Medicare Advantage

Medical Policy

Notification

Always Bundled Procedure Codes

Notification Issued Date:

This AmeriHealth New Jersey Medicare Advantage policy will become effective 01/01/2024.

Title:

Always Bundled Procedure Codes

Policy #:

MA00.026w

Policy

This policy applies to professional and outpatient facility claims.

The procedure codes listed in Attachment A are considered "always bundled", based on the Medicare Physician Fee Schedule database (MPFSD) Status B Indicator. These procedure codes are considered bundled into the reimbursement for other services and, therefore, are not eligible for separate reimbursement, whether billed alone or in conjunction with other services. Participating providers may not bill members for these services.

The procedure codes listed in Attachment B may be covered by the Company; however, are not eligible for separate reimbursement consideration whether billed alone or in conjunction with other services. Participating providers may not bill members for these services.

The procedure codes listed in Attachment C may be covered by the Company; however, they are not eligible for reimbursement consideration. Participating providers may not bill members for these services.

Guidelines

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Description

The intent of this policy is to communicate services that are not eligible for reimbursement or not eligible for separate reimbursement consideration by the Company.

The Company takes into consideration the Medicare Physician Fee Schedule Database (MPFSD), the American Medical Association Current Procedure Technology (CPT) Manual, Centers for Medicare and Medicaid Services (CMS) guidelines, Company policies, and other appropriate sources, when determining services listed in this policy.

The MPFSD identifies procedure codes with the status B indicator. The status B indicator is used when the reimbursement for certain procedure codes is always considered bundled into the reimbursement for other services.

References

Centers for Medicare & Medicaid Services (CMS). National Physician Fee Schedule Relative Value File. [CMS Web site]. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html. Accessed December 04, 2020.

Centers for Medicare & Medicaid Services Medicare Claims Processing Manual. Chapter 23 - Fee Schedule Administration and Coding. Requirements. Table of Contents. (Rev. 4188, 12-28-18). Available at:http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf. Accessed December 04, 2020.

Company Benefit Contracts.

Coding

CPT Procedure Code Number(s)

Attachment A: Always Bundled Procedures/Services (MPFSD) Status B Indicator

Attachment B: Procedures/Services Not Eligible for Separate Reimbursement

Attachment C: Procedures/Services Not Eligible for Reimbursement

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

Attachment A: Always Bundled Procedures/Services (MPFSD) Status B Indicator

Attachment B: Procedures/Services Not Eligible for Separate Reimbursement

Attachment C: Procedures/Services Not Eligible for Reimbursement

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA00.026v:

1/01/2025

This policy has been identified and updated for the CPT/HCPCS code update effective 1/01/2025.

The following CPT codes have been added to Attachment A of this policy:

38225, 38226, 38227

The following CPT codes have undergone narrative revisions in Attachment A of this policy:

98960, 98961, and 98962

The following CPT codes have been removed from Attachment A of this policy:

0537T, 0538T and 0539T

The following HCPCS code have been added to Attachment B of this policy:

G0537, G0538, G0539, G0540, G0541, G0542, G0543, G0544, G0545, G0556, G0557, G0558, and G0559

The following CPT/HCPCS codes have been added to Attachment C of this policy:

98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, G0532, G0533, G0534, G0535, G0536, G0546, G0547, G0548, G0549, G0550, G0551, and Q0521

The following HCPCS codes have been removed from Attachment C of this policy:

G1012, G1013, G1014, G1015, G1016, G1017, G1018, G1019, G2071, G2072, Q0516, Q0517, Q0518, Q0519, and Q0520

Revisions From MA00.026v:

10/01/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2024.

HCPCS codes 96202 and 96203 have moved from attachment A to attachment B of this policy:

The following HCPCS codes have been added to Attachment C of this policy:

Q0516, Q0517, Q0518, Q0519, Q0520

Revisions From MA00.026u:

07/01/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2024.

HCPCS code A9506 has been added to attachment B of this policy.

