procedure and place of service – oxford reimbursement policy · 2020-07-15 · procedure and...

Procedure and Place of Service Policy of 12 UnitedHealthcare Oxford Reimbursement Policy Effective 07/01/2020

©1996-2020, Oxford Health Plans, LLC

PROCEDURE AND PLACE OF SERVICE POLICY Policy Number: ADMINISTRATIVE 253.20 T0 Effective Date: July 1, 2020 Table of Contents Page INSTRUCTIONS FOR USE .......................................... 1 APPLICABLE LINES OF BUSINESS/PRODUCTS .............. 1 APPLICATION .......................................................... 1 OVERVIEW .............................................................. 1 REIMBURSEMENT GUIDELINES .................................. 2 DEFINITIONS .......................................................... 2 QUESTIONS AND ANSWERS ...................................... 2 APPLICABLE CODES ................................................. 2 REFERENCES .......................................................... 11 POLICY HISTORY/REVISION INFORMATION ................ 11 INSTRUCTIONS FOR USE The services described in Oxford policies are subject to the terms, conditions and limitations of the member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required

by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded members and certain insured products. Refer to the member specific benefit plan document or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the member specific benefit plan document or Certificate of Coverage, the member specific benefit plan document or

Certificate of Coverage will govern. UnitedHealthcare may also use tools developed by third parties, such as the MCG™ Care Guidelines, to assist us in administering health benefits. The MCG™ Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.

APPLICABLE LINES OF BUSINESS/PRODUCTS This policy applies to Oxford Commercial plan membership. APPLICATION

This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network

physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. OVERVIEW

The Procedure and Place of Service policy addresses the reimbursement of Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes that are reported in a Place of Service (POS) considered inappropriate based on the code’s description or available coding guidelines when reported by a physician or other health care professional.

Related Policies

None

UnitedHealthcare® Oxford

Reimbursement Policy



REIMBURSEMENT GUIDELINES Oxford will reimburse CPT and HCPCS codes when reported with an appropriate Place of Service (POS).

Oxford aligns with The Centers for Medicare & Medicaid Services (CMS) POS Code set, which are two-digit codes submitted on the CMS 1500 Health Insurance Claim Form or its electronic equivalent to indicate the setting in which a service was provided. The website containing the POS Code set can be accessed via this link: CMS Place of Service Code Set. Many CPT and HCPCS codes include a Place of Service in their description or coding guidelines include the place(s) of service where the code may be performed. For example, CPT code 94002 (Ventilation assist and management,

initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day) would not be appropriate for reporting in an office or home POS because its code description identifies hospital inpatient or observation. Oxford has established a list of CPT and HCPCS codes along with their appropriate places of service. Refer to the list located in the Applicable Codes section.

Oxford will not reimburse CPT and HCPCS codes assigned the Non-Facility Indicator “NA” when reported without an

appropriate POS. According to the CMS National Physician Fee Schedule Relative Value File, the Non-Facility Indicator identified as “NA” indicates that “this procedure is rarely or never performed in the non-facility setting.” The website containing the National Physician Fee Schedule Relative Value File can be accessed via this link: CMS National Physician Fee Schedule.

Relative Value File. DEFINITIONS Place of Service: A two-digit code used on health care professional claims to indicate the setting in which a service was provided.

QUESTIONS AND ANSWERS

1

Q: Why aren’t all CPT and HCPCS codes addressed in this policy?

A:

This policy addresses CPT and HCPCS codes that include POS in their description or where coding guidelines are provided relative to POS. Codes that do not fit this criteria, as well as mental health/substance abuse codes and codes addressed in other reimbursement policies, are out of scope for this reimbursement policy.

2

Q: Where do the Place of Service codes come from?

A: The Place of Service codes can be found on the CMS website and contains two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. The Centers for Medicare & Medicaid Services (CMS) maintains POS codes used throughout the health care industry.

