According UHC October Provider Updates- there are several new codes that are being added to the Radiology Prior Authorization List. This list applies to ALL plan types: Medicare Advantage, Community, and Commercial.
The change will go into an effect for Dates of Service on 01/01/2021 and thereafter.
Below is the list of new added codes:
This post is for Allergy & Asthma providers that accept Empire NYSHIP (TPA UHC) patients and perform diagnostic asthma/allergy testing in the office setting (POS 11).
Commonly used CPT codes in Office Setting (w/ short description)
1. 95004- skin prick allergy testing
2. 95024- intradermal allergy testing
3. 95044- patch allergy testing
4.95018- Medication (Penicillin) allergy testing
5. 94200- Peak flow
6. 95012- NIOX or FENO
Member cost-sharing/patient co-pays for year 2020 and beyond:
Most of the Empire NYSHIP plans (there are various types), have updated their co-pay to $25 per office visit (specialist) Please click here to visit my post on the updated Empire NYSHIP co-pays.
However, as recent as last year, the Empire NYSHIP plans also started to add, an extra $25 member cost-sharing fee, to the above mentioned CPT codes. In order for your office not to leave this uncollected revenue on the table, please make sure to inform your front office staff of this change!
Now let’s take a look at 2 (TWO) examples.
Ex. 1. Patient comes in for the first time and has the environmental skin prick testing done the same day. The billing would be: 99204 25 with 95004X40 -the total patient financial responsibility would be $50: $25 for OV and $25 for testing.
Ex. 2. Patient with DX of Allergic Asthma (J45.30) is coming in for a follow up visit. The billing would be: 99213 25 with 94200 59 and 95012 59. In this instance the second co-pay would be applied to 94200 and 95012 would be paid. So, the patient will still pay only $50 co-pay.
Now, If you have any more questions about this post, Empire NYSHIP patients cost-sharing or something else, please go on my (SERVICES) page and contact me for a free 30-min Evaluation ($250 Value).
Effective 09/01/2020- UHC revised its FESS medical /reimbursement Policy.
Some of Changes are listed below:
1. Replaced “Chronic Rhinosinusitis” with Chronic Rhinosinusitis with or without polyps
2. Added: Polyposis with obstructive symptoms needs to be confirmed by CT
3.Revised Coverage Criteria:
a. Chronic Rhinosinusitis-
-Revised: ” confirmation of chronic rhinosinusitis with CT for each sinus to be treated meeting all of the listed criteria”
-Revised: ” CT findings include ostial obstruction (outflow and tract obstruction) and mucosal thickening”
+Added: “CT images are obtained after completion of medical management”
+Added: CT scan report needs to use the Modified Lund-Mackay Scoring for each of sides that is requesting treatment
+Added: Sinonasal symptoms such as pain, pressure, or drainage present on the same side as CT scan findings of rhinosinusitis.
b. Recurrent Acute Rhinosinusitis–
-Revised: “CT scan evidence of ostial obstruction (outflow tract obstruction) and mucosal thickening in the sinus to be treated”
+Added: Sinonasal symptoms such as pain, pressure, or drainage present on the same side as CT scan findings of rhinosinusitis.
Partial code list that this policy applies to:
For the complete revised medical policy, including the complete list of applicable codes, please click on this link here to visit it.
KR2 Medical Billing 