on Humana’s internal review and supported by CMS LCDs, pulmonary diagnostic testing procedures are eligible for reimbursement when billed with specific diagnoses.








What is changing? Other peripheral nerve injection will be eligible for reimbursement only when at least one of the ICD codes on the claim line is an appropriate diagnosis procedure combination. Why is Humana implementing this change? Based on Humana’s internal review and supported by CMS LCDs, other peripheral nerve injection is eligible for reimbursement when billed with specific diagnoses.




Correct Coding End-stage renal disease (ESRD) monthly services

What is changing? ESRD services that include monitoring for the adequacy of nutrition, assessment of growth and development and counseling of parents (for pediatric patients) will be reimbursed once per 30 days. Why is Humana implementing this change? According to AMA CPT, ESRD services codes are defined as monthly/per month. Only one ESRD service code will be allowed in any 30-day period.




Correct Coding ESRD supply and DME suppliers

What is changing? Method II ESRD supplies or equipment will not be eligible for reimbursement when billed by a durable medical equipment (DME) supplier. Why is Humana implementing this change? According to Chapter 11 of the CMS Medicare Benefit Policy Manual, method II ESRD supply and equipment HCPCS codes are not payable to DME suppliers.







Correct Coding Holter monitors What is changing? External electrocardiographic recording services will be reimbursed once per 48-hour period. Additionally, the components of external electrocardiographic recording (scanning analysis with report, recording, review and interpretation) will not be reimbursed if the comprehensive service representing all components has been billed in the previous 48 hours. Why is Humana implementing this change? According to AMA CPT, external electrocardiographic recording service codes are defined as “up to 48 hours.” Only one external electrocardiographic service code will be allowed in any 48-hour period.




Correct Coding Infusion pumps and supplies

What is changing? Infusion pump supplies will not be reimbursed when the infusion pump has not been allowed. Why is Humana implementing this change? According to Medicare and Humana policies, supplies associated with an infusion pump are allowable only when the infusion pump is covered.




Correct Coding Rebundling What is changing? When paring or cutting of benign hyperkeratotic lesions is billed for two to four lesions for both right and left limbs on the same day, the codes will be recoded to the more appropriate code for more than four lesions total. Why is Humana implementing this change?







The code that more accurately describes services being rendered will be allowed per AMA CPT definition.

Correct Coding Rebundling What is changing? When all components for a cardiovascular stress test are billed, the codes will be recoded to the more appropriate comprehensive code for a cardiovascular stress test. Why is Humana implementing this change? The code that more accurately describes services being rendered will be allowed per AMA CPT definition.




Correct Coding Rebundling What is changing? When all components for an electrocardiogram are billed, the codes will be recoded to the more appropriate comprehensive code for an electrocardiogram. Why is Humana implementing this change? The code that more accurately describes services being rendered will be allowed per AMA CPT definition.




Correct Coding Rebundling What is changing? When adjacent tissue transfer or rearrangement is billed multiple times, the codes will be recoded to the more appropriate code for a larger tissue area. Why is Humana implementing this change? The code that more accurately describes services being rendered will be allowed per AMA CPT definition.







Correct Coding Rebundling What is changing? When X-rays are billed for a chest view and abdomen view, the codes will be recoded to the more appropriate comprehensive code that includes both services. Why is Humana implementing this change? The code that more accurately describes services being rendered will be allowed per AMA CPT definition.




Correct Coding Supplies and equipment with home infusion per diem codes

What is changing? Home infusion supplies and equipment will not be eligible for reimbursement when billed for the same date of service as a home infusion per diem code. Why is Humana implementing this change? According to the National Home Infusion Association (NHIA), the national definition of per diem includes professional pharmacy services, administrative services and other support costs. Supplies and equipment are included in the per diem reimbursement.




CPT Acupuncture for osteoarthritis

What is changing? Acupuncture will not be eligible for reimbursement when billed with a diagnosis of osteoarthrosis. Why is Humana implementing this change? According to CMS NCDs, acupuncture procedures are not considered reasonable and necessary for the treatment of osteoarthritis.






CPT Audiology services

What is changing? Treatment of speech, language, voice, communication and/or auditory processing disorder will not be eligible for reimbursement when submitted by an audiologist. Why is Humana implementing this change? According to Medicare Claims Processing Manual, Chapter 12, these services represent speech language pathology services, which are not allowed when performed by an audiologist.




CPT

Polysomno- graphy studies

What is changing? Polysomnography will be limited to 1 unit per date of service when billed by any health care provider. Why is Humana implementing this change? According to Humana policy, polysomnography should be reported only once per date of service.




CPT

Polysomno-graphy studies

What is changing? Polysomnography will be reimbursed up to two times in a three-year period. Why is Humana implementing this change? According to Humana policy, polysomnography with sleep staging is considered necessary no more than twice over a three-year period.




