CurrentMVP Health CarePolicy N/A
After‑Hours, Allergy Testing and Serum Preparation, and E&M Reimbursement
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Governs MVP Health Care reimbursement rules for after-hours service codes, allergy testing and serum preparation units, and Evaluation & Management (E&M) medical necessity and documentation; affects providers submitting claims to MVP.
Policy Summary
PayerMVP Health Care
PolicyAfter‑Hours, Allergy Testing and Serum Preparation, and E&M Reimbursement
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateMay 11, 2023
Last ReviewMar 1, 2023
Next Review DateN/A
Key ActionVerify member eligibility, benefits and prior authorization requirements via Member Benefits Display and MVP Utilization Management Guides before billing.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
8:00 am - 6:00 pmdefined normal business hours
160max allergy serum units - first year per calendar year
120max allergy serum units - subsequent years per calendar year
80max for CPT 95004 per calendar year
oneE&M CPT allowed per day per physician group per specialty
allapplies to all lines
Coverage Criteria — After-hours, Allergy Testing, and E&M
inv-01: Coverage criteria for after-hours, allergy testing, and E&M
Covered when billed with an appropriate E&M and when unit or documentation limits are met:
After-hours CPT codes (99050, 99051, 99053, 99056, 99058, 99060) must be billed with an appropriate E&M code and are considered inclusive to that E&M (not payable if listed as the only CPT on the claim); 99051 is not separately reimbursed for Commercial and Medicare products (Medicaid/HARP may reimburse at Medicaid rates).
ALL of the following
- First year: up to 40 units per claim and 160 units per calendar year.
- Subsequent years: up to 30 units per claim and 120 units per calendar year.
- Specific CPT test limits (examples): 95004 limited to 80 units per calendar year; 95024 and 95027 limited to 40 units per calendar year; 95028 limited to 30 units per calendar year.
Evaluation & Management (E&M) services are covered when medically necessary and documented per CMS/AMA guidance (CMS 1995/1997 documentation guidelines and 2021 Office/Outpatient E&M coding guidelines). Medical records may be requested to verify documentation and medical necessity; verify member eligibility and benefits prior to providing services.
inv-02: E&M coverage and bundling rules
Rules governing reimbursement, bundling, and modifier usage for E&M services and associated procedures:
When a sick E&M (99202-99205, 99211-99215) is billed the same date and by the same provider as a preventive E&M visit, the overlapping practice expense component of the sick E&M will be reduced by 50% (effective May 1, 2023).
Allow one E&M CPT code per day of service per physician group per specialty; preventive medicine visits reimburse but many office procedures listed will not be reimbursed separately when performed same day as preventive visits (see member benefits).
Specific routine screening and specimen collection codes (e.g., G0102, 36415/36416, Q0091, 92567, 99000/99001) are not reimbursed separately when performed the same day as an E&M 99202-99215 unless they are the sole service or submitted with required modifiers/conditions (e.g., external lab with modifier CG).
Smoking cessation counseling codes (99406, 99407, G0376, G0375, S9453, S9075) are not reimbursed unless member benefits indicate coverage.
Diabetes education (98960) is reimbursed only when billed alone and will be denied/bundled when billed with an office E&M visit (e.g., 99211-99215).
Certain services (e.g., allergy injections, dermatologic phototherapy) require modifier 25 when billed with an E&M/ED/Inpatient to be considered separately; follow CPT and MVP modifier guidance for same-day multiple E&M visits and modifier 25 usage.
No separate reimbursement for E&M services provided during major procedure global periods unless a significant unrelated problem exists; Modifier 24 is required for unrelated post-op E&M. Minor-procedure 10-day post-op E&M services are not separately reimbursed. Refer to MVP Virtual Check-in/Telehealth policies for non-face-to-face services.
First prenatal visit (E&M 99201-99215) is global to OB delivery charges; antepartum codes (59425, 59426) require indication of number of prenatal visits to be reimbursed. When two inpatient physician E&M codes are billed same date for same/related condition by same provider, the second E&M will be denied.
inv-03: Coverage Criteria — key coverage positions from the excerpt
Key coverage positions and operational criteria from the policy excerpt:
Prenatal E&M: the first prenatal visit (99201-99215) is global to the total OB delivery allowable; antepartum codes require the number of prenatal visits to be indicated or they will not be reimbursed.
Inpatient E&M duplicate rule: 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 code will be denied.
Consultation codes (office and inpatient 99241-99245, 99251-99255) are not reimbursed per MVP's adherence to CMS consultation guidance; providers should report appropriate E&M codes and may use modifiers (e.g., AI) to indicate attending/admitting physician when applicable.
Critical care billing: 99291 is not reimbursed if total critical care time is less than 30 minutes; time thresholds determine when additional 99292 units are payable (30-74 min = 99291 once; 75-104 min = 99291 + 99292 x1; etc.); specific procedures (e.g., intubation, central line placement) do not count toward critical care time and may be billed separately.
Arthroscopic/endoscopic non-GI multiple procedures: when multiple procedures within the same code family are performed the highest RVU procedure is reimbursed at full value and additional procedures follow Medicare multiple-procedure reduction methodology across product lines.
Split billing recognition is limited to billing entities structured to meet Article 28 guidelines (NY) or equivalent; Commercial/ASO and Exchange products are not eligible for split billing; policy applies only to Article 28 providers participating with Medicare and/or Medicaid/Government programs.
Providers must verify member eligibility, benefits, and prior authorization requirements via MVP systems since payment policies are not guarantees of payment; lack of required authorizations may result in administrative denials for affected services (e.g., outpatient surgical and radiology code sets).
inv-04: Split billing coverage parameters
Conditions under which split billing is allowed and operational billing parameters:
Split billing is permitted only when the billing entity meets Article 28 guidelines (NY) or a state equivalent and is limited to Article 28 providers participating with MVP Medicare and/or Medicaid/Government programs.
MVP Commercial/ASO and Exchange products are not eligible for split billing arrangements.
Under split billing the hospital receives technical reimbursement and provider claims should be submitted with a facility place of service (e.g., POS 22 for outpatient instead of POS 11 for office).
Procedure codes on MVP's In-Office Only list are not reimbursed under split billing regardless of product unless an authorization is obtained; if authorized, reimbursement may be allowed for Medicare and Medicaid products.
