Neighborhood Health Plan of Rhode Island
Billing and Reimbursement Policies
Billing and Reimbursement Policy Name:Billable Drug Testing Services and Limitations Pharmaceutical Supplies
Guideline Publication Date: September 1, 2010Policy Effective: February 15, 2013
KKey coding, documentation and reimbursement points include:
Applies to CPT codes 80100, 80101, 80102, 80104, 80154, 80184, 80299*, 82055, 82145, 82520, 83840, 83925, 83992, 82205, 82742, 83805 and HCPCS codes G0431 and G0434.
- Unless another supporting diagnosis or procedure can be found to support that an EKG rendered at the surgical session was not related to anesthesia, separate payment will not be allowed for EKG interpretation and report when administered by the same physician when billed with surgical procedures.
- Modifier 59 should be billed to indicate separate payment. Notes may be requested to confirm separate payment is appropriate.
As customary, CMS reimbursement policies such as CCI and MUE edits apply. For example, it is inappropriate to bill any combination of 80100, 80101, 80104, G0431 or G0434 together on the same day.
Limited to five (5) tests/units per date of service, any combination of codes. Only the first five (5) tests/units are reimbursable. Any other test/units are considered inclusive in the allowance of the first five (5).
The member cannot be balance billed for any test/units exceeding the limit of five (5).
- This guideline applies to both CMS-1500 and UB-92 claim submissions.This guideline applies to CMS-1500 claim submissions.
- This guideline applies to place of service 21, 22 and 24.
*Miscellaneous code, notes required
Publication date:
12/13/12
Please refer to Neighborhood’s provider website at www.nhpri.org for specific
provisions by product line.
This policyguideline is not a guarantee of reimbursement. Plan coverage, eligibility and claim payment edit rules may apply.
Key coding and reimbursement points include:
All pharmacy supplies should be billed with the appropriate CPT® or HCPC® code and valid NDC number. Please refer to Pharmaceutical Coverage document for list of covered drug codes.
If the supply is considered a miscellaneous supply, the claim must be billed on paper with a miscellaneous supply code, valid NDC number and an invoice attached for review. Do we need to specify all that is required on an invoice, such as units, etc?
Any pharmaceutical considered covered under NHPRI’s pharmacy benefit will be denied if billed on a medical claim..
Only pharmaceuticals that are FDA approved are reimbursable. Any pharmaceutical that is non-FDA approved will be denied.
No modifier is required.
This policy applies to all places of service.
and devices or device
Publication date:
09/16/10
Published:
September 1, 2010
Version History
Original Publish Date:September 1, 2010
Revision Date (s):
9/1/2013Format change, minor edits
Neighborhood Health Plan of Rhode Island
Billing and Reimbursement GuidelinesPage 1