CurrentMVP Health CarePolicy N/A

After-Hours, Allergy Testing and Serum Preparation, and E&M — Payment Policies (Part 1)

Defines MVP Health Care reimbursement rules for after-hours services, allergy testing/serum preparation, and evaluation & management (E&M) services; includes billing, documentation, and prior authorization considerations for providers submitting claims to MVP.

Policy Summary

PayerMVP Health Care

PolicyAfter-Hours, Allergy Testing and Serum Preparation, and E&M — Payment Policies (Part 1)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 11, 2023

Next Review DateN/A

Key ActionProviders must check member eligibility, the Member Benefits Display, and MVP's Utilization Management Guides to determine if prior authorization is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8:00 am - 6:00 pmNormal business hours

160/yrAllergy units (1st year)

120/yrAllergy units (subsequent)

1/dayOne E&M per day

No separate pay

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

50%Overlap practice expense reduction

Coverage Criteria and Medical Necessity

inv-01: After-Hours Reimbursement

After-hours services reimbursement rules

After-hours codes (99050, 99051, 99053, 99056, 99058, 99060) must be billed with an E&M code and are considered inclusive to the E&M (not separately reimbursable).

99050 will not be reimbursable when submitted with preventive visit codes (99381-99397); otherwise reimbursed only when billed with an E&M and not as the sole procedure.

99051 is not reimbursed separately for Commercial and Medicare products; for Medicaid/HARP products MVP will reimburse 99051 at the Medicaid rate.

99053, 99056, 99058, 99060 must be billed with an E&M code and are considered inclusive to the E&M (MVP does not reimburse these codes separately).

inv-02: Allergy Testing Limits

Allergy testing and serum preparation reimbursement and limits

MVP reimburses allergy testing and supervision of preparation/provision of antigens for allergen immunotherapy when units/doses are specified on the claim.

95165: Number of units/doses must be specified on the claim; first year reimbursement limited to 40 units per claim and 160 units per calendar year; subsequent years limited to 30 units per claim and 120 units per calendar year.

95004: Number of tests must be specified on the claim; reimbursement limited to 80 units per calendar year.

95024 and 95027: Number of tests must be specified on the claim; each limited to 40 units per calendar year.

95028: Intracutaneous (intradermal) delayed reaction tests must have number of tests specified on the claim; reimbursement limited to 30 units per calendar year.

inv-03: E&M Medical Necessity and Documentation

Evaluation and Management (E&M) coverage and documentation standards

MVP reimburses medically necessary E&M services consistent with AMA CPT definitions.

Documentation must follow CMS 1995/1997 E&M documentation guidelines and the CMS 2021 Office and Other Outpatient Services E&M coding guidelines; medical records may be requested to verify documentation.

Member eligibility and benefits should be verified prior to services; medical necessity definitions (AMA, CMS, and MVP) apply and insufficient documentation or inappropriate level of service may lead to denial or post-payment review.

inv-04: E&M coverage criteria and billing rules

Coverage and billing rules for E&M services, preventive services, same-day services, global periods, and specific service codes.

If the claim indicates the primary reason for the visit was preventive, the claim will be reimbursed per state and federal regulations; no member cost-share should be collected unless the product is excluded.

Effective May 1, 2023: when a sick E&M visit (99202-99205, 99211-99215) is billed same day by same provider as a preventive visit, the overlapping practice expense component of the sick E&M will be reduced by 50%.

MVP allows one E&M CPT code per day per physician group per specialty.

Specified routine screening procedures (e.g., G0102, 36415, 36416, 99000/99001, Q0091, 92567, 94760/94761) will not be reimbursed separately when billed same day as E&M 99202-99215 unless sole service or properly modifiered (see policy).

Smoking cessation counseling codes (99406, 99407, G0376, G0375, S9453, S9075) are not reimbursed unless member benefits indicate coverage.

inv-05: Coverage and billing criteria

Coverage stance and specific billing rules for various E&M and scope procedure scenarios

First prenatal visit is global to total OB delivery charges; the global OB allowable amount is reimbursed on the global delivery claim.

Antepartum care codes 59425 (visits 4-6) and 59426 (7+ visits): claims must indicate the number of prenatal visits or they will not be reimbursed.

When two inpatient physician E&M codes are billed on the same date for the same/related condition by the same provider, the second E&M will be denied.

Refer to After-Hours Payment Policy for codes 99051-99060; 99050 reimbursed unless submitted with preventive visit codes 99381-99397.

Urgent care E&M codes will not be reimbursed when billed with Well Child Care, routine diagnoses, or routine services such as immunizations.

inv-06: Article 28 Split Billing Criteria

Split billing coverage limitations and billing rules

Split billing is recognized only when the billing entity structure meets Article 28 guidelines (or state equivalent); MVP limits split billing to Article 28 providers participating with Medicare and/or Medicaid/Government programs.

MVP Commercial/ASO and Exchange products are not eligible for split billing arrangements.

When billing under split billing, hospital receives technical reimbursement and provider claims should use a facility place of service (e.g., POS 22 rather than POS 11).

Procedure codes on MVP's In-Office Only list are not reimbursed under split billing regardless of product unless an authorization is obtained; with authorization reimbursement may be allowed for Medicare and Medicaid products.

inv-07: Audiology Services Criteria

Audiology billing and coding criteria

Audiologists may not bill Evaluation and Management CPT codes (99201-99499).

Audiologists may not bill cerumen removal codes (69209, 69210); cerumen removal is included in the diagnostic test relative value; if a physician removes impacted cerumen on same day as diagnostic test, physician bills G0268.

Timed audiology CPT codes (92620, 92621, 92626, 92627, 92640) are billed only when testing meets time requirements; a timed code is billed only if testing is at least 51% of the time designated in the code descriptor.

When calculating time for audiology evaluation codes, activities such as counseling, goal setting, or evaluating potential remediation are not included in the testing time.

Audiometric test codes assume both ears are tested; if only one ear tested, modifier 52 should be billed to indicate less than the normal procedure.

inv-08: Vermont audio-only and audiology billing criteria

Vermont-specific coverage and reimbursement rules for audio-only services and supervised non-licensed behavioral health providers.

MVP covers telephone (audio-only) services in Vermont and will reimburse for telephone-only and equivalent-to-in-person codes when provided via audio-only means.

Reimbursement for covered services delivered via audio-only in Vermont will be at 75% of the medical provider physician fee schedule (where specified).

When billing in-person CPT codes performed through audio-only means, use Place of Service = 99 and Modifier = V3; Modifier V3 must be in first position for behavioral health codes delivered equivalent-to-in-person via audio-only.

Non-Physician/APRN behavioral health providers may be reimbursed for contract codes delivered through audio-only but are not eligible to bill CPT codes 99441-99443.

Qualified Non-Licensed Practitioners in Vermont may bill under direct supervision of a Qualified Licensed Practitioner when on the roster per state requirements; supervising clinician must have the same degree level and supervising information must be reported on claim (CMS 1500 fields). Use HO (Master's) or HP (Doctorate) modifiers as applicable.

inv-09: Coverage stance and billing requirements

Coverage and reimbursement positions extracted from the document segments in this window.

Services performed by non-licensed providers who cannot practice independently and are not actively working toward licensure are non-reimbursable; MVP Medicare members are not eligible to receive services from non-licensed providers even under supervision.

Supervised billing in Vermont requires reporting supervising clinician information on claims (e.g., CMS 1500 Boxes 24j and 31) and use of HO/HP modifiers indicating Master's or Doctorate level as applicable; supervising clinician degree must match the unlicensed clinician's required degree level.

MVP will deny claims for contrast materials for Commercial, Exchange, and Medicaid products because contrast material cost is considered included in the primary exam fee; HCPCS contrast codes (e.g., A9579, Q99xx series) are not separately reimbursable.

