Time span code billing guidelines - 93268 , 93272, 94005

REIMBURSEMENT GUIDELINES

Time Span Codes

Oxford will reimburse a CPT or HCPCS Level II code that specifies a time period for which it should be reported (e.g., weekly, monthly), once during that time period. The time period is based on sourcing from the AMA or CMS including: the CPT or HCPCS code description, CPT book parentheticals and other coding guidance in the CPT book, other AMA publications or CMS publications.

For example: Within the CPT book, the code description for CPT code 95250 states, “Ambulatory continuous glucose monitoring of interstitial tissue fluid via subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording”. In addition to that code description, there is also a parenthetical that provides further instructions with regard to the frequency the code can be reported. The parenthetical states, “Do not report 95250 more than once per month”. Oxford will reimburse CPT Code 95250 only once per month for the same member, for services provided by the Same Group Physician and/or Other Health Care Professional. In order to consider reimbursement for these services that may be repeated following a month with fewer than 31 days, Oxford may allow reimbursement of monthly time span codes when these codes are reported with dates of service at least 28 days apart.

CPT coding guidelines specify for physicians or other qualified health care professionals to select the name of the procedure or service that accurately identifies the services performed.



End-Stage Renal Disease Services (ESRD) 90951-90962 

CPT codes 90951-90962 are grouped by age of the patient and the number of face-to-face physician or other qualified health care professional visits provided per month (i.e., 1, 2-3, or 4 or more). Oxford will reimburse the single most comprehensive outpatient ESRD code submitted per age category (i.e., under 2 years of age, 2-11 years of age, 11- 19 years of age, and 20 years of age and older) once per month. This aligns with CPT coding guidance which states to report the age-specific ESRD codes should be reported once per month for all physician or other health care professional face-to-face outpatient services.




Time Span Comprehensive and Component Codes

When related Time Span Codes which share a common portion of a code description are both reported during the same time span period by the Same Group Physicians and/or Other Health Care Professional for the same patient, the code with the most comprehensive description is the reimbursable service. The other code is considered inclusive and is not a separately reimbursable service. No modifiers will override this denial. The following example illustrates how the CPT book lists code 93268 first as it is the comprehensive code. CPT codes 93270, 93271, and 93272 are indented and each share a common component of their code description with CPT code 93268.


When CPT code 93270, 93271, or 93272 are reported with CPT 93268 during the same 30 day period by the Same Group Physician and/or Other Health Care Professional for the same patient, only CPT code 93268 is the reimbursable service.

The Time Span Comprehensive and Component Codes list includes applicable comprehensive and related component Time Span Codes.

DEFINITIONS Calendar Month: Oxford defines Calendar Month as the time span referring to an individually named month of the year, (e.g., January, February) and includes codes with Calendar Month in their description.



Same Group Physician and/or Other Health Care Professional: All physicians and/or other health care professionals of the same group reporting the same Federal Tax Identification number.

Time Span Code: A CPT or HCPCS code that specifies a time period for which it should be reported (e.g., weekly, monthly).



APPLICABLE CODES

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply.


CPT Code Description

93268

External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; includes transmission, physician review and interpretation 93270 Recording (includes connection, recording, and disconnection) 93271 Transmission and analysis

93272 Review and interpretation by a physician or other qualified health care professional CPT® is a registered trademark of the American Medical Association QUESTIONS AND ANSWERS



1 Q: How does Oxford determine the “time span” for codes with a description of calendar month, per month or monthly?

A: The date of service (DOS) is the reference point for determining the frequency of code submission and subsequent reimbursement during that period. See the examples below: Calendar Month

CPT code 94005 (home ventilator management care plan oversight of a patient (patient not present) in home, domiciliary or rest home (e.g., assisted living) requiring review of status, review of laboratories and other studies and revision of orders and respiratory care plan (as appropriate), within a calendar month, 30 minutes or more) is submitted March 13. The Same Group Physician and/or Other Health Care Professional reports this code for the same patient on April 5. Both codes are considered eligible for reimbursement as a Time Span Code because the service was provided in a different Calendar Month.


Per Month/or Monthly

HCPCS code A4595 [Electrical stimulator supplies, 2 lead, per month, (e.g. tens, nmes)] is submitted August 31. The Same Group Physician and/or Other Health Care Professional reports this code for the same patient on September 30. Both codes are considered eligible for reimbursement.

In order to consider reimbursement for services that may be repeated following a month with fewer than 31 days, Oxford may allow reimbursement of monthly time span codes when these codes are reported with dates of service at least 28 days apart.

2 Q: Does Oxford recognize modifiers, (e.g., 59, 76), through the Time Span Codes Policy to allow reimbursement for additional submissions of a code within the designated time span?

A: No. Reimbursement for codes included in the Time Span Codes Policy is based on the time span parameter specified in the code description, CPT book parentheticals and/or other coding guidance from the AMA or CMS.