Evaluation and Management (E/M) Services

Bioimpedance with E/M services

What is changing? E/M services will not be eligible for reimbursement when billed with bioimpedance, thoracic, electrical, unless the CMS place of service code is 21 (inpatient hospital), 22 (outpatient hospital) or 23 (emergency room, hospital).






Why is Humana implementing this change? Based on Humana’s internal review and supported by CMS LCDs, it is not always appropriate to report an E/M service and cardiac output monitoring by thoracic electrical bioimpedance on the same day.



Cardiovascular services with E/M services

What is changing?

E/M services will not be eligible for reimbursement when billed the same date

of service as evaluation of cardiovascular function with tilt table, unless the

evaluation and management charge is for a significant and separately

identifiable face-to-face service.

Why is Humana implementing this change? According to Humana policy, an E/M service provided on the same day as tilt table testing must be a significant and separately identifiable face-to-face service.





Care management services

What is changing? Care management service will not be eligible for reimbursement when billed within the same calendar month as the following services: • End-stage renal disease (ESRD) services • Education and training • Preparation of special reports • Analysis of data • Care plan oversight services • Prolonged services without direct patient contact • Anticoagulant management • Medical team conferences







• Telephone services • Online medical evaluation • Transitional care management services • Medication therapy management services Why is Humana implementing this change? According to the AMA CPT Manual, certain services should not be reported separately by the same health care provider who reported care management services during the same calendar month.


Discharge services

What is changing? Hospital discharge services will not be eligible for reimbursement when hospital discharge services have been billed for the same date of service. Why is Humana implementing this change? According to the Medicare Claims Processing Manual, Chapter 12, only one hospital discharge day management service is eligible for reimbursement per patient per hospital stay.





Discharge services

What is changing? Hospital discharge services will not be eligible for reimbursement when hospital discharge services have been billed and paid for the subsequent date of service. Why is Humana implementing this change? According to the Medicare Claims Processing Manual, Chapter 12, only one hospital discharge day management service is payable per patient per hospital stay, regardless of the order in which the discharge management service codes are received.








Medication therapy management services provided by a pharmacist

What is changing? Medication therapy management; initial 15 minutes, new patient, will not be eligible for reimbursement if billed within one year of a previous medication therapy management service. Why is Humana implementing this change? According to the AMA CPT Manual, medication therapy management services describe face-to-face patient assessment and intervention as appropriate. If an initial medication therapy management service for a new patient is billed within one year of another initial medication assessment and intervention of a new patient, the subsequent medication therapy management service will not be eligible for reimbursement.





Modifier 22 (increased procedural services)

What is changing? E/M services will not be eligible for reimbursement when billed with modifier 22 (increased procedural services). Why is Humana implementing this change? According to the AMA CPT Manual, modifier 22 (increased procedural services) should not be appended to E/M services.





Multiple inpatient admission or consultation services within seven days

What is changing? Initial inpatient hospital visits will not be eligible for reimbursement if any type of inpatient visit has been billed in the previous week by the same provider group and specialty, unless an inpatient discharge visit has also been billed. Why is Humana implementing this change? According to Humana policy, an initial inpatient admission will be allowed once every seven days. If a health care provider from the same provider group and







same specialty bills an initial inpatient admission more than once within seven days, or has billed a prior inpatient visit, without a discharge in the interim, then the initial inpatient admission will be denied.


Pediatric preventative medicine services

What is changing? Preventive medicine initial or periodic visits will be limited to eight unique visits in a one-year period for patients less than 1 year old. Why is Humana implementing this change? According to the American Academy of Pediatrics, preventive services for infants should be performed no more than eight times within the first year of life.





Pediatric preventative medicine services

What is changing? Preventive medicine initial or periodic visits will be limited to six unique visits in a three-year period for patients 1 to 3 years old. Why is Humana implementing this change? According to the American Academy of Pediatrics, preventive services for patients between the age of 1 and 3 years should be performed no more than six times within a three-year period.




Genetics Tier 1 molecular pathology and HCPCS genetic analysis/ testing procedures

What is changing? Genetic testing procedures billed with a Tier 1 molecular pathology procedure will not be eligible for reimbursement based on CPT and HCPCS procedure code definitions. Why is Humana implementing this change? According to the AMA CPT Manual, Tier 1 molecular pathology procedures







include all analytical services performed in the test. It is inappropriate to bill additional genetic analysis or testing procedures for the same gene or disease on the same date of service as a Tier 1 molecular pathology procedure.