APPLICABLE CODES

CPT Code Allowed Place of Service (POS)

94002 6 8 19 21 22 23 24 25

26 51 53 56 61

94003 6 8 19 21 22 23 24 25

26 51 53 56 61

94004 31 32 34

99155 19 21 22 23 24 26 31 34

41 42 51 52 53 56 61

99156 19 21 22 23 24 26 31 34

41 42 51 52 53 56 61

99157 19 21 22 23 24 26 31 34

41 42 51 52 53 56 61

http://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html

http://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html




99201

2 3 5 6 7 8 11 15

16 17 19 20 22 24 25 26

49 50 53 57 62 65 71 72

99202

2 3 5 6 7 8 11 15

16 17 19 20 22 24 25 26

49 50 53 57 62 65 71 72

99203

2 3 5 6 7 8 11 15

16 17 19 20 22 24 25 26

49 50 53 57 62 65 71 72

99204

2 3 5 6 7 8 11 15

16 17 19 20 22 24 25 26

49 50 53 57 62 65 71 72

99205

2 3 5 6 7 8 11 15

16 17 19 20 22 24 25 26

49 50 53 57 62 65 71 72

99211

2 3 5 6 7 8 11 15

16 17 19 20 22 24 25 26

49 50 53 55 62 65 71 72

99212

2 3 5 6 7 8 11 15

16 17 19 20 22 24 25 26

49 50 53 57 62 65 71 72

99213

2 3 5 6 7 8 11 15

16 17 19 20 22 24 25 26

49 50 53 57 62 65 71 72

99214

2 3 5 6 7 8 11 15

16 17 19 20 22 24 25 26

49 50 53 57 62 65 71 72

99215

2 3 5 6 7 8 11 15

16 17 19 20 22 24 25 26

49 50 53 57 62 65 71 72

99217 6 8 19 21 22 23 24 25

26 51 52 53 56 61

99218 6 8 19 21 22 23 24 25

26 51 52 53 56 61

99219 6 8 19 21 22 23 24 25

26 51 52 53 56 61

99220 6 8 19 21 22 23 24 25

26 51 52 53 56 61

99221 6 8 21 25 26 34 51 52

56 61

99222 6 8 21 25 26 34 51 52

56 61

99223 6 8 21 25 26 34 51 52

56 61

99224 6 8 19 21 22 23 24 25

26 51 52 53 56 61




99225 6 8 19 21 22 23 24 25

26 51 52 53 56 61

99226 6 8 19 22 23 24 25 26

51 52 53 56 61

99231 2 6 8 21 25 26 34 51

52 56 61

99232 2 6 8 21 25 26 34 51

52 56 61

99233 2 6 8 21 25 26 34 51

52 56 61

99234 6 8 19 21 22 23 24 25

26 34 51 52 53 56 61

99235 6 8 19 21 22 23 24 25

26 34 51 52 53 56 61

99236 6 8 19 21 22 23 24 25

26 34 51 52 53 56 61

99238 6 8 21 25 26 34 51 52

56 61

99239 6 8 21 25 26 34 51 52

56 61

99241

2 5 6 7 8 11 15 17

19 20 22 23 24 25 26 33

49 50 53 57 60 62 65 71

72

99242

2 5 6 7 8 11 15 17

19 20 22 23 24 25 26 33

49 50 53 57 60 62 65 71

72

99243

2 5 6 7 8 11 15 17

19 20 22 23 24 25 26 33

49 50 53 57 60 62 65 71

72

99244

2 5 6 7 8 11 15 17

19 20 22 23 24 25 26 33

49 50 53 57 60 62 65 71

72

99245

2 5 6 7 8 11 15 17

19 20 22 23 24 25 26 33

49 50 53 57 60 62 65 71

72

99251 2 6 8 21 25 26 31 32

34 51 52 54 56 61

99252 2 6 8 21 25 26 31 32

34 51 52 54 56 61

99253 2 6 8 21 25 26 31 32

34 51 52 54 56 61




99254 2 6 8 21 25 26 31 32

34 51 52 54 56 61

99255 2 6 8 21 25 26 31 32

34 51 52 54 56 61

99281 23

99282 23

99283 23

99284 23

99285 23

99304 8 31 32 33 34 51 56

99305 8 31 32 33 34 51 56

99306 8 31 32 33 34 51 56

99307 2 8 21 31 32 34 51 56

99308 2 8 21 31 32 34 51 56

99309 2 8 21 31 32 34 51 56

99310 2 8 21 31 32 34 51 56

99315 8 31 32 34 51 56

99316 8 31 32 34 51 56

99318 8 31 32 34 51 56

99324 4 13 14 54 55

99325 4 13 14 54 55

99326 4 13 14 54 55

99327 4 13 14 54 55

99328 4 13 14 54 55

99334 4 13 14 54 55

99335 4 13 14 54 55

99336 4 13 14 54 55

99337 4 13 14 54 55

99341 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99342 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99343 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99344 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99345 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99347 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99348 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99349 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99350 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99460 6 8 21 25 26




99461

