CurrentMolina HealthcarePolicy N/A

Bundled (CMS Status Indicator B) procedure code reimbursement

Governs Molina Healthcare's reimbursement stance that procedure codes assigned CMS Status Indicator 'B' are always bundled and not eligible for separate reimbursement; applies to Molina providers subject to state and federal rules.

Policy Summary

PayerMolina Healthcare

PolicyBundled (CMS Status Indicator B) procedure code reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionDo not submit prior authorization for separate reimbursement of procedure codes assigned CMS Status Indicator 'B' because these codes are not eligible for separate payment.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Status Indicator 'B'procedure codes not eligible for separate reimbursement

Included paymentRVUs not considered for Medicare reimbursement for 'B' codes

State exceptionsstate-specific deviations may apply

CMS & NCCIsource guidance used

Coverage Criteria

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Bundled Code Coverage Criteria

Covered stance for Molina Healthcare regarding CMS Status Indicator 'B' procedure codes:

Procedure codes assigned CMS Status Indicator 'B' are not eligible for separate reimbursement; payment is bundled into the related primary service payment.

Bundling applies regardless of whether the 'B' code is billed on the same date of service or on a separate claim or date; payment remains included with the related service.

If Relative Value Units (RVUs) are assigned to a Status Indicator 'B' code, those RVUs are not considered for separate Medicare reimbursement; payment is included in the related service payment.

Examples: services such as a telephone call from a hospital nurse are considered bundled and will not be reimbursed separately when assigned Status Indicator 'B'.

Operational rule: Do not submit prior authorization requests seeking separate reimbursement for procedure codes assigned CMS Status Indicator 'B'.

Hierarchy of authority: In the event of a conflict, applicable federal or state guidance, the member's benefit plan, or provider contract language take precedence over this policy.

Coding and Reimbursement Details

CMS Status Indicator B codesmixedNot Covered

No codes listed

RVU consideration — CMS Status Indicator 'B' codes

RVU inclusion and Medicare reimbursementIf RVUs are provided for codes with CMS Status Indicator 'B', those RVUs are not considered for separate Medicare reimbursement — payment is included in the related service payment.

Status Indicator 'B' payment treatmentProcedure codes assigned CMS Status Indicator 'B' are not eligible for separate reimbursement and are bundled into payment for related services.

Effect on prior authorizationDo not submit prior authorization requests seeking separate reimbursement for procedure codes assigned Status Indicator 'B' because they are not separately payable.

Provider Actions and Billing Rules

Prior Authorization

Do not request prior authorization for CMS Status Indicator 'B' codes

Do not submit prior authorization requests seeking separate reimbursement for procedure codes assigned CMS Status Indicator 'B' because these codes are not eligible for separate payment and their payment is always included with related services.

Procedure codes assigned a CMS status Indicator flag 'B' are not eligible for separate reimbursement.
Payment for these services is integrated into the payment for related services; RVUs (if provided) are not considered for separate Medicare reimbursement.

Definitions

CMS — definition of the Centers for Medicare & Medicaid Services

Agency nameCenters for Medicare & Medicaid Services — federal agency within the U.S. Department of Health and Human Services administering Medicare and partnering with states to administer Medicaid and CHIP.

Primary roleAdministers the Medicare program and collaborates with state governments on Medicaid and the Children’s Health Insurance Program (CHIP).

Authority in policyMolina follows CMS classifications (NPFS) when determining bundled status and reimbursement treatment for procedure codes.

CPT — definition of Current Procedural Terminology

TermCurrent Procedural Terminology (CPT).

PurposeA set of medical codes used by physicians, allied health professionals, nonphysician practitioners, hospitals, outpatient facilities, and laboratories to describe procedures and services performed.

Use in policyCPT codes in the NPFS are used to determine status indicator flags and reimbursement treatment.

HCPCS — definition of Healthcare Common Procedure Coding System

TermHealthcare Common Procedure Coding System (HCPCS).

PurposeA standardized coding system that Medicare and other health insurance programs use to identify services and procedures provided by medical professionals.

Relation to NPFSHCPCS procedure codes are included in the NPFS and classified with status indicator flags affecting claims processing and payment.

NPFS — definition of National Physician Fee Schedule

TermNational Physician Fee Schedule (NPFS).

DefinitionA list of fees used by Medicare to pay physicians and other providers/suppliers; updated annually and contains relative value units (RVUs) and payment amounts for each CPT code.

Role in status indicatorsThe NPFS contains CPT and HCPCS procedure codes and the status indicator flags that guide claims processing and reimbursement determinations.

Status Indicator Flag — definition of status indicator flag for codes

TermStatus Indicator Flag.

DefinitionA classification of a CPT or HCPCS procedure code into a specific category indicating how it will be handled in claims processing and whether it will be reimbursed.

ImplicationCodes assigned Status Indicator 'B' are not eligible for separate reimbursement and are bundled into payment for related services.

RVUs — definition of Relative Value Units

TermRelative Value Units (RVUs).

DefinitionA measure used in the Medicare reimbursement formula representing the relative resources required to provide a service, including physician work, practice expense, and malpractice expense.

Policy impact for 'B' codesWhen RVUs are provided for codes with CMS Status Indicator 'B', those RVUs are not considered for separate Medicare reimbursement; payment is included within the related service payment.