Payment Policies
These payment policies describe Aspirus Health Plan’s application of payment rules and methodologies for claims submitted under Aspirus Health Plan’s health benefit plans. This information is offered as a helpful resource regarding Aspirus Health Plan payment policies. Aspirus Health Plan cannot address every possible aspect of a reimbursement scenario.
Product Information
The information outlined below applies to all Aspirus Medicare Advantage Products.
General Payment Information
The information provided below outlines the impact appending a specific modifier will have on payment on the specific services. Payment for each eligible service is based on the lesser of charge, or the increase, decrease or change in payment that is specific to the modifier that has been appended to the service.
Modifiers
Modifiers are used as means to communicate that a service or procedure has been altered by some specific circumstance without changing the description of the service provided, communicate additional information regarding the provider performing the service, provide clarity regarding the service performed or to meet specific payment policy requirements. Outlined below is general information regarding the use of modifiers and the impact the use of those modifiers may have on payment.
Refer to the Aspirus Health Plan Anesthesia Policies for detailed information on the use and payment associated with the use of anesthesia modifiers.
AA - Anesthesia services performed personally by anesthesiologist.
AD - Medical supervision by a physician: more than four concurrent anesthesia procedures.
GC - Services performed in part by a resident under the direction of a teaching physician.
G8 - Monitored anesthesia care (MAC) for deep complex complicated or markedly invasive surgical procedures.
G9 - Monitored anesthesia care (MAC) for a patient who has a history of severe cardiopulmonary condition.
QK - Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals.
QS - Monitored anesthesia care (MAC) services.
QX - Qualified non-physician anesthetist with medical direction by a physician.
QY - Medical direction of one qualified non-physician anesthetist by an anesthesiologist.
QZ - CRNA without medical direction by a physician.
Links to pertinent information:
Physical Status Modifiers provide additional information regarding the overall physical status of the patient, identifying various levels of complexity impacting the patient and the administration of anesthesia. Medicare considers these modifiers to be informational and does not provide any additional payment when any of these modifiers are appended to anesthesia services.
P1 - A normal healthy patient.
P2 - A patient with mild systematic disease.
P3 - A patient with severe systematic disease.
P4 - A patient with severe systematic disease that is a constant threat to life.
P5 - A moribund patient who is not expected to survive without the operation.
P6 - A declared brain-dead patient whose organs are being removed for donor purposes.
Links to pertinent information:
59 - Separate Procedural Service
XE - Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter.
XP - Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner.
XS- Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure.
XU - Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.
Links to pertinent information:
EM - Emergency Reserve Supply (for ESRD benefit only)
For patients beginning to self-administer and ESA at home receiving an extra month supply of drug, bill one-month reserve supply on one claim line and append the -EM modifier.
Link to pertinent information:
All hemodialysis claims must indicate the most recent URR for dialysis patient. Submit CPT code 90999 (unlisted dialysis procedure, inpatient or outpatient) to be reported in field location 44 for all bill types 72X. One of the modifiers listed below must be appended to the claim line. Modifiers G1-G5 are used for patients who received seven or more dialysis treatments in a month. Modifier G6 is used for patients who have received dialysis for six days or fewer in a month.
G1 - Most recent Urea Reduction Ration (URR) reading of less than 60%.
G2 - Most recent URR reading of 60 - 64.9%.
G3 - Most recent URR reading of 65 - 69.9%.
G4 - Most recent URR reading of 70 - 74.9%.
G5 - Most recent URR reading of 75% or greater.
G6 - ESRD patient for whom fewer than seven dialysis sessions have been provided in a month.
Link to pertinent information:
AY - AY item or service furnished to an ESRD patient that is not for treatment of ESRD.
The ESRD prospective payment system (PPS) includes consolidated billing for limited Part B services included in ESRD facility bundled payment. When laboratory services and limited drugs are provided to a patient but are not related to treatment for ESRD, claim lines must be submitted with AY modifier to allow for separate payment outside of ESRD PPS.
Link to pertinent information:
One of the modifiers listed below must be appended to the claim line to specify the type of administration used for ESA for ESRD.
JA - Intravenous injection administration of ESA for ESRD.
JB - Subcutaneous injection administration of ESA for ESRD.
JE - Append this modifier to all ESRD claims where drugs and biologicals are furnished via dialysate solution.
Link to pertinent information:
KX - Any medically necessary extra beyond the monthly maximum. The documentation in the patient's medical record must support the reason why extra hemodialysis sessions were given beyond the frequency.