Global reimbursement (single-bill) situations result in no additional payments to facilities for professional or technical components beyond the global amount.
inv-05: Audiology coverage and billing rules
Audiology coverage definitions and billing restrictions:
Audiology services include prevention, identification, evaluation of hearing disorders, hearing-aid evaluation and follow-up, and audiological diagnostic testing for hearing and vestibular function.
Audiologists may not bill Evaluation & Management (E&M) CPT codes 99201-99499.
Audiologists may not bill CPT 69209/69210 (impacted cerumen removal); cerumen removal is included in the relative value for diagnostic tests. If a physician removes impacted cerumen same day as a diagnostic test, physician may bill G0268.
Audiometric test codes assume testing of both ears; if only one ear is tested, bill modifier 52 to indicate reduced service.
Timed audiology CPT codes (92620, 92621, 92626, 92627, 92640) have explicit time designations and may be billed as timed codes only when testing comprises at least 51% of the code's designated time; codes without time designations are billed as a session.>=51%
inv-06: Audio-only and Audiology Billing/Coverage Criteria
Audio-only service and audiology billing specifics, plus Vermont audio-only behavioral health rules:
Timed audiology CPT codes (92620, 92621, 92626, 92627, 92640) are billed only when testing meets at least 51% of the code's designated time; CPT procedures without time designations are billed as a session without regard to time.>=51%
MVP covers telephone (audio-only) services in Vermont and will reimburse audio-only services equivalent to in-person codes when provided via audio-only means; place of service 99 and Modifier V3 are required for in-person CPTs delivered via audio-only as directed in provider contract guidance.
Non-Physician/APRN behavioral health providers will be reimbursed for contractually allowed codes when delivered audio-only, but are not eligible to bill CPT codes 99441-99443; Modifier V3 must be in first position for audio-only equivalence claims.
Reimbursement for covered services delivered audio-only (medical providers) is set at 75% of the medical provider physician fee schedule for applicable services in Vermont per policy guidance.
Audiology timing vs. non-timed: If CPT descriptor includes time use timed-code rule; otherwise bill as session.
inv-07: Vermont Non-Licensed Behavioral Health Provider Billing Criteria
Billing requirements for supervised billing by non-licensed behavioral health practitioners in Vermont:
Claims must include the supervising licensed clinician's NPI and taxonomy in Box 24j of the CMS-1500 and the supervising provider's name and degree/title in Box 31.
The supervising clinician must be a licensed practitioner with the same degree level (Master's or Doctorate) as the unlicensed clinician being supervised.
Append modifier HO for Master's-level supervised billing or HP for Doctorate-level supervised billing to the billed CPT codes to indicate the practitioner level for Vermont supervised billing claims.
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.
inv-08: Contrast Materials Reimbursement Criteria
Contrast material reimbursement positions:
Cost of ionic and non-ionic contrast materials (listed HCPCS such as A9579, Q9951, Q9965-67, Q9958, etc.) is considered inclusive to the primary contrast-enhanced exam fee and is not separately reimbursable.
Claims for contrast materials will be denied for MVP Commercial, Exchange, and Medicaid products; this applies to all participating providers (physicians, hospitals, and other facilities).
Specific HCPCS codes for gadolinium- and iodine-based contrast agents are listed in the policy and will not be reimbursed separately when submitted with the associated imaging procedures.
inv-09: COVID-19 testing coverage criteria
COVID-19 testing coverage and limitations:
MVP covers COVID-19 diagnostic (virus/antigen detection) and antibody testing when medically appropriate for the diagnosis and treatment of an individual member; providers are encouraged to use reliable FDA-authorized tests.
Testing ordered or performed solely for pandemic control, surveillance, reopening, employer or third-party screening, or asymptomatic self-assessment (not medically appropriate for diagnosis/treatment) is not covered.
Claims for COVID-19 testing are subject to post-payment review and audit; examples of inappropriate primary diagnosis codes (administrative/screening reasons) will be denied and providers bear responsibility for denied claims for Medicare Advantage and Medicaid Managed Care members unless testing is required by law/regulation.
inv-10: Default Pricing rules
Default Pricing methodology when no contractual or assigned rate exists:
When a reimbursement rate has not been assigned by MVP, contract, CMS, or NYS Medicaid, MVP will establish a rate based on an acceptable gap pricing method or an industry standard; if none exists, Default Pricing applies.
Under Default Pricing MVP will pay up to 30% of billed charges unless otherwise specified by contract or an assigned CMS/NYS rate.<=30%
inv-11: Coverage criteria for nutritional counseling and DSME
Coverage criteria for nutritional counseling and diabetes self-management education (DSME):
Nutritional counseling/medical nutrition therapy is reimbursable when medically necessary for chronic diseases in which dietary adjustment has a therapeutic role, must be prescribed by a physician or qualified non-physician practitioner, and must be furnished by a recognized qualified provider (e.g., licensed nutritionist, registered dietitian, nurse trained in nutrition) billed under their provider number.
Diabetic self-management education (DSME) is medically necessary when the member has a diabetes diagnosis and services are prescribed by a physician or qualified non-physician practitioner; services must be provided by a licensed healthcare professional (e.g., registered dietician, registered nurse, or certified diabetes educator - CDE).
Reimbursable CPT/HCPCS for medical nutrition therapy include 97802, 97803, 97804, and Medicare-specific codes G0270 and G0271. For Medicare MSA plans these codes are limited to specified ICD-10 diabetes diagnoses; other plans generally reimburse within the E08-E13 ranges as described in policy.
Coverage is subject to member eligibility, benefits, and any prior authorization requirements as determined by MVP's Utilization Management Guides and the Member Benefits Display.
inv-12: ICD-10 codes relevant to nutritional counseling
ICD-10 codes listed in the policy appendix that indicate diagnoses associated with nutritional counseling eligibility (partial listing shown in policy):
ICD-10 entries in the policy appendix include numerous diabetes-related codes (examples in the extract: E09.3211, E09.3212, E09.3213, E09.329, E09.3291) that are associated with nutritional counseling and diabetic complications; refer to the Appendix for the full reimbursable diagnosis list.
inv-13: Nutritional counseling exclusions and diabetic management coverage
Exclusions and conditions for nutritional counseling and diabetic management coverage:
Nutritional counseling is not reimbursable for services such as commercial diet plans, gym memberships, holistic therapy, services offered by health resorts/recreational programs, skill/relaxation/lifestyle programs, supplemental fasting, or physical therapy solely for weight loss.