HCPCS Home INR monitoring

What is changing? Home prothrombin time (INR) monitoring will be eligible for reimbursement only when billed with a required diagnosis as indicated in Chapter 1 of the Medicare National Coverage Determinations (NCD) Manual. Why is Humana implementing this change? According to Chapter 1 of the Medicare NCD Manual, home prothrombin time (INR) monitoring is covered for chronic oral anticoagulation management for patients with mechanical heart valves or chronic atrial fibrillation.


HCPCS Kidney disease patient education services

What is changing? Face-to-face educational services related to the care of chronic kidney disease will be eligible for reimbursement only if billed with a diagnosis of chronic kidney disease, stage III, or chronic kidney disease, stage IV (severe). Why is Humana implementing this change? According to Chapter 32 of the CMS Medicare Claims Processing Manual, a diagnosis of chronic kidney disease, stage III, or chronic kidney disease, stage IV (severe), is required for face-to-face educational services related to the care of chronic kidney disease.




HCPCS Physician payment for implantable tissue markers

What is changing? Tissue marker, implantable, any type, each, or implantable radiation dosimeter, each, will be eligible for reimbursement only when billed with one of the following procedures on the same date of service:






(A4648) and radiation dosimeters (A4650)

• Unlisted procedure, breast • Placement of interstitial device(s) for radiation therapy guidance,

percutaneous, intra-thoracic, single or multiple • Placement of interstitial device(s) for radiation therapy guidance,

percutaneous, intra-abdominal, intra-pelvic (except prostate) and/or retroperitoneum, single or multiple

• Placement of interstitial device(s) for radiation therapy guidance, prostate (via needle, any approach), single or multiple

Why is Humana implementing this change? According to CMS policy, in order for implantable tissue markers or implantable radiation dosimeters to be paid to physicians, there must be a qualifying service or procedure paid on the same claim, or in history, with the same date of service.


HCPCS – DME Knee orthoses What is changing? Addition to lower extremity orthosis for custom-fabricated orthosis will be eligible for reimbursement only when a custom-fabricated knee orthosis has also been billed within the previous three years. Why is Humana implementing this change? Based on Humana’s internal review and supported by CMS LCDs, the allowance for the addition to lower extremity orthosis for custom-fabricated orthosis is contingent on a custom-fabricated knee orthosis having been billed in the previous three years.




HCPCS – DME Medicare intravenous immune globulin

What is changing? Services, supplies and accessories used in the home under the Medicare intravenous immune globulin (IVIG) demonstration will be eligible for


Select self-funded*




(IVIG) demonstration

reimbursement only when billed with one of the following as the place of service: • Pharmacy • School • Homeless shelter • Home • Assisted living facility • Group home • Temporary lodging • Walk-in retail health clinic • Custodial care facility • Intermediate care facility/mentally retarded • Residential substance abuse facility • Psychiatric residential treatment center Why is Humana implementing this change? According to CMS policy, services, supplies and accessories used in the home under the Medicare intravenous immune globulin (IVIG) demonstration are covered only when billed in a patient’s home or a setting that is “home like.”

products


HCPCS – Drugs & Biologicals

Ado-trastuzumab emstansine

What is changing? Injection, ado-trastuzumab emtansine, 1 mg, is eligible for reimbursement only when billed with a diagnosis of breast cancer. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, injection, ado-trastuzumab emtansine, 1 mg, is used only for an indication of breast cancer.








Ado-trastuzumab emstansine

What is changing? Injection, ado-trastuzumab emstansine, 1 mg, will be limited to 450 units per date of service by any health care provider. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information and the pharmaceutical compendia, the daily maximum dosage of ado-trastuzumab emtansine for any indication should not exceed 450 units.





Aflibercept What is changing? Injection, aflibercept, 1 mg, will be eligible for reimbursement only when billed with a diagnosis of diabetic macular edema and diabetes mellitus with ophthalmic manifestations. Why is Humana implementing this change? According to the FDA-labeled prescribing information, injection, aflibercept, 1 mg, is used to treat an indication of diabetic macular edema and diabetes mellitus with ophthalmic manifestations.





Belimumab What is changing? Injection, belimumab, 10 mg, is eligible for reimbursement only when billed with a diagnosis of systemic lupus erythematosus. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, injection, belimumab, 10 mg, is used only for an indication of systemic lupus erythematosus.








Belimumab What is changing? Injection, belimumab, 10 mg, is not eligible for reimbursement when billed by any health care provider more than once every two weeks. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, injection, belimumab, 10 mg, should not be administered more frequently than once every two weeks.





Belimumab What is changing? Therapeutic, prophylactic or diagnostic injection (specify substance or drug), intravenous push, will not be reimbursed when billed with injection, belimumab, 10 mg, unless another drug has been billed for the same date of service. Why is Humana implementing this change? According to the AMA CPT, administration of highly complex drugs (like belimumab) should be billed with a code representing chemotherapy and other highly complex drug or highly complex biological agent administration.