4 5 7 9 11 12 13 14

16 17 20 26 31 32 33 49

54 55 56 61 65 71 72

99462 6 8 21 25 26

99463 6 8 21 25 26

99465 6 8 21 25 26

99466 41 42

99468 6 8 21 26

99469 6 8 21 26

99471 6 8 21 26

99472 6 8 21 26

99475 6 8 21 26

99476 6 8 21 26

99477 6 8 21 26

99478 6 8 21 26

99479 6 8 21 26

99480 6 8 21 26

99483

2 3 4 5 6 7 8 9

31 32 54 55 56 61 11 12

13 14 15 16 17 19 20 22

23 24 25 26 33 34 49 50

53 57 62 65 71 72

99500 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99501 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99502 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99503 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99504 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99505 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99506 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99507 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99509 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99510 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99511 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99512 4 9 12 13 14 16 31 32

33 54 55 56 61 65




99600 4 9 12 13 14 16 31 32

33 54 55 56 61 65

99601 4 9 12 13 14 16 26 31

32 33 49 54 55 56 61 65

99602 4 9 12 13 14 16 31 32

33 54 55 56 61 65

CPT® is a registered trademark of the American Medical Association

HCPCS Code Allowed Place of Service (POS)

G0076 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0077 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0078 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0079 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0080 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0081 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0082 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0083 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0084 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0085 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0128 62

G0151 4 9 12 13 14 16 31 32

33 34 54 55 56 61 65

G0152 4 9 12 13 14 16 31 32

33 34 54 55 56 61 65

G0153 4 9 12 13 14 16 31 32

33 34 54 55 56 61 65

G0155 4 9 12 13 14 16 31 32

33 34 54 55 56 61 65

G0156 4 9 12 13 14 16 31 32

33 34 54 55 56 61 65

G0157 4 9 12 13 14 16 31 32

33 34 54 55 56 61 65

G0158 4 9 12 13 14 16 31 32

33 34 54 55 56 61 65

G0159 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0160 4 9 12 13 14 16 31 32

33 54 55 56 61 65




G0161 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0162 4 9 12 13 14 16 31 32

33 34 54 55 56 61 65

G0257 6 8 19 22 23 26

G0299 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0300 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0398 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0399 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0400 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0490 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G0493 4 9 12 13 14 16 31 32

33 34 54 55 56 61 65

G0494 4 9 12 13 14 16 31 32

33 34 54 55 56 61 65

G0495 4 9 12 13 14 16 31 32

33 34 54 55 56 61 65

G0496 4 9 12 13 14 16 31 32

33 34 54 55 56 61 65

G0511 50 72

G0512 50 72

G2001 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G2002 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G2003 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G2004 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G2005 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G2006 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G2007 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G2008 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G2009 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G2013 4 9 12 13 14 16 31 32

