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New Coding Reimbursement Guidelines & Appropriate Place of Service Billing

April 30, 2021

Thank you for your valued partnership.

WellCare has been working to implement a significant enhancement to our physician reimbursement policies that promote correct coding. The goals of this endeavor are to implement, to the extent possible, claim payment policies that are simple to understand and in alignment with Kentucky Medicaid policies. We believe that this will enable you and your billing staff to better understand our claims payment process given the widespread use of these policies.

Effective June 15, 2021, we will introduce new Coding Reimbursement Guidelines based on WellCare historical claims edits, industry standards and coding rules published within the Medicare Claims Processing Manual, Current Procedural Terminology (CPT®) by the American Medical Association (AMA) and Kentucky Medicaid Billing Manuals. These are the same rules used by most healthcare claims payers and enforced by the Centers for Medicare and Medicaid Services.

WellCare payment policies focus on areas such as:

·         DME Maximum Units Over Time

·         Physical Therapy Guidelines

·         National Drug Code Requirements

Durable Medical Equipment and Supplies- Maximum Units Over Time

According to Kentucky Medicaid guidelines, durable medical equipment and supplies have been assigned a maximum number of units that may be billed within a specified time frame in the Medicaid Program DME Fee Schedule. When the total number of billed units exceed the assigned number allowed, the units will be adjusted to match the assigned allowed units and the excess units will be denied.

Physical Therapy- Physical Medicine

According to Kentucky Medicaid guidelines, only certain services that are within the scope of practice for physical, occupational and speech therapy are covered. All other services out of scope of practice will be denied with the exception of the following codes: 31579, 92507-92512, 92520-92526, 92540-92550, 92552-92557, 92561-92588, 92597-92604, 92607-92617, 92620-92627, 92640, 96105, 96125, 97533, G0451 96110, 96112, 96113, 99446, 99447, 99448, 99449, 99451, 99452, 99453, and 99454 (as it relates to this policy).

Place of Service Restriction

According to Kentucky Medicaid guidelines, services reported by physical therapists, occupational therapists and speech-language pathologists will be denied when billed in Place of Service 99 (Other place of service) and the member is over the age of 21.

Physician Administered Drugs- National Drug Code (NDC)

The National Drug Code (NDC) is a unique, three-segment number that identifies a drug. The three segments identify the labeler, the product, and the commercial package size. The NDC serves as a universal product identifier for drugs. According to Kentucky Medicaid guidelines, certain physician-administered drugs must be reported with the National Drug Code (NDC) that corresponds directly to the drug related procedure code.

Examples of physician administered drugs:

·         J0129 (Abatacept, Orencia®)

·         J0202 (Alemtuzumab, Lemtrada®)

·         J0585 (OnabotulinumtoxinA, Botox®)

·         J1743 (Idursulfase, Elaprase®)

·         Q0138 (Ferumoxytol, Feraheme®)

The proper reporting of CPT® procedure codes enables WellCare to more precisely apply reimbursement guidelines and ensure that an accurate record of patient care history is maintained.

Behavioral Health Services Organizations (BHSOs)

The Department for Medicaid Services (DMS) recognizes three BHSO licensure types, also referred to as tiers: Tier I (outpatient), Tier II (outpatient), and Tier III (residential).

Codes eligible for BHSO Tier III reimbursement are the residential codes on DMS’s behavioral health facility fee schedule. BHSO IIIs are not eligible to be paid for outpatient codes on DMS’s facility fee schedule. Only outpatient hospitals may be paid for outpatient codes listed on DMS’s behavioral health facility fee schedule. WellCare will deny any claims with outpatient codes billed by a BHSO Tier III.

BHSO Tier III providers must use place of service 55. WellCare will deny any BHSO Tier III claim with a place of service other than 55.

BHSO Tier II providers must use place of service modifier 57 for all outpatient services performed by a BHSO Tier II provider. WellCare will deny any BHSO Tier II provider claims that are not billed with place of service 57.

The applicable fee schedule for BHSO Tier II providers is the non-facility behavioral health fee schedule.

If you have any questions or need further information, please contact your Provider Relations Representative at 1-855-538-0454, Monday – Friday from 8:00 a.m. to 6:30 p.m. Eastern.

Thank you for helping WellCare members live better, healthier lives.


WellCare Health Plans