Bevacizumab What is changing? Injection, bevacizumab, 10 mg, injection, epirubicin HCl, 2 mg, and injection, doxorubicin HCl, 10 mg, when billed with a diagnosis of breast cancer, will be eligible for reimbursement only when the required drug combination has been billed for the same date of service by any health care provider. Why is Humana implementing this change? According to pharmaceutical compendium, injection, bevacizumab, 10 mg, injection, epirubicin HCl, 2 mg, and injection, doxorubicin HCl, 10 mg, should be







billed in combination with another required drug for the treatment of breast cancer.


Bortezomib What is changing? Injection, bortezomib, 0.1 mg, will be limited to 34 units when billed with modifier JW (drug amount discarded/not administered to any patient). Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, bortezomib is supplied in a 3.5 mg vial. It is inappropriate for a health care provider to bill drug wastage that equals or exceeds the size of the vial.





Botulinum toxin A and B

What is changing? Injection, onabotulinumtoxinA, 1 unit, is limited to 100 combined units per date of service when billed with a diagnosis of tension-type headache and if a diagnosis of chronic migraine headache is not also present. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, the maximum daily dosage of injection, onabotulinumtoxinA, 1 unit, for an indication of tension-type headache without chronic migraine headache, is 100 units.






What is changing? Injection, onabotulinumtoxinA, 5 units, is not reimbursable for patients under the age of 18 unless there is a diagnosis of cerebral palsy. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information,







abobotulinumtoxinA, 5 units, is only appropriate for an indication of cerebral palsy for patients under the age of 18.



What is changing? Injection, onabotulinumtoxinA, 1 unit, will be limited to 38 units when billed with a diagnosis of anal fissure. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information and the pharmaceutical compendia, for an indication of anal fissure, the maximum daily dosage of injection, onabotulinumtoxinA, 1 unit, is 38 units.






What is changing? Injection, onabotulinumtoxinA, 1 unit, will be limited to 120 units per date of service by any health care provider when the diagnosis is Gilles de la Tourette's syndrome. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information and the pharmaceutical compendia, for an indication of Gilles de la Tourette's syndrome, the maximum daily dosage of injection, onabotulinumtoxinA, 1 unit, is 120 units.





Carfilzomib What is changing? Injection, carfilzomib 1 mg, will be limited to 59 units when billed with modifier JW (drug amount discarded/not administered to any patient). Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information,







carfilzomib is supplied in a 60 mg single-use vial. It is inappropriate for a health care provider to bill drug wastage that equals or exceeds the size of the vial.


Darbepoetin alfa What is changing? When injection, darbepoetin alfa, 1 mcg (non-ESRD use), is billed with a diagnosis of peri-surgical adjuvant therapy, then a diagnosis of anemia must also be present. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, injection, darbepoetin alfa, 1 mcg (non-ESRD use), is used for an indication of perisurgical adjuvant therapy in conjunction with anemia.





Denosumab What is changing? Injection, denosumab, 1 mg, will not be eligible for reimbursement when billed by any health care provider more than two times every 48 weeks and the diagnosis is any of the following: • Prophylaxis of postmenopausal osteoporosis • Treatment of postmenopausal women with osteoporosis at high risk for fracture • Treatment to increase bone mass in men at high risk for fracture receiving

androgen deprivation therapy for nonmetastatic prostate cancer • Treatment to increase bone mass in men with osteoporosis at high risk for

fracture • Treatment to increase bone mass in women at high risk for fracture receiving

adjuvant aromatase inhibitor therapy for breast cancer. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information,







injection, denosumab, 1 mg, should not be administered more frequently than twice every 48-week period for an indication of prophylaxis of postmenopausal osteoporosis, treatment of postmenopausal women with osteoporosis at high risk for fracture, treatment to increase bone mass in men at high risk for fracture receiving androgen deprivation therapy for nonmetastatic prostate cancer, treatment to increase bone mass in men with osteoporosis at high risk for fracture or treatment to increase bone mass in women at high risk for fracture receiving adjuvant aromatase inhibitor therapy for breast cancer.


Docetaxel What is changing? Injection, docetaxel, 1 mg, will be limited to 19 units when billed with modifier JW (drug amount discarded/not administered to any patient). Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, docetaxel is supplied in both an 80 mg single-use vial and a 20 mg single-use vial. It is inappropriate for a health care provider to bill drug wastage based upon the 80 mg single-use vial when one or more of the 20 mg single-use vials could have been used to eliminate or minimize drug wastage.





