New Payment Policies and Reminder on Correct Coding Guidelines
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Governs reimbursement changes effective Feb 1, 2021 for multiple therapeutic and diagnostic ophthalmology services performed same day by the same provider, and reminds providers of correct coding/editing and authorization implications; applies to physicians, participating physician groups, hospitals and ancillary providers (with county-specific Medi-Cal applicability noted).
Implemented two new payment policies effective February 1, 2021 describing reimbursement changes for multiple therapeutic and diagnostic ophthalmology services performed same day by the same provider.
Editing for correct coding does not modify or rescind prior authorization nor affect medical necessity determinations.
Multiple Procedure Reimbursement
Multiple procedure reimbursement criteria
When multiple procedures/units are billed for the same patient on the same day by the same provider:
ALL of the following
Therapeutic services MPPR
- Therapeutic services: full payment (100%) is made for the unit or procedure with the highest value; payment for subsequent procedures/units is reimbursed at 90% of the allowance.
Applies to all therapy services furnished on the same day by the same provider, regardless of single or multiple therapy disciplines (e.g., PT, OT, SLP).
Diagnostic ophthalmology MPI=7 reduction
- Diagnostic ophthalmology procedures assigned MPI=7: when two or more such diagnostic ophthalmology procedures are performed by the same provider on the same patient on the same day, 100% of the maximum allowance is allowed for the first (highest-cost) diagnostic procedure and 80% of the allowance is allowed for each subsequent diagnostic ophthalmology procedure.
Coding and Payment Rules
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Provider Responsibilities and Billing Reminders
Correct coding edits do not change prior authorization or medical necessity
All claims are subject to editing to ensure compliance with National Correct Coding Guidelines and the ICD‑10‑CM Official Guidelines for Coding and Reporting; editing for correct coding does not modify or rescind an authorization for services, nor does it affect medical necessity determinations. If a claim is denied after editing, resubmit a corrected claim following the National and ICD‑10 coding guidelines.
- Claims may be edited and denied for coding noncompliance; resubmission must follow National Correct Coding Guidelines and ICD‑10‑CM Official Guidelines.
- Editing does not change prior authorizations or medical necessity determinations.
Key Payment Terms
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