Diabetic management codes G0108 and G0109 are reimbursable; for Medicare MSA plans these codes are limited to specified ICD-10 diagnoses (policy lists the applicable diagnoses), whereas other plans reimburse diabetes-related diagnoses generally within the E08–E13 ranges as specified in the policy.
inv-14: Reimbursement guidance (note)
Operational reimbursement reminder:
Providers should consult their provider fee schedule or IPA agreement for specific reimbursement details; this policy provides coverage positions but fee/payment specifics are determined by contractual agreements and fee schedules.
inv-15: Diagnosis matching requirement
Diagnosis matching and medical-necessity submission requirements:
Claims for procedures listed in this policy must include the correct diagnosis codes consistent with applicable Medicare Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or referenced clinical society guidance; failure to submit the correct diagnosis will result in denial for lack of medical necessity.
For specific procedure groups (e.g., transthoracic echocardiography), MVP requires the diagnosis submitted with the claim to conform to the Medicare LCD (see referenced Document ID(s)); pediatric cardiology specialty may be excluded from some edits per policy notes.
inv-16: Prior authorization and eligibility
Prior authorization and eligibility verification requirements:
Participating providers must verify member eligibility and benefits via the Member Benefits Display and determine if prior authorization is required by consulting MVP's Utilization Management Guides prior to rendering services.
When an authorization is required, it applies to all technical, professional, global and facility claims for the service; lack of required prior approval can result in administrative denial for services such as outpatient surgical and radiology code sets.
Payment policies are not guarantees of payment — providers should use the Benefit Interpretation Manual and MVP systems to confirm coverage and authorization requirements before billing.
inv-17: Coverage with medical-necessity diagnosis requirements
Coverage contingent on appropriate medical-necessity diagnoses for specified laboratory and procedure codes:
For listed laboratory and diagnostic codes (examples: 82746 Folic Acid, 82607 Vitamin B12, 83001 FSH, TSH/T4 panel codes, T3 assays), MVP requires the correct diagnosis be submitted in accordance with referenced clinical guidance or Medicare LCD/NCD; claims may be denied for medical necessity if the correct diagnosis is not provided.
Providers should consult the Appendix in the policy for reimbursable ICD-10 diagnosis codes associated with these tests; references to specific LCD/NCD documents (e.g., Novitas L34914 for 82607, NCD Pub ID 100-3 Section 190.22 for TSH) are provided to determine acceptable diagnoses.
inv-18: Diagnostic indications (ICD-10 list) — ESR testing
ICD-10 diagnoses listed as relevant indications for ESR testing (partial listing):
Sample malignant and hematologic ICD-10 codes associated with ESR testing include (partial examples): C549 (malignant neoplasm of corpus uteri), C562 (malignant neoplasm of left ovary), C574 (malignant neoplasm of uterine adnexa), and multiple lymphoma and Hodgkin lymphoma codes listed in the Appendix; refer to the Appendix for the full reimbursable diagnosis list.
Coding — Procedure and Diagnosis Codes
After-hours and allergy testing codesCPTCovered
| 99050 | Office services outside regularly scheduled hours; must be billed with an E&M; not reimbursable when submitted with preventive visit codes |
| 99051 | Regularly scheduled evening/weekend/holiday office hours; must be billed with E&M; considered inclusive to the E&M; not separately reimbursed for Commercial and Medicare (Medicaid/HARP reimbursed at Medicaid rate) |
| 99053 | Services between 10:00 pm and 8:00 am at 24-hour facility; must be billed with E&M and considered inclusive |
| 99056 | Office services provided out of office at patient request; must be billed with E&M and considered inclusive |
| 99058 | Emergency basis in office disrupting scheduled services; must be billed with E&M and considered inclusive |
| 99060 | Emergency services provided out of the office disrupting scheduled services; must be billed with E&M and considered inclusive |
| 95165 | Supervision of preparation and provision of antigens for allergen immunotherapy |
| 95004 | Allergy testing — number of tests must be specified; limited to 80 units per calendar year |
| 95024 | Allergenic extract immediate type reaction test and interpretation; number of tests must be specified; limited to 40 units per calendar year |
| 95027 | Allergy test — number of tests must be specified; limited to 40 units per calendar year |
1–10 of 11
1/2
E&M and related codesCPT
| 99202-99215 | Office/Clinic/Outpatient E&M services (sick and preventive interactions referenced across rules) |
| 99381-99387, 99391-99397 | Preventive Medicine E&M visits — reimbursed but many procedures not separately reimbursed when performed same day |
| G0102 | Manual rectal neoplasm screening — not reimbursed separately same day as E&M 99202-99215 |
| 36415 | Venipuncture — not reimbursed separately same day as E&M when performed in office unless modifier CG and external lab |
| 36416 | Capillary blood collection — not reimbursed separately same day as E&M |
| 99000 | Lab specimen handling — not reimbursed separately same day as E&M |
| 99001 | Lab specimen handling — not reimbursed separately same day as E&M |
| Q0091 | Pap smear collection — not reimbursed separately same day as E&M |
| 92567 | Tympanometry — not reimbursed separately same day as E&M |
| 94760, 94761 | Pulse oximetry — not reimbursed separately same day as E&M |
1–10 of 13
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Prenatal/Obstetric CodesCPTCovered
| 99201-99215 | Prenatal E&M visit; first prenatal visit is global to OB delivery charges |
| 59425 | Antepartum Care (visits 4-6) |
| 59426 | Antepartum Care (7+ visits) |
| 59400, 59410, 59510, 59515, 59610, 59614, 59618, 59620, 59812, 59820, 59821, 59830, 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857 | Obstetric and antepartum care; first prenatal visit global to OB delivery |
E&M and Consultation CodesCPT
| 99201-99499 | Evaluation & Management codes including inpatient and urgent care |
| 99241-99245; 99251-99255 | Consultation codes — MVP follows CMS guidance and does not reimburse consultation CPT codes |
| 99221-99223 | Initial hospital visit; rules for AI modifier and one visit per provider per day |