Doxorubicin HCL liposome

What is changing? Injection, doxorubicin hydrocholoride, liposomal, imported Lipodox, 10 mg, and not otherwise specified, 10 mg, is reimbursable only once every four weeks when billed with a diagnosis of bladder cancer, endometrial carcinoma, uterine sarcoma, ovarian cancer/primary peritoneal cancer, Sezary's disease or soft tissue sarcoma of the extremities, trunk, retroperitoneum or abdomen. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information,







injection, doxorubicin hydrocholoride, liposomal, imported Lipodox, 10 mg, and not otherwise specified, 10 mg, should not be administered more frequently than once every four weeks for these indications.


Filgrastim What is changing? Injection, filgrastim (G-CSF), 1 mcg, will be limited to 1,250 combined units per date of service by any health care provider when the diagnosis is any of the following: • Aplastic anemia • Cancer patient receiving a bone marrow transplant • Chemotherapy-induced neutropenia • Infectious disease prophylaxis in a patient with esophageal cancer • Decreasing the period of neutropenia following reinfusion of peripheral blood stem cells • Febrile neutropenia, ganciclovir-induced neutropenia • HIV-induced neutropenia • Prophylaxis for a patient with acute lymphoid leukemia receiving induction or

consolidation chemotherapy • Prophylaxis for a patient with acute myeloid leukemia receiving induction or

consolidation chemotherapy • Pre-eclampsia-associated neutropenia • Zidovudine-induced neutropenia Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information and the pharmaceutical compendia, the daily maximum dosage of injection, filgrastim (G-CSF), 1 mcg, for any indication, should not exceed 1,250 units.








Filgrastim What is changing? Injection, filgrastim (G-CSF), 1 mcg, will not be reimbursed when billed on the same day as, or within two weeks of, an injection of pegfilgrastim, 6 mg. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, injection, filgrastim (G-CSF), 1 mcg, should not be administered in conjunction with, or within two weeks of an injection of pegfilgrastim, 6 mg.





Golimumab What is changing? Injection, golimumab 1 mg, will be limited to 49 units when billed with modifier JW (drug amount discarded/not administered to any patient). Why is Humana implementing this change? According to Humana policy, which is based on the FDA-approved package insert/prescribing information, golimumab for intravenous use is supplied in a 50 mg single-use vial. It is inappropriate for a health care provider to bill drug wastage that equals or exceeds the size of the vial.





Goserelin acetate implant

What is changing? Goserelin acetate implant, per 3.6 mg, will not be eligible for reimbursement when billed more than once per month by any health care provider. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information and the pharmaceutical compendia, goserelin acetate implant, per 3.6 mg, should not be administered more frequently than once every four weeks.








Idursulfase What is changing? Injection, idursulfase, 1 mg, is not reimbursable for patients under the age of 5. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, injection, idursulfase, 1 mg, is appropriate for patients 5 years of age and older only.





Ipilimumab What is changing? Injection, ipilimumab, 1 mg, is eligible for reimbursement only when billed with a diagnosis of malignant melanoma. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, injection, ipilimumab, 1 mg, is used to treat an indication of malignant melanoma.





Ipilimumab What is changing? Injection, ipilimumab 1 mg, will be limited to 49 units when billed with modifier JW (drug amount discarded/not administered to any patient). Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, ipilimumab is supplied in 50 mg and 200 mg single-use vials. It is inappropriate for a health care provider to bill drug wastage based upon the 200 mg single-use vial when a 50 mg single-use vial could have been used to eliminate or minimize drug wastage.








Iron dextran What is changing? When injection, iron dextran, 50 mg, is billed with an encounter for antineoplastic chemotherapy and immunotherapy or convalescence and palliative care following chemotherapy, one of the following diagnoses must also be present:

Diagnosis of anemia in neoplastic disease

Antineoplastic chemotherapy-induced anemia Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, injection, iron dextran, 50 mg, is used for an encounter for antineoplastic chemotherapy and immunotherapy or convalescence and palliative care following chemotherapy in conjunction with a diagnosis of anemia in neoplastic disease or antineoplastic chemotherapy-induced anemia.





Iron dextran What is changing? Injection, iron dextran, 50 mg, is limited to five units per date of service when billed with a diagnosis of iron deficiency anemia of pregnancy. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, the maximum daily dosage of injection, iron dextran, 50 mg, for an indication of iron deficiency anemia of pregnancy is five units.





Iron sucrose What is changing? Injection, iron sucrose 1 mg, will be limited to 49 units when billed with modifier JW (drug amount discarded/not administered to any patient). Why is Humana implementing this change?



All Medicare




According to the FDA-approved package insert/prescribing information, iron sucrose is supplied in 50 mg, 100 mg and 200 mg single-use vials. It is inappropriate for a health care provider to bill drug wastage based upon the 200 mg or 100 mg single-use vial when one or more of the 50 mg or 100 mg single-use vials could have been used to eliminate or minimize drug wastage.