Authorizations are required for select services per MVP's Utilization Management Guides; when authorization is required it applies to Technical, Professional, Global and/or Facility claims and services provided without prior approval will be denied administratively (applies to Outpatient Surgical Services and Radiology).

inv-10: COVID-19 testing coverage criteria

Coverage is provided when testing is medically appropriate; testing for pandemic control or administrative/screening purposes without medical determination is not covered.

COVID-19 diagnostic/viral and antibody testing are covered when the test is medically appropriate for diagnosis and treatment of the individual member as determined by the provider.

Testing ordered or performed solely for pandemic control, reopening the economy, employer/government/school/common carrier requirements, or at member request solely to self-assess immune status is not covered.

Tests submitted with administrative or screening primary diagnosis codes (examples listed in policy) will be denied; providers should use appropriate clinical diagnoses.

Exceptions

MVP will cover testing when required by applicable law and regulation.

inv-11: Default Pricing reimbursement criteria

Default Pricing when no reimbursement rate assigned.

Default Pricing applies when no reimbursement rate has been assigned by MVP, an executed contract, CMS, or NYS Medicaid; MVP will establish a rate based on gap pricing or default pricing.

Under Default Pricing, MVP will pay up to 30% of billed charges unless otherwise specified in the parties' executed contract or an assigned CMS/NYS Medicaid rate.

inv-12: Nutritional Counseling and Diabetic Management Coverage Criteria

Coverage and billing requirements for nutritional counseling and diabetic management services

Nutritional counseling is reimbursable when medically necessary for chronic diseases where dietary adjustment has a therapeutic role and must be prescribed by a physician or qualified non-physician practitioner.

Services must be furnished by recognized providers (e.g., licensed nutritionist, registered dietitian, registered nurse, certified diabetes educator) and must be billed under the individual provider's number.

Reimbursable CPT/HCPCS codes for nutritional counseling include 97802, 97803, 97804 and G0270, G0271.

Medicare MSA limitation

For Medicare MSA plans only, use of codes 97802-97804 and G0270-G0271 is limited to specified ICD-10-CM diagnosis codes; other MVP plans have no diagnosis code restrictions.

inv-13: ICD-10 code inclusion for nutritional counseling

The document lists diagnosis codes that can be used to justify nutritional counseling related to diabetes and its complications.

The policy includes extensive ICD-10 code listings for drug/chemical induced diabetes (E09.*), Type 1 diabetes (E10.*), Type 2 diabetes (E11.*), other specified diabetes (E13.*), and pregnancy-related diabetes (O24.*) that may be used to support nutritional counseling claims; see appendix/code lists for specific codes.

inv-14: Nutritional Counseling and Diabetic Management Coverage Criteria

Coverage and exclusions for nutritional counseling and limitations for diabetic management codes

Diabetic management reimbursable codes include G0108 (individual, per 30 minutes) and G0109 (group, per 30 minutes).

For Medicare MSA plans, G0108 and G0109 are limited to specified diagnoses; other MVP plans will reimburse diagnoses in the E08–E13 ranges as applicable.

Nutritional counseling is not reimbursed for commercial diet plans, gym memberships, holistic therapy, health resorts/recreational programs, skill/relaxation/lifestyle programs, supplemental fasting, or treatment by a physical therapist for weight loss.

inv-15: Coverage/coding guidance

This excerpt provides ICD-10 diagnosis codes to be used for claims; specific reimbursement criteria and payment rates are governed by provider fee schedules and IPA agreements.

Providers must refer to provider fee schedules or IPA agreements for specific reimbursement guidelines; policy lists ICD-10 diagnosis codes relevant to diabetic management and nutritional counseling but payment specifics are determined by fee schedules/contracts.

inv-16: Diagnosis matching and medical necessity criteria

For each listed procedure code or code group, MVP requires the correct associated diagnosis per the referenced Medicare LCD/NCD or specialty guidance; failure to submit the correct diagnosis will result in denial for lack of medical necessity.