| 99211-99215 | Office/outpatient E&M for established patients |
| 99304-99306; 99307-99310 | Skilled Nursing Facility initial and follow-up visits |
Critical Care Related CodesCPTCovered
| 99291 | Critical care management code — reimbursed when time spent is 30-74 minutes (minimum 30 minutes) |
| 99292 | Add-on critical care time code — units added per specified additional minute ranges (e.g., 75-104: +1, 105-134: +2, etc.) |
Arthroscopic/Endoscopic Non-GI CodesmixedCovered
| various arthroscopy and endoscopy CPT families | Arthroscopic, endoscopic, and non-GI scope procedures; when multiple procedures in same family performed same day highest RVU reimbursed and additional procedures follow Medicare multiple-procedure reduction methodology |
Audiology billing rulesCPTCovered
| 99201-99499 | Evaluation & Management CPT codes — audiologists may not bill these codes |
| 69209, 69210 | Cerumen removal codes — audiologists may not bill; cerumen removal included in diagnostic test RVUs |
| G0268 | Physician removal of impacted cerumen on same day as diagnostic test |
| 92620, 92621, 92626, 92627, 92640 | Audiology codes with time designations — timed code billed only if testing is ≥51% of designated time |
Timed audiology CPT codesCPT
| 92620 | Evaluation of central auditory function, with report; initial 60 minutes |
| 92621 | Evaluation of central auditory function, with report; each additional 15 minutes |
| 92626 | Evaluation of auditory rehabilitation status; first hour |
| 92627 | Evaluation of auditory rehabilitation status; each additional 15 minutes |
| 92640 | Diagnostic analysis with programming of auditory brainstem implant, per hour |
Telephone E/M codesCPTCovered
| 99441 | Telephone E/M service; 5-10 minutes of medical discussion |
| 99442 | Telephone E/M service; 11-20 minutes of medical discussion |
| 99443 | Telephone E/M service; 21-30 minutes of medical discussion |
Contrast HCPCS codes not separately reimbursedHCPCSNot Covered
| A9579 | Injection, gadolinium-based MR contrast agent, per ml |
| Q9951 | Low osmolar contrast material, 400+ mg/ml iodine, per ml |
| Q9965 | Low osmolar contrast material, 100-199 mg/ml iodine, per ml |
| Q9966 | Low osmolar contrast material, 200-299 mg/ml iodine, per ml |
| Q9967 | Low osmolar contrast material, 300-399 mg/ml iodine, per ml |
| Q9958 | High osmolar contrast material, up to 149 mg/ml iodine, per ml |
Supervised billing modifiers for Vermont non-licensed behavioral health providersModifierCovered
| HO | Modifier for Master's level non-licensed practitioner supervised billing (Vermont) |
| HP | Modifier for Doctorate level non-licensed practitioner supervised billing (Vermont) |
Example denied/inappropriate primary diagnosis codes for COVID-19 testingICD-10Not Covered
| Z02.0 | Encounter for examination for admission to educational institution (denied when submitted for COVID-19 testing) |
| Z02.1 | Encounter for administrative examinations (denied when submitted for COVID-19 testing) |
| Z02.4 | Encounter for administrative examinations (denied when submitted for COVID-19 testing) |
| Z02.5 | Encounter for examination for participation in sport (denied when submitted for COVID-19 testing) |
| Z02.79 | Encounter for issue of other medical certificate (denied when submitted for COVID-19 testing) |
| Z02.89 | Encounter for other administrative examinations (denied when submitted for COVID-19 testing) |
| Z02.9 | Encounter for administrative examinations, unspecified (example denied diagnoses) |
| Z56.89 | Other problems related to employment (example denied diagnoses) |
| Z56.9 | Unspecified problems related to employment (example denied diagnoses) |
| Z03.818 | Encounter for observation for suspected exposure to other biological agents ruled out (example inappropriate) |
1–10 of 19
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Nutritional counseling / medical nutrition therapyCPT | HCPCSCovered
| 97802 | Medical nutritional therapy; initial assessment and intervention, individual, each 15 minutes |
| 97803 | Medical nutritional therapy; reassessment and subsequent intervention, individual, each 15 minutes |
| 97804 | Medical nutritional therapy; group (2 or more individuals), each 30 minutes |
| G0270 | Nutrition counseling for the management of diabetes mellitus, each 15 minutes (Medicare-specific) |
| G0271 | Medical nutrition therapy; reassessment and subsequent intervention (Medicare-specific) |
Diabetes ICD-10 groups referencedICD-10
| E10.* | Type 1 diabetes mellitus codes including retinopathy, neuropathy, and other complications |
| E11.* | Type 2 diabetes mellitus codes including retinopathy, neuropathy, and other complications |
| E09.* | Drug or chemical induced diabetes mellitus codes including retinopathy and complications |
| E13.* | Other specified diabetes mellitus codes including retinopathy and complications |
Reimbursable diabetic management codesCPT | HCPCSCovered
| G0108 | Diabetes outpatient self-management training services, individual, per 30 minutes |
| G0109 | Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes |
Relevant ICD-10 diagnosis codesICD-10
| E08-E13, E09, etc. | Numerous ICD-10-CM codes for diabetes with specified complications (retinopathy, nephropathy, neuropathy, gestational diabetes, etc.) listed as relevant to nutritional counseling/diabetic management |
Selected ICD-10-CM diabetes codes (partial list)ICD-10Covered
| E09.3592 | Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eye |
| E09.3593 | Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateral |
| E09.36 | Drug or chemical induced diabetes mellitus with diabetic cataract |
| E10.21 | Type 1 diabetes mellitus with diabetic nephropathy |
| E11.21 | Type 2 diabetes mellitus with diabetic nephropathy |
Pregnancy and other specified diabetes codes (partial list)ICD-10Covered
| E13.3211 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye |
| O24.011 | Pre-existing type 1 diabetes mellitus in pregnancy, first trimester |
| O24.414 | Gestational diabetes mellitus in pregnancy, insulin controlled |
Transthoracic EchocardiographyCPTCovered
| 93303-93352, 93306-93308, 93308, 93350-93352 | Transthoracic echocardiography procedure codes grouped with CMS document references and diagnosis matching rules |
Facet joint proceduresCPTCovered
| 64490-64495, 64625, 64633-64636 | Facet joint injections, medical branch blocks, and radiofrequency neurotomy codes with diagnosis matching requirements |
NCS/EMGCPTCovered
| 51785, 92265, 95860-95874, 95885-95887, 95905-95913, 95933, G0255, 95937 | Nerve conduction studies, electromyography, and neuromuscular junction testing with diagnosis matching rules |