Advantage products


Multiuse vials What is changing? When a drug code packaged for multiple doses is billed with modifier JW (drug amount discarded/not administered to any patient), it will not be eligible for reimbursement. Why is Humana implementing this change? According to the FDA and the pharmaceutical compendia, only drugs that are supplied as single-dose vials are eligible for reimbursement for drug wastage. Drugs that are dispensed only as vials that are intended for multiple doses are not eligible for wastage reimbursement.





Omalizumab What is changing? Injection, omalizumab, 5 mg, will be limited to 60 units every three weeks when billed by any health care provider and the diagnosis is seasonal allergic rhinitis or adjunct to subcutaneous immunotherapy, along with a diagnosis of moderate to severe persistent asthma. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information and the pharmaceutical compendia, injection, omalizumab, 5 mg, should not be administered more frequently than 60 units every three weeks for an indication of seasonal allergic rhinitis or adjunct to subcutaneous immunotherapy.








Paclitaxel What is changing? Injection, paclitaxel, 1 mg, is limited to 162 units when billed on the same date of service as chemotherapy administration into the peritoneal cavity, and the diagnosis is ovarian and peritoneal cancer. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, the maximum dosage of injection, paclitaxel, 1 mg, is 162 units when the indication is ovarian and peritoneal cancer, and chemotherapy administration to the peritoneal cavity has also been billed.





Panitumumab What is changing? Injection, panitumumab, 10 mg, will be eligible for reimbursement only when billed with a diagnosis of colorectal cancer. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, injection, panitumumab, 10 mg, is used to treat an indication of colorectal cancer.





Panitumumab What is changing? Injection, panitumumab 10 mg, will be limited to 9 units when billed with modifier JW (drug amount discarded/not administered to any patient). Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, panitumumab is supplied in 100 mg, 200 mg and 400 mg single-use vials. It is inappropriate for a health care provider to bill drug wastage based upon the 400 mg or 200 mg single-use vial when one or more of the 200 mg or 100 mg







single-use vials could have been used to eliminate or minimize drug wastage.


Pemetrexed What is changing? Injection, pemetrexed, 10 mg, is limited to 162 units when billed for a diagnosis of bladder cancer, breast cancer, cervical cancer, colorectal cancer, non-small cell lung cancer, pancreatic cancer or renal cell cancer. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, the maximum dosage of injection, pemetrexed, 10 mg, for an indication of bladder cancer, breast cancer, cervical cancer, colorectal cancer, non-small cell lung cancer, pancreatic cancer or renal cell cancer is 162 units.





Pertuzumab What is changing? The following chemotherapy administration procedures are not eligible for reimbursement when billed with injection, pertuzumab, 1 mg, unless another drug administered by IV push chemotherapy administration has been billed for the same date of service:

Chemotherapy administration, intravenous, push technique, single or initial substance/drug

Chemotherapy administration, intravenous, push technique, each additional substance/drug

Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, pertuzumab should not be administered as an IV push or bolus injection.








Pertuzumab What is changing? Injection, pertuzumab, 1 mg, is reimbursed only when billed on the same day as injection, docetaxel, 1 mg, and injection, trastuzumab, 10 mg. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, injection, pertuzumab, 1 mg, should be administered in conjunction with injection, docetaxel, 1 mg, and injection, trastuzumab, 10 mg.





Ranibizumab What is changing? Injection, ranibizumab, 0.1 mg, when billed with a diagnosis of central retinal vein occlusion or branch retinal vein occlusion, will be eligible for reimbursement only when a diagnosis of retinal edema is also present. Why is Humana implementing this change? Based on Humana’s internal review and supported by CMS LCDs, when injection, ranibizumab, 0.1 mg, is billed for an indication of central retinal vein occlusion, a diagnosis of retinal edema must also be present.




Ranibizumab What is changing? Injection, ranibizumab, 0.1 mg, when billed with a diagnosis of diabetic macular edema, will be eligible for reimbursement only when a diagnosis of diabetes mellitus with ophthalmic manifestations is present also. Why is Humana implementing this change? According to the current ICD diagnosis codes manual, when injection, ranibizumab, 0.1 mg, is billed for an indication of diabetic macular edema, a diagnosis of diabetes mellitus with ophthalmic manifestations also must be present.







Ranibizumab What is changing? Injection, ranibizumab, 0.1 mg, will be eligible for reimbursement only when billed with intravitreal injection of a pharmacologic agent. Why is Humana implementing this change? Based on Humana’s internal review and supported by CMS LCDs, the code for ranibizumab and the appropriate administration code must be billed on the same claim.





Ranibizumab What is changing? When billed with injection, ranibizumab, 0.1 mg, intravitreal injection of a pharmacologic agent must be billed with modifier LT (left side), RT (right side) or 50 (bilateral procedure) to be eligible for reimbursement. Why is Humana implementing this change? Based on Humana’s internal review and supported by CMS LCDs, the appropriate modifier must be appended to the administration procedure for ranibizumab to indicate into which eye the injection was given.