Correct diagnosis must be submitted with the claim in accordance with the applicable Medicare Local Coverage Determination (LCD), National Coverage Determination (NCD), or specialty society guidance; MVP will deny claims that do not meet these diagnosis-matching requirements.

Procedure groups (examples)

Transthoracic echocardiography (93303-93308, 93350-93352): correct diagnosis per referenced CMS Document ID(s) or Article is required; pediatric cardiology specialty excluded from some edits.
Facet joint injections, medical branch blocks, and radiofrequency neurotomy (64490-64495, 64625, 64633-64636): correct diagnosis per LCD required.
Nerve conduction studies and electromyography (51785, 92265, 95860-95874, 95885-95913, 95933, G0255, 95937): correct diagnosis per LCD required.

inv-17: Diagnosis-linked coverage requirements for listed lab tests

Coverage is conditioned on submission of correct/reimbursable diagnosis codes aligned with cited clinical or Medicare coverage guidance; lack of appropriate diagnosis may result in denial for medical necessity.

Specific laboratory assays require appropriate diagnoses per referenced guidance; claims without correct diagnosis will be denied for medical necessity.

Examples by test code

82746 (Folic Acid): diagnosis per ASCP guidance required; claim may be denied if not met.
82607 (Cyanocobalamin/Vitamin B12): diagnosis must match Medicare Local Coverage Determination (Novitas) or claim will be denied.
83001 (FSH): diagnosis must align with American Society for Reproductive Medicine guidance or claim will be denied.

inv-18: Diagnosis code appendix for ESR

ICD-10 diagnoses listed as relevant indications for ESR

The policy appendix enumerates multiple ICD-10 diagnosis codes across neoplasm, hematologic, immune, endocrine, neurologic, and ophthalmologic categories that are considered relevant indications for Erythrocyte Sedimentation Rate (85652) testing; providers must use appropriate diagnosis codes from the appendix when submitting claims.

Codes, Units, and Billing Thresholds

Transthoracic Echocardiography — CPTCPTCovered

93303	Transthoracic echocardiography for congenital cardiac anomalies; Group 2
93304	Transthoracic echocardiography for congenital cardiac anomalies; Group 2
93306	Real time transthoracic echocardiography; Group 1
93307	Real time transthoracic echocardiography; Group 1
93308	Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study; Group 3
93350	Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test; Group 4
93351	Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test; Group 4
93352	Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test; Group 4

Facet Joint and Neurotomy — CPTCPTCovered

64490	Injection, anesthetic agent and/or steroid, diagnostic or therapeutic agent injection with image guidance; cervical or thoracic
64491	...; lumbar or sacral
64492	...
64493	...
64494	...
64495	...
64625	Destruction by neurolytic agent, paravertebral facet joint nerve; cervical, thoracic, lumbar, or sacral
64633	Destruction by neurolytic agent; facet joint nerve, lumbar
64634	...
64635	...

1–10 of 11

1/2

Nerve Conduction Studies, EMG, and Related — CPT/HCPCSmixedCovered

51785	Electroneurography, voiding dysfunction studies (when applicable) — included in NCS/EMG group per policy
92265	Electroretinography; diagnostic — included where applicable per LCD
95860	Needle electromyography, one limb, with or without related nerve conduction studies
95861	Needle electromyography, two limbs
95863	Needle electromyography, thoracic paraspinal
95864	Needle electromyography, larynx
95865	Needle electromyography, cranial nerve supplied muscles
95866	Needle electromyography, related studies
95867	Needle electromyography additional
95868	Nerve conduction studies components

1–10 of 29

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Antibody Herpes Simplex Virus — CPTCPTCovered

86695	Herpes Simplex, type 1 — requires appropriate diagnosis per clinical guidance
86696	Herpes Simplex, type 2 — requires appropriate diagnosis per clinical guidance