Links to pertinent information:
- Medicare Benefit Policy Manual, Chapter 11, Section 50A (1)
- Medicare Claims Processing Manual, Chapter 8, Section 50.6.2
CG - ESRD facilities billing for more than 13 or 14 treatments per month must provide medical justification to receive payment for the additional treatments. Additional treatments provided without meeting the medical justification required must append the -CG modifier on the claim line. This modifier indicates that the facility attests the additional treatment does not meet medical justification requirements.
Links to pertinent information:
Q3 - Live Kidney Donor
Surgery and related services all eligible for physicians' services rendered to the living donor and all physicians' services rendered to the transplant recipient are billed to the Medicare program in the same manner as all Medicare Part B services are billed. All donor physicians' services must be billed to the account of the recipient (i.e., the recipient's Medicare number). The -Q3 modifier (Live Kidney Donor and Related Services) should be appended to the claim line(s).
Links to pertinent information:
ESRD claims for hemodialysis must indicate type of vascular access used.
V5 - Vascular catheter (alone or with any other vascular access)
V6 - Arteriovenous graft (or other vascular access not including vascular catheter in use with two needles)
V7 - Arteriovenous fistula only (in use with two needles)
Link to pertinent information:
24 - Unrelated Evaluation and Management (E/M) Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period
The -24 modifier should be appended to an E/M service or eye exam performed within the global period of a major (90 days) or minor surgery (10 days) performed by a surgeon to indicate that the E/M service is unrelated to the surgery.
It is not necessary to submit supporting documentation with the claim. However, Aspirus Health Plan reserves the right to request supporting documentation that indicates the E/M service is unrelated to the surgery. Supporting documentation must be made available upon request.
25 - Significant, Separately Identifiable Evaluation and Management (E/M) Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
The -25 modifier should be appended to an E/M service to indicate that on the day a procedure or service was performed the patient's condition required significant, separately identifiable E/M service above and beyond other services provided.
It is not necessary to submit supporting documentation with the claim. However, Aspirus Health Plan reserves the right to request documentation to support that the E&M service is significant and separate. Supporting documentation must be made available upon request.
57 - Decision for Surgery
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22 - Increased Procedural Services
Link to pertinent information:
50 - Bilateral Procedure
Links to pertinent information:
- Medicare Claims Processing Manual, Chapter 12, Section 40.7
- Medicare Claims Processing Manual, Chapter 23, Section 50.6
51 - Multiple Procedures
Links to pertinent information:
52 - Reduced Services
Link to pertinent information:
53 - Discontinued Procedure
Link to pertinent information:
- Medicare Claims Processing Manual, Chapter 12, Section 30.1
- Medicare Claims Processing Manual, Chapter 18, Section 60.2
54 - Surgical Care Only
55 - Postoperative Management Only
56 - Preoperative management Only
Links to pertinent information:
58 - Stage or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
Links to pertinent information:
- Medicare Claims Processing Manual, Chapter 12, Section 40.2
- Medicare Claims Processing Manual, Chapter 4, Section 20.6
- MLN907166 - Global Surgery
62 - Two Surgeons
The MPFSDB professional fee schedule includes an Indicator Co-Surgeon (two surgeons) (CO-SURG). Indicator 1 and 2 identifies services which must be sufficiently documented to establish that a co-surgeon was medically necessary.
The base allowed for eligible co-surgeon payment is 62.5% of Aspirus Health Plan's global surgery fee schedule amount.
Links to pertinent information;
63 - Procedure Performed on an Infant less Than 4kg
66 - Surgical Team
HCPCS/CPT© codes on the MPFSDB professional fee schedule with a Team Surgery Indicator (TEAM SURG) of 1 and 2 may be eligible for team surgery reimbursement. Each surgeon should submit a claim, an operative report and any other supporting documentation for the surgery performed. Modifier -66 should be appended to each HCPCS/CPT© code submitted.
Team surgeons should submit the same HCPCS/CPT© codes. Payment will be determined based on review of the documentation submitted. Claims submitted without documentation will be denied. When multiple surgical procedures are performed, multiple surgery guidelines do apply.
Links to pertinent information:
78 - Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following the Initial Procedure During the Postoperative Period.
Links to pertinent information:
79 - Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
The -79 modifier indicates that a procedure or service furnished during a postoperative period was unrelated to the original procedure. New post-operative period begins when unrelated procedure is billed.
Links to pertinent information:
80 - Assistant Surgeon
81 - Minimal Assistant Surgeon
82 - Assistant Surgeon (when a qualified resident surgeon is not available)
AS - Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist services for assist at surgery.