33 54 55 56 61 65




G2067 58

G2068 58

G2069 58

G2070 58

G2071 58

G2072 58

G2073 58

G2074 58

G2075 58

G2076 58

G2077 58

G2078 58

G2079 58

G2080 58

G2082

5 6 7 8 11 15 17 19

20 22 23 26 49 50 51 52

53 56 57 71 72

G2083

5 6 7 8 11 15 17 19

20 22 23 26 49 50 51 52

53 56 57 71 72

G2168 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G2169 4 9 12 13 14 16 31 32

33 54 55 56 61 65

G9147 6 8 11 13 17 19 22 24

26 49 50 71 72

G9490 2 4 9 12 13 14 16 31

32 33 54 55 56 61 65

G9685 8 31 32 33 34 51 56

Q5001 4 9 12 13 14 16 31 32

33 54 55 56 61 65

Q5002 13

Q5003 32 34

Q5004 31 32

Q5005 6 8 21 26 51 61

Q5006 6 8 21 26 34 51

Q5007 31 32 34

Q5010 34

S0260

5 6 7 8 11 17 19 20

22 24 25 26 49 50 53 57

65 71 72

S0273 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S0274 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S5108 4 9 12 13 14 16 31 32

33 54 55 56 61 65




S5109 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S5110 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S5111 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S5115 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S5116 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S5180 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9097 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9098 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9122 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9123 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9124 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9125 9 12 13 14 16 31 32 33

54 55 56 61 65

S9126 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9127 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9128 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9129 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9131 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9208 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9209 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9211 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9212 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9213 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9214 4 9 12 13 14 16 31 32

33 54 55 56 61 65




S9335 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9339 4 9 12 13 14 16 31 32

33 54 55 56 61 65

S9590 4 9 12 13 14 16 31 32

33 54 55 56 61 65

T1015 5 6 7 8 11 17 19 22

26 49 50 53 60 65 71 72

T1021 4 9 12 13 14 16 31 32

33 54 55 56 61 65

T1022 4 9 12 13 14 16 31 32

33 54 55 56 61 65

T1025 5 6 7 8 11 17 19 22

26 49 50 53 71 72

T1026 5 6 7 8 11 17 19 22

26 49 50 53 71 72

T1028 4 9 12 13 14 16 31 32

33 54 55 56 61 65

T1030 4 9 12 13 14 16 31 32

33 54 55 56 61 65

T1031 4 9 12 13 14 16 31 32

33 54 55 56 61 65

T2042 4 9 12 13 14 16 31 32

33 54 55 56 61 65

T2043 4 9 12 13 14 16 33 34

54 55 56 61 65

T2044 6 8 21 26 51 61

T2045 6 8 21 26 51 61

T2046 31 32 34

REFERENCES The foregoing Oxford policy has been adapted from an existing UnitedHealthcare national policy that was researched, developed and approved by UnitedHealthcare Payment Policy Oversight Committee. [2020R0127C]

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services.

Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System Release and Code Sets.

Centers for Medicare and Medicaid Services, National Physician Fee Schedule (NPFS).

Centers for Medicare and Medicaid Services, Place of Service Code Set.

POLICY HISTORY/REVISION INFORMATION

Date Action/Description

07/01/2020

Applicable Codes • Removed CPT codes 90846, 90847, 90849, and 90853 • Revised list of allowed place of service (POS) codes for CPT/HCPCS code:

o 99466:

▪ Added POS 42 ▪ Removed duplicate listing for POS 41

o 99601: Added POS 49 o T2042: Removed duplicate listing for POS 9 o 99211: Replaced “57” with “55”



Date Action/Description

Supporting Information

• Archived previous policy version ADMINISTRATIVE 253.19 T0

procedure and place of service – oxford reimbursement policy · 2020-07-15 · procedure and...

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