Vitamin D Testing — CPTCPTCovered

82306	Vitamin D 25 hydroxy — requires correct diagnosis per Medicare LCD
82652	Vitamin D 1.25 hydroxy — requires correct diagnosis per LCD

Allergen and Immunology Assays — CPTCPTCovered

82785	Assay of Gammaglobulin IGE — requires appropriate diagnosis per clinical guidance
86003	Allergen specific IGE; quantitative or semiquantitative, crude allergen extract, each — requires appropriate diagnosis
86008	Allergen specific IGE; quantitative or semiquantitative, recombinant/purified component, each — requires appropriate diagnosis

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior authorization and eligibility checks

MVP Payment policies are not a guarantee of payment. Providers must check member eligibility, the Member Benefits Display, and MVP's Utilization Management Guides and Benefit Interpretation Manual to determine benefits and whether prior authorization is required. These resources are available by signing into your account at mvphealthcare.com. When an authorization is required per MVP's Utilization Management Guides, that authorization applies to all technical, professional, global and/or facility claims for the service. Services provided without required prior approval will be denied administratively (this administrative denial is applied to specified service sets, including Outpatient Surgical Services and the Radiology code set as defined in MVP Payment Policies).

Prior authorization (when required) applies to Technical, Professional, Global and Facility claims.
Administrative denials will be applied if services requiring authorization are provided without prior approval; examples include Outpatient Surgical Services and Radiology code set.
Check Member Benefits Display for benefit specifics and eligibility before rendering or billing services.

Definitions and Key Terms

Medical Necessity — definition and documentation

Medical Necessity — MVP definitionServices necessary to prevent, diagnose, correct or cure conditions causing acute suffering, endanger life, impair function, recommended by treating provider, and determined by MVP or its designee to meet appropriateness criteria

Documentation standardMVP follows CMS 1995/1997 documentation guidelines and CMS 2021 Office and Other Outpatient Services guidance; medical records may be requested

CMS/AMA referencesPolicy references AMA and CMS definitions and requires documentation to support level of service billed

Normal business hours

Normal business hours8:00 am - 6:00 pm EST, Monday through Friday

After‑hours coding implicationAfter‑hour codes are used when services occur outside these normal business hours and are inclusive to E&M when billed

Policy Summary

PayerMVP Health Care

PolicyAfter-Hours, Allergy Testing and Serum Preparation, and E&M — Payment Policies (Part 1)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 11, 2023

Next Review DateN/A

Key ActionProviders must check member eligibility, the Member Benefits Display, and MVP's Utilization Management Guides to determine if prior authorization is required.

SourceLink

On This Page

Diabetes education code 98960 is reimbursable only when billed alone and will deny as bundled when billed with E&M office visit codes (example 99211-99215).

Osteopathic manipulation codes (98925-98929) are not reimbursed unless there is a contractual exception.

Immunization administration codes (90460-90474, G0008-G0010) are reimbursed only when billed with diagnosis code Z23.

When an E&M is provided during a major procedure global period, no separate reimbursement unless a significant unrelated problem exists and Modifier 24 must be appended; minor procedure 10-day post-op period E&M not reimbursed.

First prenatal E&M visit (99201-99215) is global to the total OB delivery charges; antepartum codes 59425/59426 require the claim to indicate number of prenatal visits or will not be reimbursed.

When two inpatient physician E&M codes are billed on same date for same/related condition by same provider, the second E&M will be denied.

MVP follows CMS guidelines and does not reimburse consultation codes (99241-99245, 99251-99255); use appropriate E&M codes instead.

Only the provider who orders observation services can bill observation codes; initial hospital consultation should be billed as initial hospital visit; one visit per provider per day per condition allowed.

Certain procedures (e.g., intubation 31500, central line 36555/36556, CPR 92950) do not count toward critical care time and may be reimbursed separately; critical care timing and exclusions described in policy.

When multiple arthroscopic/endoscopic/non-GI scope procedures within same code family are performed same date, highest RVU procedure reimbursed and additional procedures reduced per Medicare methodology.

Split billing arrangements are accepted only for Article 28 providers participating in Medicare and/or Medicaid/Government programs; Commercial/ASO and Exchange products are not eligible.

Services by non-licensed providers who cannot practice independently and are not actively working toward licensure are non-reimbursable; MVP Medicare Members are excluded from receiving services by non-licensed providers even under supervision.

For audiology timed codes in Vermont, only testing time counts; timed audiology codes billed only if testing is at least 51% of designated time.

For CPT codes designated in 15-minute units, unit counts correspond to specified minute ranges (policy provides unit-to-minute mappings).

Corneal pachymetry (76514) and visual field testing (92081-92083): correct diagnosis per LCD required.

84443, 84436, 84439, 84479 (TSH, thyroxine, free thyroxine, THBR): diagnoses must follow CMS Medicare LCD/NCD guidance or claim will be denied.

84481 (T3): refer to appendix for appropriate diagnosis codes; correct diagnosis required or claim may be denied.

Billing Rule

In-Office Only list authorization requirement

MVP Commercial/ASO and Exchange products are not eligible for split billing. Under split billing the hospital generally receives technical reimbursement; provider claims must be billed with facility place of service. Procedure codes on the MVP In‑Office Only list are not reimbursed under split billing arrangements regardless of product unless prior authorization is obtained. If authorization is obtained, reimbursement may be allowed for Medicare and Medicaid products.

MVP In‑Office Only list: procedure codes require authorization for split billing reimbursement.
If split billing is used, submit physician claims with facility place of service (e.g., POS 22 rather than POS 11).
Commercial/ASO/Exchange products: split billing not eligible.

Denial Risk

Prior authorization and administrative denials

MVP requires authorizations for select services as identified in MVP's Utilization Management Guides. When required and not obtained, claims will be denied administratively. Providers should obtain prior authorization where indicated to avoid administrative denials.

Authorizations identified in Utilization Management Guides must be secured prior to service.
Denials for lack of authorization are administrative and affect all claim components (technical, professional, facility).
Applied administrative denials include Outpatient Surgical Services and Radiology code set per policy.

Note

Reimbursement reference

Please see your provider fee schedule or your IPA agreement for specific reimbursement guidelines and contract-specific instructions.

Reimbursement specifics (rates, modifiers, place of service rules) are defined in your provider fee schedule or IPA agreement.

Documentation Required

Laboratory test documentation and medical necessity requirements

MVP requires appropriate diagnosis codes to support medical necessity for select lab and assay codes. Claims submitted without the correct diagnosis will be denied per Medicare Local Coverage Determinations or specialty society guidance.

Folic Acid assay (82746): MVP requires the correct diagnosis be submitted in accordance with ASCP clinical guidance.
Cyanocobalamin / Vitamin B12 (82607): MVP requires diagnoses consistent with Medicare Local Coverage Determinations (Novitas) or the claim will be denied.
Gonadotropin Follicle Stimulating Hormone (83001): MVP requires diagnoses per the American Society for Reproductive Medicine or claim will be denied.
Thyroid testing (TSH 84443, Thyroxine 84436, Free T4 84439, THBR 84479): Claims require appropriate diagnoses per Medicare LCDs or will be denied.
Triiodothyronine (T3 84481): MVP requires the correct diagnosis be submitted or claim will be denied; follow ASCP and Endocrine Society guidance.

Note

ICD-10 code lists for diabetes and diabetic management

The policy references multiple ICD‑10 diagnosis lists used to support diabetic/nutritional counseling and related services. Providers should code claims using the applicable ICD‑10 codes from these lists when billing diabetes management or nutritional counseling services.

Drug/chemical induced diabetes (examples): E09.3211, E09.3212, E09.3213, E09.329, E09.3291 (and related E09.x codes for retinopathy and complications).
Type 1 diabetes (examples): E10.3212, E10.3213, E10.3291, E10.3292, E10.3293, E10.8, E10.9 (and related E10.x codes).
Type 2 diabetes (examples): E11.00, E11.01, E11.21, E11.22, E11.29, E11.3211, E11.3212, E11.3213, E11.329, E11.3291, E11.3292, E11.3293, E11.331, E11.3311, E11.3312, E11.3313 (and related E11.x codes).
Other specified diabetes (examples): E13.22, E13.29, E13.3211, E13.3212 (and related E13.x codes).
Diabetic management CPT/HCPCS: G0108 (individual DSMT, per 30 min) and G0109 (group DSMT, per 30 min). Medicare MSA plan restrictions: follow ICD‑10 ranges as noted; other plans reimburse ICD‑10 in range E08–E09 as indicated.

Documentation Required

Appendix code lists and sample diagnosis groupings

Appendix code lists referenced in the policy include diagnosis groupings used to support lab testing and other services. Providers should reference the policy appendix or corresponding document IDs for full code sets when submitting claims.

Follicle Stimulating Hormone related diagnoses (sample codes include E66.3, E66.9, E78.00, E78.2, E78.5, E83.110, etc.).
Herpes Simplex Virus related diagnoses: extensive list including B00‑B09 and many symptom/encounter codes (see appendix for full set).
Gammaglobulin IGE related diagnoses: broad allergy, respiratory, dermatologic, and related codes (see appendix for full set).
Erythrocyte Sedimentation Rate (ESR) related diagnoses: neoplasm, hematologic, immune, neurologic/ophthalmologic sample codes and many specific C/D/G/H codes (see appendix for full set).
Neoplasm diagnoses (sample): multiple malignant neoplasm codes across C00–C97 ranges shown in appendix.
Hematologic/immune diagnoses (sample): anemia, hemoglobinopathies, myelodysplastic disease, multiple myeloma, leukemias (see appendix).
Neurologic/ophthalmologic diagnoses (sample): Parkinson’s, multiple sclerosis, migraine variants, retinal and optic nerve disorders (see appendix).
Providers must use the specific appendix code lists tied to each test or service to substantiate medical necessity on claims.

Claiming restrictionAfter‑hour CPT codes are not payable if they are the only CPTs listed on the claim

Medical Necessity — CMS guidance

Medical Necessity — CMS/Medicare definitionMedical necessity is the overarching criterion for payment; billing a higher level of E&M when a lower level is warranted is inappropriate; documentation must support level billed

Documentation influenceVolume of documentation should not be the primary influence for selecting service level

ConsequencesClaims lacking appropriate medical necessity/documentation may be denied

New Patient

New Patient definitionA patient who has not received professional services from the same provider or another qualified health care professional of the exact same specialty and sub‑specialty within the same group (same tax ID) in the past three years

ApplicabilityApplies when determining New vs Established patient status for E&M coding

ReferenceFollows AMA definition per policy

Significant E&M Service

Significant E&M ServiceA service that at minimum warrants an expanded problem focused examination; routine reassurance, monitoring, med refills, and minor problem‑focused issues are not considered significant

Billing implicationSignificant services support higher-level E&M reporting when documentation reflects expanded examination and medical decision making

Examples of non‑significant servicesRoutine reassurance, monitoring, medication refills, minor problem‑focused care

Critically ill — definition

Critically ill definitionA critical illness/injury that acutely impairs one or more vital organ systems with high probability of imminent or life‑threatening deterioration

ExamplesCentral nervous system failure, circulatory failure, shock, renal/hepatic/metabolic/respiratory failure

Billing noteTime counted toward critical care must be documented and directly related to patient care; some procedures and family discussions do not count

Critical care time rules

Critical care time rulesTime counted toward critical care is time directly related to patient care (bedside or elsewhere) and must be documented; certain procedures and activities do not count toward critical care time

Timing unit rules99291 not allowed if <30 minutes; additional 99292 units added per specified minute ranges

Documentation requirementRecord start/stop times and activities to support billed critical care minutes

Split Billing

Split Billing — definitionTwo separate charges: professional (physician) and technical (facility) reimbursement

Professional componentServices by physician (consultation, interpretation) billed to provider group

Technical componentFacility‑based services (labs, imaging, E&M in facility) billed to hospital/facility

Global reimbursement

Global reimbursement — definitionOne bill representing both professional and technical services billed and reimbursed at a global rate

Typical payment flowGlobal payment usually goes to physician practice unless providers employed by hospital

Contrast with split billingGlobal reimbursement bundles professional and technical into single payment vs split billing separates them

Professional vs Technical

Professional vs Technical — summaryProfessional: services by physicians (interpretation, consults) paid to provider group; Technical: facility‑based services (labs, x‑rays, E&M in facility) reimbursed to hospital

Use caseDetermines billing entity and reimbursement routing under split billing arrangements

Policy noteSplit billing eligibility limited to Article 28 providers for Medicare/Medicaid per policy sections

Audiological diagnostic testing

Audiological diagnostic testing — definitionTests of audiological and vestibular systems including hearing, balance, auditory processing, tinnitus, and diagnostic programming performed by qualified audiologists

Timed audiology codes requirementWhen CPT descriptor has time, testing must meet time designations and testing must be ≥51% of designated time to bill timed code

Examples of timed audiology codes92620, 92621, 92626, 92627, 92640

CPT

CPT — definitionCurrent Procedural Terminology (CPT) — medical code set used to report medical, surgical, and diagnostic procedures and services

E&M codes rangeE&M CPT codes generally fall in range 99202‑99499 for physician/qualified health professional services

Use in policyPolicy references CPT/AMA definitions for coverage and billing rules

E&M Codes

E&M Codes — definitionEvaluation and Management (E&M) codes — CPT codes 99202‑99499 representing evaluation and management services

Documentation guidanceMVP follows CMS 1995/1997 and 2021 E&M documentation guidelines for determining medical necessity and level

Billing implicationOne E&M CPT code allowed per day per physician group per specialty (policy rule)

Qualified Licensed / Non‑Licensed Practitioner

Qualified Licensed Practitioner — definitionLicensed and credentialed provider acting within scope of practice

Qualified Non‑Licensed Practitioner — definitionProvider actively working towards licensure as specified by profession

Supervised billingQualified Licensed Practitioner may bill for services provided by Qualified Non‑Licensed Practitioner under direct supervision per policy rules

Qualified Non‑Licensed Practitioner

Qualified Non‑Licensed Practitioner — definitionProvider actively working towards licensure as specified by their profession

Supervision requirementDirect supervision by licensed practitioner required for supervised billing eligibility

Billing fieldsSupervising clinician information must be reported on claims per policy (CMS 1500 Boxes 24j and 31)

HO / HP modifiers

HO / HP modifiersModifier HO required for Master's‑level supervised billing; Modifier HP required for Doctorate‑level supervised billing

Use caseAppend appropriate modifier when claim is for supervised billing of eligible unlicensed practitioners (Vermont guidance)

Claim fieldsAlso populate Box 24j (supervisor NPI/taxonomy) and Box 31 (supervisor name/degree) on CMS 1500

Contrast material reimbursement rationale

Contrast material reimbursement rationaleMVP considers both ionic and non‑ionic contrast material inclusive to the primary examination fee and not separately reimbursable

RationaleCost convergence and routine non‑ionic use mean separate payment is not warranted

Affected codesContrast HCPCS (e.g., A9579, Q9951, Q99xx) are listed in policy as not separately reimbursable

COVID‑19 diagnostic / antibody test definitions

COVID‑19 diagnostic (viral) test — definitionA virus/antigen detection (diagnostic) test that determines if a person is currently infected with COVID‑19

Antibody (serology) test — definitionMay determine if a person has been exposed to COVID‑19 and should not be used to diagnose current infection per FDA guidance

Policy applicabilityPolicy applies to participating and non‑participating practitioners, facilities, labs, pharmacies and all lines of business