New York – Anthem Reimbursement Policy Updates

December 2018 ~

Anthem has posted several reimbursement policy updates, including updates to its Rule of Eight” Reporting Guidelines, system updates for 2019, and updates to policy for Modifier 69.

“Rule of Eight” Reporting Guidelines for Physical Medicine and Rehabilitation Services – Professional

Anthem has updated the title of its “Rule of Eight” Reporting Guidelines for Physical Medicine and Rehabilitation Services reimbursement policy to Guidelines for Reporting Timed Units for Physical Medicine and Rehabilitation Services.

System Updates for 2019 – Professional

Anthem’s claim editing software will be updated monthly throughout 2019 with the most common updates occurring in quarterly in February, May, August and November of 2019. These updates will:

• reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits
• include updates to National Correct Coding Initiative (NCCI) edits
• include updates to incidental, mutually exclusive, and unbundled (rebundle) edits
• include assistant surgeon eligibility in accordance with the policy
• include edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)

Modifier 79 – Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional during the Postoperative Period – Professional

This coding tip is based on recent findings for claims processed with modifier 79 during a postoperative period. CPT^® specifically states modifier 79 should be reported by the same individual when reporting unrelated procedures or services during the postoperative period. For example, this modifier is used when a patient presents with a problem that is unrelated to a previous surgery (yet within the postoperative period) and requires additional services by the same provider/individual.  When modifier 79 is appended for a different provider (e.g. Nurse Practitioner or Physician Assistant) during the postoperative period the claim line will deny.

In addition to modifier 79, modifiers 58 and 78 are also based on Same Physician or Other Qualified Health Care Professional as documented below:

• 58 – Staged/Related Procedure/Service by the Same Physician/Other Qualified Health Care Professional during the Postoperative Period.
• 78 – Unplanned Procedure/Service by Same Physician/Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure during the Postoperative Period.

 CPT^® is a registered trademark of the American Medical Association.

Source(s): December 2018 Empire Provider Newsletter;