Rituximab What is changing? Injection, rituximab, 100 mg, is reimbursable only once every four days when billed with a diagnosis of Evans syndrome or Waldenstrom macroglobulinemia. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, injection, rituximab, 100 mg, should not be administered more frequently than







once every four weeks for these indications.


Rituximab What is changing? Injection, rituximab, 100 mg, is eligible for reimbursement only when billed with an FDA-approved indication or an approved off-label indication. Why is Humana implementing this change? According the FDA-approved package insert/prescribing information and the pharmaceutical compendia, injection, rituximab, 100 mg, is used to treat certain indications.




TBO-filgrastim What is changing? Injection, TBO-filgrastim, 5 mcg, will not be reimbursed when billed on the same day as, or within two weeks of, an injection of pegfilgrastim, 6 mg. Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, injection, TBO-filgrastim, 5 mcg, should not be administered in conjunction with, or within two weeks of, injection, pegfilgrastim, 6 mg.





Ustekinumab What is changing? Injection, ustekinumab, 1 mg, is limited to three times in a five-year period when billed with a diagnosis of regional enteritis (Crohn’s disease). Why is Humana implementing this change? According to the FDA-approved package insert/prescribing information, injection, ustekinumab, 1 mg, should not be administered more frequently than three times per five years for an indication of regional enteritis (Crohn's







disease).

HCPCS – Durable Medical Equipment (DME)

Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) bundled to the inpatient admission

What is changing? Any code reported by a DME provider will not be eligible for reimbursement when the date of service falls after the admission date and prior to the discharge date for any inpatient admission. Why is Humana implementing this change? According to the CMS Medicare Claims Processing Manual, Chapter 20, DMEPOS items are for use by a patient in his or her home. The institution is expected to provide all medically necessary DMEPOS items during a patient’s inpatient stay.




Laboratory/ Pathology

Alpha-fetoprotein

What is changing? Alpha-fetoprotein serum will be eligible for reimbursement only when billed with a covered diagnosis as indicated in the Medicare NCD Manual, Chapter 1. Why is Humana implementing this change? According to Chapter 1 of the Medicare NCD Manual, alpha-fetoprotein is eligible for reimbursement only when billed with specific diagnoses



Bacterial urine culture

What is changing? Bacterial urine cultures will be eligible for reimbursement only when billed with a covered diagnosis as indicated in Chapter 1 of the Medicare NCD Manual. Why is Humana implementing this change? According to Chapter 1 of the Medicare NCD Manual, bacterial urine cultures are eligible for reimbursement when billed with specific diagnoses.








Blood counts What is changing? Blood counts will not be eligible for reimbursement when billed with a noncovered diagnosis, as indicated in Chapter 1 of the Medicare NCD Manual, if the noncovered diagnosis is the only diagnosis on the claim. Why is Humana implementing this change? According to Chapter 1 of the Medicare NCD Manual, blood counts are not eligible for reimbursement when billed with specific diagnoses.





Carcino- embryonic antigen

What is changing? Carcinoembryonic antigen will be eligible for reimbursement only when billed with a covered diagnosis as indicated in Chapter 1 of the Medicare NCD Manual. Why is Humana implementing this change? According to Chapter 1 of the Medicare NCD Manual, carcinoembryonic antigen is eligible for reimbursement only when billed with specific diagnoses.



Collagen crosslinks

What is changing? Collagen crosslinks, any method will be eligible for reimbursement only when billed with a covered diagnosis as indicated in Chapter 1 of the Medicare National Coverage Determinations (NCD) Manual. Why is Humana implementing this change? According to Chapter 1 of the Medicare NCD Manual, collagen crosslinks are eligible for reimbursement only when billed with specific diagnoses.






Gamma glutamyl-transferase

What is changing? Glutamyltransferase, gamma, is eligible for reimbursement only when billed with a covered diagnosis as indicated in Chapter 1 of the Medicare NCD Manual. Why is Humana implementing this change? According to Chapter 1 of the Medicare NCD Manual, gamma glutamyltransferase is eligible for reimbursement only when billed with specific diagnoses.



Hepatitis panel/acute hepatitis panel

What is changing? Acute hepatitis panel is eligible for reimbursement only when billed with a covered diagnosis as indicated in Chapter 1 of the Medicare NCD Manual. Why is Humana implementing this change? According to Chapter 1 of the Medicare NCD Manual, acute hepatitis panel is eligible for reimbursement only when billed with specific diagnoses.