Visual fieldsCPTCovered
| 92081-92083 | Visual field examination codes requiring appropriate diagnosis per LCD |
Laboratory and serology testsCPTCovered
| 82306 | Vitamin D 25 hydroxy assay (Vitamin D) with LCD requirements |
| 82652 | Vitamin D 1.25 hydroxy assay with LCD requirements |
| 85652 | Erythrocyte sedimentation rate (automated) with ASCP guidance |
| 82746 | Folic acid serum assay — correct diagnosis required per ASCP guidance |
| 82607 | Cyanocobalamin (Vitamin B12) — correct diagnosis required per Novitas LCD |
| 86695-86696 | Herpes Simplex Virus antibody tests requiring appropriate diagnosis per USPSTF/AAFP |
| 82785, 86003, 86008 | IgE and allergen specific testing with AAAAI guidance |
Folic Acid testingCPTCovered
| 82746 | Assay of Folic Acid Serum |
Vitamin B12 testingCPTCovered
| 82607 | Cyanocobalamin (Vitamin B12) |
FSH testingCPTCovered
| 83001 | Gonadotropin Follicle Stimulating Hormone (FSH) |
Thyroid panelsCPTCovered
| 84443 | Thyroid stimulating hormone (TSH) |
| 84436 | Thyroxine; total |
| 84439 | Free thyroxine |
| 84479 | Thyroid hormone uptake (T4 uptake/THBR) |
Triiodothyronine testingmixedCovered
| 84481 | Assay of Triiodothyronine Free |
| TT3 | T3 Total (assay) |
Follicle Stimulating Hormone – sample diagnosis codesICD-10
| E663 | Overweight |
| E669 | Obesity, unspecified |
| I4891 | Unspecified atrial fibrillation |
| I10 | Essential (primary) hypertension |
Herpes Simplex Virus – sample diagnosis/encounter codesICD-10
| Z135 | Encounter for screening for eye and ear disorders |
| R509 | Fever, unspecified |
| B009 | Herpesviral infection, unspecified |
| A609 | Anogenital herpesviral infection, unspecified |
Gammaglobulin IgE – sample diagnosis codes and adverse reaction codesICD-10
| J309 | Allergic rhinitis, unspecified |
| J441 | Chronic obstructive pulmonary disease with (acute) exacerbation |
| L209 | Atopic dermatitis, unspecified |
| T7800XA | Anaphylactic reaction due to unspecified food, initial encounter |
Erythrocyte Sedimentation Rate – sample malignant/hematologic diagnosis codesICD-10
| C169 | Malignant neoplasm of stomach, unspecified |
| C3411 | Malignant neoplasm of upper lobe, right bronchus, or lung |
| C61 | Malignant neoplasm of prostate |
| C8207 | Follicular lymphoma grade I, spleen |
Sample malignant neoplasm codesICD-10
| C549 | Malignant neoplasm of corpus uteri, unspecified |
| C562 | Malignant neoplasm of left ovary |
| C574 | Malignant neoplasm of uterine adnexa, unspecified |
Sample hematology/immunology codesICD-10
| C9000 | Multiple myeloma not having achieved remission |
| D631 | Anemia in chronic kidney disease |
| D692 | Other nonthrombocytopenic purpura |
Sample endocrine/diabetes codesICD-10
| E1121 | Type 2 diabetes mellitus with diabetic nephropathy |
| E11621 | Type 2 diabetes mellitus with foot ulcer |
Sample neurologic codesICD-10
| G35 | Multiple sclerosis |
| G43A0 | Cyclical vomiting, in migraine, not intractable |
| G9201 | Immune effector cell-associated neurotoxicity syndrome, grade 1 |
Sample ophthalmologic codesICD-10
| H15013 | Anterior scleritis, bilateral |
| H348130 | Central retinal vein occlusion, bilateral, with macular edema |
| H353221 | Exudative age-related macular degeneration, left eye, with active choroidal neovascularization |
Allergy serum unit limits — first year and subsequent year limits
First-year unit limitsReimbursement limited to 40 units per claim and 160 units per calendar year (first year)
Subsequent-year unit limitsReimbursement limited to 30 units per claim and 120 units per calendar year (subsequent years)
CPT 95004 annual limit95004 limited to 80 units per calendar year
CPT 95024 annual limit95024 limited to 40 units per calendar year
CPT 95027 annual limit95027 limited to 40 units per calendar year
CPT 95028 annual limit95028 limited to 30 units per calendar year
new patient definition lookback — 3 years
Lookback period3 years — member is a 'new patient' if no professional services from same provider or another qualified professional of the exact same specialty and sub-specialty in the same group (same tax ID) within the past three years
Scope of 'same group'Applies when provider belongs to same Participating Provider Group (same tax ID)
Definition sourceMVP follows the American Medical Association's definition of a new patient
Critical care time thresholds for 99291/99292
Minimum time for 9929199291 will not be reimbursed if time spent is less than 30 minutes
30–74 minutesReport 99291 once for 30–74 minutes
75–104 minutesReport 99291 once and 99292 x 1 for 75–104 minutes
105–134 minutesReport 99291 once and 99292 x 2 for 105–134 minutes
135–164 minutesReport 99291 once and 99292 x 3 for 135–164 minutes
165–194 minutesReport 99291 once and 99292 x 4 for 165–194 minutes
Timed code billing threshold — >=51% time requirement
Timed code billing thresholdA timed code (audiology) is billed only if testing is at least 51% of the time designated in the code descriptor
ApplicabilityApplies to the five CPT audiology codes with time designations (e.g., 92620, 92621, 92626, 92627, 92640)
Non-timed CPT proceduresIf CPT descriptor has no time designation, bill as a session without regard to time
15-minute code unit time thresholds — unit minute ranges
1 unit (15-minute code)1 unit = 8 minutes to < 23 minutes
2 units (15-minute code)2 units = 23 minutes to < 38 minutes
3 units (15-minute code)3 units = 38 minutes to < 53 minutes
5 units (15-minute code) example5 units = 68 minutes to < 83 minutes
6 units (15-minute code) example6 units = 83 minutes to < 98 minutes
Timed code billing rule (duplicate emphasis)
Timed code billing rule (reminder)A timed code is billable only when testing meets at least 51% of the code's designated time — ensure test time documentation supports billed timed units
Excluded activities from timed test timeCounseling, goal setting, or evaluating remediation potential are not included in timed test calculations
Codes affectedSpecifically noted for audiology timed CPTs (92620, 92621, 92626, 92627, 92640)
Supervising clinician degree requirement for Vermont supervised billing
Supervisor degree match requirementSupervising clinician must be a licensed practitioner with the same degree level (Masters or Doctorate) as the unlicensed clinician
Claim fields for supervisor detailsList supervising clinician NPI and taxonomy in Box 24j and supervising provider name and degree/title in Box 31 of the CMS-1500 form
Vermont supervised billing modifiersAppend modifier HO for Master's level or HP for Doctorate level supervised billing claims (Vermont only)
Coding guidance sources — use CPT/HCPCS and CDC coding guidelines for COVID-19 testing
Coding source sets for COVID-19 testingUse CPT codes published by the AMA or HCPCS codes published by CMS for applicable COVID-19 tests
Diagnosis coding guidanceFollow CDC ICD-10-CM Official Coding Guidelines when selecting diagnosis codes for COVID-19 testing
Test selection recommendationProviders encouraged to use reliable FDA-authorized tests for COVID-19 diagnostic and antibody testing
Diagnosis restrictions for Medicare MSA plans (97802-97804, G0270-G0271)
Diagnosis restriction for Medicare MSA plansCPT/HCPCS codes 97802-97804 and G0270-G0271 are limited to specified ICD-10-CM diabetes diagnoses for Medicare MSA plans only
Other plansAll other plans have no diagnosis code restrictions for these nutrition/DSME codes
Reimbursable nutrition codesCodes listed as reimbursable: 97802, 97803, 97804, G0270, G0271
Document scope — partial ICD-10 listing for diabetic management
Document scope — ICD-10 listingThis section contains a partial segment of a longer ICD-10-CM code listing for diabetic management (multiple E08–E13 and related subcodes)
Examples includedIncludes drug/chemical-induced, type 1, type 2, gestational and other specified diabetes codes and associated complications
Use with DSME/nutritional counselingICD-10 entries in this segment are referenced for diagnosis matching and coverage of diabetic management services
Provider Actions — Authorization, Documentation, and Billing
Prior Authorization
Verify eligibility and check Utilization Management Guides
Providers must check member eligibility, review the Member Benefits Display, and consult MVP's Utilization Management Guides (and Benefit Interpretation Manual) to determine whether prior authorization is required; these resources are available by signing into your account at mvphealthcare.com. MVP payment policies are not guarantees of payment.
Prior Authorization
Confirm eligibility and prior authorization requirements
Providers must confirm member eligibility, refer to the Member Benefits Display, and review MVP's Utilization Management Guides to determine if prior authorization is required; access the referenced resources via your provider account at mvphealthcare.com. MVP payment policies do not guarantee payment.
Documentation Required
Respond to periodic medical record requests
MVP may periodically request medical records to verify that documentation supports billed services and the medical necessity of E&M claims; providers should retain and produce records when requested.
Prior Authorization
Prior authorization and eligibility check (verify before service)
Providers must check member eligibility, the Member Benefits Display, and MVP's Utilization Management Guides to determine whether prior authorization is required; these resources are available via your account at mvphealthcare.com and policies do not guarantee payment.
Prior Authorization
Verify eligibility and review UM Guides before billing
Verify member eligibility and consult the Member Benefits Display and MVP's Utilization Management Guides (and Benefit Interpretation Manual) to determine prior authorization requirements before providing services; resources accessible by signing into mvphealthcare.com.
Prior Authorization
Obtain authorization for In-Office Only codes for split billing
Procedure codes listed on MVP's In-Office Only list will not be reimbursed under split billing arrangements unless an authorization is obtained; if authorized, reimbursement may be allowed for Medicare and Medicaid products.
Prior Authorization
Check eligibility and prior authorization via MVP systems
Providers must check member eligibility and consult the Member Benefits Display and MVP's Utilization Management Guides (and Benefit Interpretation Manual) to determine if prior authorization is required prior to delivering services.
Prior Authorization
Prior authorization required — lack of approval leads to administrative denial
If an authorization is required and not obtained, MVP will administratively deny all technical, professional, global and/or facility claims for that service; authorizations apply to all claim types for the service.
Denial Risk
Administrative denial risk if no prior authorization for surgical or radiology services
Administrative denials will be applied to Outpatient Surgical Services and the Radiology code set when required prior authorization is not obtained; providers must secure prior approval per MVP's Utilization Management Guides.
Documentation Required
Policies are not payment guarantees — verify benefits and guidance
MVP payment policies are not guarantees of payment; providers must verify member benefits using the Member Benefits Display and consult the Utilization Management Guides and Benefit Interpretation Manual before providing services.
Prior Authorization
Eligibility & prior authorization check — use Member Benefits Display
Providers must check member eligibility and the Member Benefits Display and review MVP's Utilization Management Guides to determine if prior authorization is required; access these resources by signing into mvphealthcare.com.
Prior Authorization
Confirm eligibility and UM Guide requirements (provider reminder)
Providers must confirm member eligibility, consult the Member Benefits Display, and review MVP's Utilization Management Guides and the Benefit Interpretation Manual to determine prior authorization requirements before billing.
Documentation Required
Use Appendix ICD-10 list for nutritional counseling claims
Refer to the ICD-10 code listings in the policy Appendix for diagnosis codes associated with members eligible for nutritional counseling services; use the listed ICD-10 codes when submitting claims for nutritional counseling.
Billing Rule
Reimburse G0108/G0109 per 30 minutes for DSME
Diabetes outpatient self-management training codes G0108 (individual) and G0109 (group) are reimbursable per 30 minutes when billed appropriately.
- G0108 and G0109 reimburseable per 30-minute increment
Billing Rule
Refer to provider fee schedule or IPA agreement for reimbursement details
For specific reimbursement rates and contractual payment terms, providers must consult their provider fee schedule or IPA agreement.
Prior Authorization
Participating providers must verify eligibility and prior authorization
Participating providers must check member eligibility, use the Member Benefits Display, and review MVP's Utilization Management Guides (and Benefit Interpretation Manual) to determine prior authorization and coverage before furnishing services.
Denial Risk
Submit correct diagnosis codes per LCD/NCD or risk denial
Claims for listed procedures must include the correct diagnosis code(s) in accordance with applicable Medicare LCD/NCD or referenced clinical guidance; MVP will deny claims for lack of medical necessity when diagnosis matching requirements are not met.
- Use the referenced Medicare LCD/NCD document IDs when selecting diagnoses
- Pediatric cardiology specialty may be excluded from some echocardiography edits
Prior Authorization
Include appropriate diagnosis with CPT 82746 (Folic Acid assay)
MVP requires that the correct diagnosis be submitted with claims for folic acid assay (CPT 82746) in accordance with ASCP clinical guidance; refer to the Appendix for appropriate diagnosis codes.
Denial Risk
Provide proper diagnosis for CPT 82607 or claim will be denied
Claims for Cyanocobalamin (Vitamin B12, CPT 82607) must include the correct diagnosis per the Medicare Local Coverage Determination (Novitas LCD Document ID #L34914) or the claim will be denied for medical necessity.
- Reference Novitas Solutions Inc. LCD Document ID #L34914 for required diagnoses
Denial Risk
Submit appropriate diagnosis for CPT 83001 per ASRM guidance
For Gonadotropin Follicle Stimulating Hormone testing (CPT 83001), providers must submit the correct diagnosis in accordance with American Society for Reproductive Medicine guidance (see Appendix) or the claim will be denied for medical necessity.
Denial Risk
Use NCD/LCD-specified diagnoses for TSH and thyroid panel claims
TSH and related thyroid tests (e.g., CPTs 84443, 84436, 84439, 84479) require correct diagnoses per the Medicare NCD (Publication ID #100-3 Manual Section #190.22) and Novitas LCDs; claims will be denied for medical necessity if diagnoses do not match.
Denial Risk
Provide correct diagnosis for T3 assays (84481/TT3) to avoid denial
Assays of Triiodothyronine (T3 total and free, CPT 84481 and TT3) require submission of the correct diagnosis per ASCP/Endocrine Society guidance and Appendix listings; claims lacking appropriate diagnoses will be denied for medical necessity.
Documentation Required
Use Appendix diagnosis list for FSH testing claims
Refer to the policy Appendix for the partial list of diagnosis codes associated with Follicle Stimulating Hormone testing and use those ICD-10 codes when submitting claims.
Documentation Required
Apply Appendix HSV diagnosis/encounter codes on claims
Use the policy Appendix sample diagnosis/encounter codes listed for Herpes Simplex Virus when submitting related laboratory claims; ensure submitted codes match the Appendix.
Documentation Required
Use Appendix ICD-10 codes for IgE testing claims
Consult the Appendix diagnosis code listings for Gammaglobulin IgE testing and submit appropriate ICD-10 codes tied to allergic, respiratory, or dermatologic conditions when billing.
Documentation Required
Submit Appendix-listed ICD-10 diagnoses for ESR testing
When billing for ESR testing, submit diagnosis codes consistent with the Appendix malignant/hematologic ICD-10 listings provided in the policy to support medical necessity.
Documentation Required
Use Appendix ICD-10 list for ESR claim coding and verification
Refer to the Appendix ICD-10 listing contained in the policy when coding ESR-related claims; use the provided diagnosis codes for accurate claim coding and potential coverage verification.
Definitions and Key Terms
Medical Necessity — definition
DefinitionServices necessary to prevent, diagnose, or treat a condition consistent with accepted medical practice; clinically appropriate in type, frequency, extent, site and duration
Documentation requirementDocumentation must support the level of service reported; billing a higher E&M level when a lower level is warranted is inappropriate
Source alignmentMVP adopts AMA and CMS concepts and follows CMS E&M documentation guidelines (1995/1997 and 2021)
Medically Necessary / Medical Necessity (MVP)
MVP policy definitionMedically Necessary/Medical Necessity: services necessary to prevent, diagnose, correct or cure conditions that cause acute suffering, endanger life, or interfere with capacity for normal activity and recommended by the treating provider
Criteria listServices must be appropriate to diagnosis; not primarily for convenience; required for direct care; consistent with good medical practice; provided in a safe, cost-effective setting
Review and external oversightDeterminations may be subject to external review and must align with peer-reviewed literature and recognized guidelines
New Patient — 3-year lookback definition
New patient lookbackA new patient is one who has not received professional services from the same provider or another qualified professional of the exact same specialty and sub-specialty in the same group (same tax ID) within the past three years
Billing impactUsed to determine new vs. established patient E&M coding and billing
AuthorityMVP follows AMA definition
Significant E&M Service — definition
DefinitionSignificant E&M service: at minimum warrants an expanded problem focused examination; routine reassurance, monitoring, medication refills, or minor problem-focused visits are not considered significant
ImplicationSignificant E&M necessary to bill separate from global or bundled services
Documentation standardClinical record must support that criteria for a significant service were met
Critically ill or injured Member (critical illness)
DefinitionCritically ill or injured Member: condition acutely impairing one or more vital organ systems with high probability of imminent or life‑threatening deterioration
Time countingTime spent directly related to patient care (bedside or elsewhere) counts toward critical care when documented; some activities do not count (certain procedures, routine family updates)
Billing unitCritical care time billed per calendar day and must be documented in the medical record
Split Billing — definition
DefinitionSplit Billing: two separate charges — professional (physician/practice) and technical (facility)
Use caseAllows separate reimbursement flows when billing entity meets applicable requirements (Article 28 etc.)
