Posted in NY Providers, Payer Updates, Payers and CPT reinbursement, Training, Updates

MVP Health Plans: reimbursement of sick E&M codes billed w/preventative codes -05/01/23

According to the latest announcement MVP Health Plan will change the reimbursement of sick E/M codes when they are billed on the same day as a preventative codes.

This policy applies to Primary Care Physicians.

According to the new reimbursement policy the sick E&M codes will be reimbursed at 50% of allowable amount if the codes are billed on the same date of service as the preventative codes.

The reimbursement will be applied with or without the modifier 25 present.

Policy applies to the following codes:

Preventive medicine services are represented in evaluation and management (E/M) codes 99381–99429. These E/M codes may be reported by any qualified physician or other qualified healthcare professional.

Preventative cpt codes 99381–99397 for comprehensive preventive evaluations are age-specific, beginning with infancy and ranging through patients age 65 and over for both new and established office patients.

E&M codes may include: 99202-99205, 99212-99215

For more information please refer to MVP Evaluation and Management (E&M) policy.

Find this type of blog useful? Follow my blog for the latest news in healthcare field: reimbursement, policy changes, medical billing and coding updates, reimbursement, prior authorization updates.

Recent Blog Posts:

Posted in #unitedhealthcare, NY Providers, Payer Updates, Training

UHC NY Community Plan Referral requirement change-effective immediately

As per UniteHealthCare- NY community Plan -members will no longer require referrals to see specialists (most specialties).

This change is made to help Primary Care Physicians with reducing administrative burden and make it easier for the members to see some specialists.

The specialists that do or do not require a referral still need to be In Network with UHC NY Community Plan.

Below are the specialties that still require the referral. The members will need to contact their PCP office in order to obtain a referral and ensure that the Specialist will get reimbursed for the services provided.

  • Allergy and immunology
  • Dermatology
  • Endocrinology
  • Gastroenterology
  • General surgery
  • Neurological surgery
  • Orthopedic surgery
  • Otolaryngology
  • Physical medicine and rehabilitation/physiatry
  • Plastic surgery
  • Podiatry
  • Pulmonary medicine
  • Sports medicine
  • Urology
  • Vascular surgery

I am a provider, where should I go in order to request a referral?

Providers can request a referral on the UHC provider portal ( ) Providers need to sign into the portal.

I am a provider and still have questions regarding the referral process, where should I go to find more infomation?

Provider can visit interactive guide in order to get more information regarding referral process.

Find this information useful? Follow my blog for more current healthcare related changes/updates.

Recent Blog Posts:

#NYMedicaid, #UHCCommunityPlan #UHC #referrals #specialists

Posted in BCBS (Various States), Payer Updates, Training, Updates

BCBS of Virginia and It’s affiliate Healthkeepers, Inc 3 new Lab coverage-07/01/22

If you are a provider or a LAB that is ordering or offering the following tests for your Anthem BCBS of Virginia and its Affiliate Healthkeepers Inc. patients this blog post is for you! Effective date is 07/01/2022

These following NEW LAB guidelines impact all our products – with the exception of Anthem HealthKeepers Plus (Medicaid), Medicare Advantage, the Commonwealth Coordinated Care Plus (Anthem CCC Plus) plan, and the BlueCross and Blue Shield Service Benefit Plan (also called the Federal Employee Program® or
FEP®). Furthermore, the guidelines were among those recently approved at the Medical Policy and Technology Assessment Committee meeting held on February 17, 2022.

LAB.00043-Immune Biomarker Tests for Cancer -This new lab policy addresses the coverage for immune response algorithmic tests for oncologic disease management At least one test, Immunoscore® (Veracyte Inc.), which has been investigated for management of colon cancer, is commercially available. According to this policy Anthem BCBS of Virginia and its affiliate Healthkeepers Inc., consider oncologic immune biomarker tests are considered investigational and not medically necessary for all indications. CPT codes: 0261U

LAB.00044-Saliva-based Testing to Determine Drug-Metabolizer Status– this new lab policy addresses the coverage for saliva-based testing to determine drugmetabolizer status. Saliva-based testing to determine drug-metabolizer status is considered investigational and not medically necessary for all indications. The CPT code associated with this new coverage guideline is 84999.

LAB.00045-Selected Tests for the Evaluation and Management of Infertility– this NEW Lab policy addresses the coverage for selected tests that are part of the diagnostic work-up to determine the cause of infertility or manage infertility treatment. According to Anthem BCBS of Virginia and its affiliate the following tests or procedures are considered investigational and not medically necessary for diagnosing or managing infertility:

• Endometrial receptivity analysis;

• Sperm-capacitation test;

• Sperm deoxyribonucleic acid (DNA) fragmentation test;

• Sperm penetration assay; and

• Uterine natural killer (uNK) cells test.

The CPT codes associated with this new coverage guideline are 86357, 89329, 89330, 89398, 0253U, and 0255U.

Find this type of content useful? Follow my blog for more medical billing and coding guideline updates/revisions/new policies.

Recent Blog Posts: