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.

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Posted in #unitedhealthcare, Payers and CPT reinbursement, Training, Updates

Michigan Medicaid: reimburses for Doula Services-01/01/23

The new coverage policy applies to Medicaid, Healthy Michigan Plan, MI Health Link, MIChild, Maternity
Outpatient Medical Services Programs.

Effective 01/01/23 – Michigan Medicaid members that belong to the above mentioned programs will be able to receive services from a certified doula during the the prenatal, labor and delivery, and postpartum

Doula- non clinical professional that provides physical, emotional, and educational support services to pregnant individuals.

In order for the Doula Services to be covered they need to be recommended by a licensed healthcare

Some of the Doula Services may include: (partial list) complete list is available click here.

Prenatal services, which include:
o Promoting health literacy and knowledge;
o Assisting with the development of a birth plan;
o Supporting personal and cultural preferences around childbirth;

Labor and delivery services, which include:
o Providing continual physical comfort measures, information, and emotional support;
o Advocating for beneficiary needs; and

Postpartum services, which include:
o Educating regarding newborn care, nutrition, and safety;
o Supporting breastfeeding;
o Providing emotional support and encouraging self-care measures;

Doula services are expected to be covered for face-to-face visits with the patient. Although the prenatal and Postpartum services may be done vial telemedicine, please MDHHS telemedicine policy.

Frequency: up to 6 visits are allowed plus 1 extra visit during the delivery. The duration of each visit needs to be at least 20 minutes. If the patient requires over the max allowed number of visits, then the provider may request more via PA process.

Documentation requirements: doulas need to document the start and end time of the visit for each patient. The documentation should include a description of the professional services rendered and information regarding the source of the licensed healthcare provider recommendation for services.

Reimbursement: in order to receive reimbursement doulas need to be a registered Michigan Medicaid Provider. Reimbursement amounts as follows:

Prenatal visit: S9445 Modifier- HD ICD-10 codes- Prenatal: Z33.1Postpartum: Z39.2 6 total visits Fee-$75 per visit

Attendance at Labor and Delivery: CPT code- T1033 Modifier- HD ICD-10 Code- Z33.1 Max 1 visit Fee- $700

For complete information regarding coverage/reimbursement/provider enrollment, please visit Michigan Medicaid Site click here.

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Posted in BCBS Empire NY, NY Providers, Payers and CPT reinbursement, Pharmacy (Various Insurance Payers), Training, Updates

BCBS Empire NY Medicaid: Reimbursement for Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Counseling program

If you are a pediatrician that provides vaccination counseling for patients under 18 years of age and younger then this blog post is for you!

The following is a clarification on the proper coding and billing for or provider reimbursement for pediatric vaccine counseling visits as part of the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.

This reimbursement policy applies to Medicaid members (Empire BCBS).

Note: Vaccine counseling visits align with the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP)

The following is the correct CPT code with the ICD-10 code that the providers would use in order to get proper reimbursement.

 CPT® codeFeeNotes
Claims basedCPT 99401DX: Z71.85$12.50A provider submitting professional claims should bill Current Procedure Terminology (CPT) code 99401 for preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) for reimbursement for childhood vaccine counseling. A minimum of eight minutes is required and recommended for ages 18 years or younger.
via Empire BCBS Medicaid Updates

Documentation requirements: In order to get paid for the above mentioned code, the providers need to document the following in either the medical record or a pharmacy record.

  • CPT 99402: Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure).
  • Providers should bill CPT 99402 with ICD-10 code Z71.85.
  • Confirm vaccination status in the New York State Immunization Information System (NYSIIS) or City Immunization Registry (CIR), whenever possible.
  • Providers are encouraged to counsel all members who have not already have an appointment scheduled to receive the vaccine dose for which they are being counseled.
  • For more information, visit

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