The following CPT/HCPCS codes have been added to attachment C of this policy:

G0519, G0520, G0521, G0522, G0523, G0524, G0525, G0526, G0527, G0528, G0529, G0530, G0531, G9037, and G9038

________________________________________________________________

The following procedure codes have been removed from attachment B of this policy:

99492, 99493, 99494, G0136 G2214, 99459

Effective 1/01/2024 The following procedure codes have been added to attachment C of this policy:

G9873, G9874, G9875, G9876, G9877, G9878, G9879, G9882, G9883, G9884, G9885, and G9891

Revisions From MA00.026t:

01/02/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2024 .

The following HCPCS/CPT codes have been added to Att B of this policy:

G0019, G0022, G0023, G0024, G0136, G0140, G0146, G2211, 97550, 97551, 97552, and 99459

The following procedure codes have been removed from Att A and added to Att B because CMS has removed the code's Indicator Status B:

G2211

Revisions From MA00.026s:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
10/23/2023	This version of the policy will become effective 10/23/2023. The intent of this policy remains unchanged, but has been updated to communicate the reimbursement position of cognitive geriatric assessment services represented by procedure code 99483. The reimbursement position of procedure code 99483 has been revised from Not Eligible for Reimbursement to Eligible. Procedure code 99483 has been removed from the policy.

01/01/2024

Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.

10/23/2023

This version of the policy will become effective 10/23/2023. The intent of this policy remains unchanged, but has been updated to communicate the reimbursement position of cognitive geriatric assessment services represented by procedure code 99483.

The reimbursement position of procedure code 99483 has been revised from Not Eligible for Reimbursement to Eligible.

Procedure code 99483 has been removed from the policy.

Revisions From MA00.026r:

07/01/2023

This policy has been identified and updated for the CPT/HCPCS code update effective 7/01/2023.

The following procedure codes have been removed from Att B to Att A of the policy because they have been added to CMS Indicator Status B:

96202 and 96203

Revisions From MA00.026q:

04/03/2023

This version of the policy will become effective 4/03/2023. This policy has been updated to because procedure code 99091 has been removed from this policy and is now addressed in policy# MA12.010a: Remote Patient Monitoring.

Revisions From MA00.026p:

02/13/2023

This version of the policy will become effective 2/13/2023. This policy has been updated to communicate The Company's reimbursement position for the following procedures/services:

The following procedure codes have been removed from this policy because, the Company's reimbursement position has changed from Not Eligible for Reimbursement to Eligible: 99453, 99454, and 99457.

Revisions From MA00.026o:

01/01/2023

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/20223.

The following procedures code were added to the policy:

15853, 15854, 96202, 96203, and G0323

The following procedure codes had narrative revisions:

99242, 99243, 99244, 99245, 99252, 99253, 99254, 99255, 99446, 99447, 99448, 99449, 99451, and 99483

The following procedure codes were removed from the policy:

15850, 99241, 99251, 99339, and 99340

Revisions From MA00.026n:

04/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2022.

The procedures code H2038 was added to the policy

Revisions From MA00.026m:

01/01/2022

This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2022.

The following procedures code were added to the policy:

99424, 99425, 99426, 99427, 99437, 99241, 99242, 99243, 99244, 99245, 99251, 99252,

99253, 99254, 99255, G2168 , and G2169

The following HCPCS codes were removed from the policy:

G2064 and G2065

HCPCS code G1013 had had a narrative revision

Revisions From MA00.026l:

10/11/2021

This version of the policy will become effective 10/11/2021. The intent of this policy remains unchanged, but has been updated to communicate the removal of a procedure code from the policy.

CPT code 96040 has been deleted from Attachment A of this policy.

CPT Code 96904 has been added to Attachment B of this policy to communicate the Company's continued reimbrusement position. This reimbursement position was previously communicated in policy:

MA07.020a: Photography, including Documentation and Record-Keeping Photography, Whole Body Integumentary Photography, Dermoscopy, and Dermatoscopy.

Revisions From MA00.026k:

07/01/2021

This policy has been identified and updated for the CPT/HCPCS code update effective 07/01/2021.

The following procedure code was added to Attachment B of the policy:

0662T and 0663T

Revisions From MA00.026j:

04/01/2021

This policy has been identified and updated for the CPT/HCPCS code update effective 04/01/2021.

The following procedure code was added to Attachment A of the policy:

G2211: Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)

The following procedure codes were added to Attachment C of the policy:

G2020: Services for high intensity clinical services associated with the initial engagement and outreach of beneficiaries assigned to the sip component of the pcf model (do not bill with chronic care management codes)

Revisions From MA00.026i:

01/18/2021

This version of the policy will become effective 01/18/2021. This has been updated to communicate the reimbursement position of all services not eligible for reimbursement or not eligible for separate reimbursement by the Company. Attachment B: Procedures/Services Not Eligible for Separate Reimbursement and Attachment C: Procedures/Services Not Eligible for Reimbursement, have been introduced to this policy to represent services that are not eligible for separate reimbursement or not eligible for reimbursement and were previously communicated in other policies.

The following criteria have been added to the policy:

The following CPT code has been added to this policy in attachment B and is not eligible for separate reimbursement. This position was previously communicated in other policies:

92285

Additonal:
This policy has been identified and updated for the CPT/HCPCS code update effective 01/01/2021.

Procedure code 96040 was added to Attachment A of this policy.

Procedure code 99072 has moved from Attachment B to Attachment A of this policy.

Procedure code G2058 has termed and was removed from Attachment B of this policy:

The following procedure codes were added to Attachment B of this policy:
G2214, 99072, and 99439

Procedure code 99490 in Attachment B of this policy had a narrative revision.

Revisions From MA00.026h:

10/01/2020

This policy has been identified and updated for the CPT/HCPCS code update effective 10/01/2020

The following procedure code has been added to the policy:
36000

Revisions From MA00.026g:

01/01/2020

This version of the policy will become effective 01/01/2020. Effective 01/01/2020, the following three Healthcare Common Procedure Coding System (HCPCS) codes will be included in the Always Bundled Procedure Codes policy. They are not eligible for separate reimbursement.

99360
G0175
S0220
S0221

CPT code 99360 previously resided in the policy entitled Physician/Nonphysician Standby Services (MA00.013). The other three codes previously resided in the policy entitled Medical Team Conferences (MA00.017).

Revisions From MA00.026f:

07/01/2019

This version of the policy will become effective 07/01/2019.

Effective 07/01/2019, language regarding Healthcare Common Procedure Coding System (HCPCS) code S8030 will be removed from the Proton Beam Therapy Radiation policy. It is not eligible for separate reimbursement, as the service is included in the treatment planning. As such, it will be included in the Always Bundled Procedure Codes policy. This policy update reflects this change.

S8030 Scleral application of tantalum ring(s) for localization of lesions for proton beam therapy

Revisions From MA00.026e:

01/01/2019

This version of the policy will become effective 01/01/2019.

The following CPT codes has been deleted from this policy: 99090.

The following CPT codes have been added to this policy: 0537T, 0538T, 0539T.

Revisions From MA00.026d:

11/26/2018

This version of the policy will become effective 11/26/2018.

This policy has been updated as a result of the quarterly update to the Medicare Physician Fee Schedule.

The following Procedure codes have been added to Attachment A of the policy:
34839, G0501

The following Procedure codes have been deleted from Attachment A of the policy:
99091, 99487, 99488, 99489

Revisions From MA00.026c:

01/01/2017

Claim payment policy MA00.026b has been updated, and has been re-issued as policy MA00.026c on 01/01/2017.
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Note: On 09/25/2017 codes 99358 and 99359 were removed from Attachment A. These codes were inadvertently included in this version.

Revisions From MA00.026b:

10/01/2016

Claim payment policy MA00.026a has been updated, and has been re-issued as policy MA00.026b on 10/01/2016.

The following Procedure codes have been added to Attachment A of the policy: 99100, 99116, 99135, 99140

Revisions From MA00.026a:

08/05/2015

This version of the policy will become effective 08/05/2015.

The policy has been reviewed and reissued to communicate the Company’s reimbursement position for procedure codes that are always bundled.

Procedure code 96040 has been removed from Attachment A.

Revisions From MA00.026:

01/01/2015

This is a new policy.

Version Effective Date:

1/1/2025

Version Issued Date:

1/20/2025

Version Reissued Date: