CurrentAnthemPolicy C-08012

Frequency Editing - Professional (unit/frequency limits)

Defines Anthem's rules for unit and frequency edits for professional CPT/HCPCS codes, including when multiple units or repeat services on the same date or across date spans will be limited; applies to claim submissions for Anthem commercial members.

Policy Summary

PayerAnthem

PolicyFrequency Editing - Professional (unit/frequency limits)

Policy CodePolicy C-08012

Change TypeCode list update (non-material)

Effective Date10/01/2024

Next Review Date

Key ActionEnsure claims use industry-standard CPT/HCPCS codes supported by medical records; services billed in excess of frequency/unit limits are not eligible for reimbursement.

SourceLink

POLICY UPDATE CHANGES

Updated CPT and HCPCS code lists; moved and removed specific codes per attachment updates.

2024-10-01policy effective date

2024-04-24last approval date

C-08012internal policy identifier

2008-2024policy history entries

Unit and Frequency Editing Rules

Policy Summary

PayerAnthem

PolicyFrequency Editing - Professional (unit/frequency limits)

Policy CodePolicy C-08012

Change TypeCode list update (non-material)

Effective Date10/01/2024

Next Review Date

Key ActionEnsure claims use industry-standard CPT/HCPCS codes supported by medical records; services billed in excess of frequency/unit limits are not eligible for reimbursement.

SourceLink

On This Page

Unit and Frequency Edit Criteria

Rules governing when codes are limited in units or frequency for reimbursement:

A procedure billed for a single member on a single date of service by the same provider or provider group is reimbursed up to the maximum units allowed; Anthem applies unit/frequency edits pre-adjudication using the unit field and multiple line submissions.

Anthem uses CPT/HCPCS nomenclature, CMS MUEs designation, industry standards, manufacturer's guidelines, FDA approval, claims data analysis, and clinical reasonableness to determine and apply unit and frequency maximums per date and/or per date span.

Services reported in excess of unit or frequency restrictions are not eligible for reimbursement even when reported with an override modifier; inclusion or exclusion of a code in attachments does not guarantee coverage in all circumstances.

Anthem may apply frequency edits across dates of service by accumulating claim line history (previous, current, and subsequent dates of service) to enforce limits for certain codes.

When a procedure is submitted with multiple units but only a single unit is acceptable, reimbursement will be based on one unit; modifiers generally will not override this edit, except that RT/LT or site-specific modifiers may allow separate processing when they identify different sites.

A base code that has a related add-on code (CPT Appendix D) is eligible for reimbursement only once per date of service when the add-on describes 'each additional' or 'list separately in addition to the primary procedure.'

Factors that may limit reimbursement to a single unit

The procedure code description includes the word(s) 'bilateral' or 'unilateral or bilateral'.
The procedure code description specifies 'unilateral' and there is another CPT code for the bilateral service or an add-on code for additional services (the unilateral code cannot be submitted more than once on a single date).
The procedure code description or its parenthetical statement includes a specific time frame.
The procedure code description implies multiplicity or the total number of times it is clinically possible or reasonable to perform the procedure on a single date is limited.

Code Lists and Application of Limits

Custom CPT/HCPCS frequency listsmixedCovered

See attached CPT Maximum Frequency list

CPT Maximum Frequency. HCPCS Maximum Frequency

Updated/Removed Codes (history note)mixed

36415	Removed from CPT list (moved to Laboratory and Venipuncture C-10001)
36416	Removed from CPT list (moved to Laboratory and Venipuncture C-10001)
96158	Removed from CPT list (moved to Health and Behavioral Assessment/Intervention C-11003)
96159	Removed from CPT list (moved to Health and Behavioral Assessment/Intervention C-11003)
96164	Removed from CPT list (moved to Health and Behavioral Assessment/Intervention C-11003)
96165	Removed from CPT list (moved to Health and Behavioral Assessment/Intervention C-11003)
S9529	Removed from HCPCS list (moved to Laboratory and Venipuncture C-10001)
G0480	Removed from HCPCS list (moved to Drug Screen Testing-Professional C-12004)
G0481	Removed from HCPCS list (moved to Drug Screen Testing-Professional C-12004)
G0482	Removed from HCPCS list (moved to Drug Screen Testing-Professional C-12004)

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Unit/frequency maximum application

Application scopeAnthem applies frequency maximums per date and/or per date span; limits may be based on CMS MUEs, industry standards, code description, manufacturer's guidelines, FDA approval, or claims data analysis.

Pre-adjudication enforcementAll unit/frequency edits are applied pre-adjudication using both the unit field and multiple submissions of line items; history of prior, current, and subsequent claim lines may be used to accumulate across dates.

Same member across providersIn certain circumstances frequency limits are applied for the same member and same date of service across providers (see Related Coding list for reference).

Modifiers and overridesServices reported in excess of limits are not eligible for reimbursement even when reported with an override modifier; modifiers generally will not override frequency/unit edits though site-specific modifiers (RT/LT) may allow separate processing for different sites.

Custom code logicAnthem uses customized unit/frequency logic for procedure codes listed in attachments; inclusion in attachments does not guarantee coverage under all circumstances.

Claim Submission and Documentation Requirements

Documentation Required

Claim submission and documentation requirements

Use industry-standard CPT/HCPCS codes on all claim submissions and ensure the codes billed are fully supported in the medical record or office notes; failure to follow proper billing and submission guidelines may result in claim rejection, denial, or recoupment. Services billed in excess of the policy's unit or frequency limits are not eligible for reimbursement even with override modifiers, and authorization/medical necessity requirements still apply.

Submit claims with Current Procedure Terminology (CPT), HCPCS, and/or revenue codes that are supported by documentation in the medical record or office notes.
Services reported in excess of unit/frequency restrictions are not eligible for reimbursement even with override modifiers.
Anthem may reject or deny the claim or recover/recoup payment if coding/billing guidelines or reimbursement policies are not followed.
Authorization and medical necessity guidelines remain applicable.

Key Terms

Medically Unlikely Edit (MUE)

DefinitionMedically Unlikely Edit (MUE): Maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.

PurposeMUEs are used as a basis for frequency maximums and may inform Anthem's per-date limits and pre-adjudication edits.

Interaction with editsAnthem may base frequency maximums on CMS MUEs among other sources; MUE-informed limits are applied pre-adjudication and are not overridden by modifiers.