Human chorionic gonadotropin

What is changing? Gonadotropin, chorionic, quantitative, will be eligible for reimbursement only when billed with a covered diagnosis as indicated in Chapter 1 of the Medicare NCD Manual. Why is Humana implementing this change? According to Chapter 1 of the Medicare NCD Manual, human chorionic gonadotropin is eligible for reimbursement only when billed with specific diagnoses.






Pathology – technical component

What is changing? Humana will no longer allow pathology technical component (TC) reimbursement for services provided to a member registered as a hospital patient because only the hospital where the patient is registered may bill for those charges.

Why is Humana implementing this change? Chapter 16 of the Medicare Claims Processing Manual states that, "Effective on or after July 1, 2012, only the hospital may bill for the TC of a physician pathology service provided to an inpatient or outpatient." (After further review, this edit will not implemented at this time.)





Serum iron studies

What is changing? Ferritin, iron, iron-binding capacity or transferrin, will be eligible for reimbursement only when billed with a covered diagnosis as indicated in Chapter 1 of the Medicare NCD Manual. Why is Humana implementing this change? According to Chapter 1 of the Medicare NCD Manual, serum iron studies are eligible for reimbursement only when billed with specific diagnoses.



Thyroid testing What is changing? The following will be eligible for reimbursement only when billed with a covered diagnosis as indicated in Chapter 1 of the Medicare NCD manual: • Thyroxine • Total, thyroxine • Free, thyroid-stimulating hormone • Thyroid hormone uptake





• Thyroid hormone binding ratio Why is Humana implementing this change? According to Chapter 1 of the Medicare NCD Manual, thyroid testing is eligible for reimbursement only when billed with specific diagnoses.


Tumor antigen by immunoassay CA 125

What is changing? Immunoassay for tumor antigen, quantitative, CA 125, will be eligible for reimbursement only when billed with a covered diagnosis as indicated in Chapter 1 of the Medicare NCD Manual. Why is Humana implementing this change? According to Chapter 1 of the Medicare NCD Manual, tumor antigen by immunoassay CA 125 (86304) is payable only when billed with specific diagnoses.



Tumor antigen by immunoassay CA 15-3/CA 27.29

What is changing? Immunoassay for tumor antigen, quantitative, CA 15-3 [27.29], will be eligible for reimbursement only when billed with a covered diagnosis as indicated in Chapter 1 of the Medicare NCD Manual. Why is Humana implementing this change? According to Chapter 1 of the Medicare NCD Manual, tumor antigen by immunoassay CA 15-3/CA 27.29 is eligible for reimbursement only when billed with specific diagnoses.



Tumor Antigen by Immunoassay CA 19-9

What is changing? Immunoassay for tumor antigen, quantitative, CA 19-9, will be eligible for reimbursement only when billed with a covered diagnosis as indicated in





Chapter 1 of the Medicare NCD Manual. Why is Humana implementing this change? According to Chapter 1 of the Medicare NCD Manual, tumor antigen by immunoassay CA 19-9 is eligible for reimbursement only when billed with specific diagnoses.

Modifiers Modifiers 50, RT and LT for bilateral services

What is changing? When modifiers LT (left) and RT (right) are appended to a bilateral service, they will be replaced with modifier 50 (bilateral procedure). Why is Humana implementing this change? Bilateral services billed with modifiers RT and LT are subject to the same bilateral allowable (150 percent) as bilateral services billed with modifier 50. Changing the modifier to 50 will allow Humana to apply the appropriate bilateral allowable.




Surgery Multiple procedure payment reduction (MPPR)

What is changing? The following CPT codes are subject to the multiple procedure payment reduction (MPPR) commonly known as “multiple surgery” reduction: 20902, 51725, 51726, 51727, 51728, 51729, 51736, 51785, 51792, 51741, 51784, 64644, 93455, 93530, 93531, 93532 and 0308T. Why is Humana implementing this change? Humana is updating its processes to ensure that multiple surgery calculations are applied to all services subject to those calculations. A multiple surgery reduction has been applicable to these services for some time. A reduction is already being applied in many instances, and Humana is not changing those payment processes. This change will begin to apply a multiple surgery reduction to those services in instances when it is not already applied.







Units Pulmonary rehabilitation

What is changing? Pulmonary rehabilitation will be limited to two units per date of service. Why is Humana implementing this change? According to Chapter 32 of the Medicare Claims Processing Manual, pulmonary rehabilitation program sessions are limited to a maximum of two, one-hour sessions per day.




Units Pulmonary rehabilitation

What is changing? Pulmonary rehabilitation will be limited to 36 units in a patient's lifetime when billed by any health care provider. Why is Humana implementing this change? According to Chapter 32 of the Medicare Claims Processing Manual, pulmonary rehabilitation program sessions are limited to 36 units in a patient's lifetime.




cms requires the kx modifier to signify requirements

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