Contrast with globalOpposite of global reimbursement where one bill represents both components
Professional component — definition
DefinitionProfessional component: billable services provided by physicians such as consultations and interpretation; payment made to provider group
Typical inclusionsPhysician interpretation of imaging, consultations, and other physician-performed services
Relation to split billingProfessional component is billed separately in split billing arrangements
Technical component — definition
DefinitionTechnical component: billable services provided in a facility setting (labs, x-rays, E&M services, procedures); reimbursement made to the hospital
Typical inclusionsFacility resources, equipment, and non-physician staff time associated with service delivery
Relation to split billingTechnical component is billed to the facility in split billing arrangements
Global reimbursement — definition
DefinitionGlobal reimbursement: one bill representing both professional and technical services paid at a global rate
Payment flowTypically a single payment is made to the physician practice unless providers are hospital-employed
Effect on separate billingNo additional payments made to facilities under global reimbursement methodology
Audiological diagnostic testing — definition
DefinitionAudiological diagnostic testing: tests of audiological and vestibular systems including hearing, balance, auditory processing, tinnitus, and diagnostic programming of certain prosthetic devices performed by qualified audiologists
Provider scopePerformed by qualified audiologists as defined in policy
Billing noteSome audiology codes are timed and subject to the 51% rule for billing
CPT — definition
CPT definitionCurrent Procedural Terminology (CPT): medical code set used to report medical, surgical, and diagnostic procedures and services
UsePublished by the AMA and used for provider claims coding
Relation to MVP policyMVP references CPT for procedural and E&M coding guidance
E/M Codes — definition
DefinitionE/M Codes: CPT codes (range 99202-99499) representing services involving evaluation and management of patient health
ScopeIncludes office/outpatient, hospital, ER, nursing facility and other E&M encounters
DocumentationMVP follows CMS E&M documentation guidelines for determinations of appropriate E&M level
Qualified Licensed Practitioner — definition
Qualified Licensed PractitionerA provider who is licensed and credentialed by MVP and is acting within the scope of his/her practice
Qualified Non-Licensed PractitionerA provider actively working towards licensure as specified by profession; may deliver services under direct supervision
Supervised billingQualified Licensed Practitioner can bill for services furnished by a Qualified Non-Licensed Practitioner when direct supervision requirements are met
Qualified Non-Licensed Practitioner — definition
DefinitionQualified Non-Licensed Practitioner: provider actively working towards licensure and may provide services under supervision
Supervision requirementMust be supervised by a licensed practitioner meeting degree equivalence and documentation requirements for supervised billing
Vermont specificsRostered Non-Licensed & Non-Certified Psychotherapists in VT may bill under supervised billing rules
Contrast materials reimbursement — definition and policy position
Policy positionCost of ionic and non-ionic contrast materials is considered inclusive to the primary examination fee and is not separately reimbursable
RationaleNon-ionic contrast costs have approached ionic contrast and usage is routine; therefore both are included in exam fee
ApplicabilityApplies to CT and other contrast-enhanced exams and to participating providers across product lines indicated in policy
Non-licensed provider services (Vermont) — definition and scope
Definition and scope (Vermont)Non-licensed provider services: services performed by non-licensed providers who cannot practice independently and are not actively working toward licensure are non-reimbursable; MVP Medicare members ineligible to receive such services even under supervision
Supervised billing exceptionRostered non-licensed psychotherapists in Vermont may bill under supervised billing when direct supervision and documentation requirements are met
Form and modifier requirementsClaims must include supervising clinician NPI/taxonomy in Box 24j, supervising name/degree in Box 31, and modifier HO/HP to indicate practitioner level
Diagnostic test — COVID-19 diagnostic test definition
Diagnostic test definitionCOVID-19 diagnostic/virus or antigen detection test determines if a person is currently infected with COVID-19
Antibody test noteAntibody (serology) test may determine prior exposure but per FDA should not be used to diagnose current infection
Policy applicabilityPolicy applies to participating and non-participating practitioners, facilities, laboratories and pharmacies and all lines of business
Antibody test — definition and limitation per FDA
Antibody test limitationAntibody (serology) tests may indicate prior exposure but should not be used to diagnose current infection per FDA guidance
Coding guidanceProviders should use CPT/HCPCS codes and follow CDC ICD-10-CM Official Coding Guidelines for reporting
Policy contextAntibody testing covered under COVID-19 testing policy with stated limitations
Policy scope — COVID-19 testing policy scope
Scope statementDefines coverage, reimbursement and billing guidelines for COVID-19 viral and antibody testing
Who it applies toParticipating and non-participating practitioners, facilities, laboratories and pharmacies across all lines of business
Coding and test selectionProviders encouraged to use FDA-authorized tests and CPT/HCPCS coding; follow CDC ICD-10-CM Official Coding Guidelines
Nutritional Counseling — definition
DefinitionNutritional Counseling: services reimbursable when medically necessary for chronic diseases where dietary adjustment has a therapeutic role and must be prescribed and furnished by recognized providers (licensed nutritionist, registered dietitian or other qualified licensed professionals)
Provider requirementMust be prescribed by a physician or qualified non-physician practitioner and furnished by recognized providers billed under their provider number
IncludesMedical nutrition therapy involving assessment, individualized diet, counseling and specialized nutrition therapies
Diabetic Management / DSME — definition
DefinitionDiabetic Management/DSME: education and management services medically necessary for diagnosis and treatment of diabetes, including self-management education when prescribed and delivered by qualified licensed professionals (CDEs)
Reimbursable codesG0108 (individual, per 30 minutes) and G0109 (group, per 30 minutes) for diabetic self-management training
Diagnosis limitationsMedicare MSA plans limit these codes to specified ICD-10 diagnoses; other plans reimburse broader E08–E13 ranges
Medical nutrition therapy — definition
DefinitionMedical nutrition therapy: assessment of overall nutritional status followed by individualized diet, counseling and specialized nutrition therapies provided by a registered dietitian
PurposeUsed to treat chronic illnesses or conditions where nutrition intervention is therapeutic
Billing contextCoded under CPT codes 97802-97804 when applicable
Diabetic macular edema / retinopathy codes — definition
Diabetic macular edema/retinopathy codesE09.37X1–E09.37X3 and related E09.* entries listed in the appendix denote drug/chemical induced diabetes with macular edema/retinopathy designations
ScopeAppendix lists multiple diabetic ophthalmic complication codes used for diagnosis matching
UseCodes guide medically-necessary determinations for nutritional counseling and diabetic management services
E09 codes — definition and scope
E09 codes meaningCodes beginning with E09 indicate diabetes mellitus due to drugs or chemicals and list multiple microvascular and macrovascular complications
ExamplesIncludes neuropathy, nephropathy, skin complications, periodontal disease, hypoglycemia and hyperglycemia entries under E09.*
RelevanceUsed in appendix diagnosis lists for nutrition/diabetic service reimbursement limitations and matching
Nutritional Counseling exclusions — list of excluded service types
Excluded servicesCommercial diet plans, gym memberships, holistic therapy, services offered by health resorts/recreational programs, skill/relaxation/lifestyle programs, supplemental fasting, and physical therapy for weight loss are not reimbursable under Nutritional Counseling
RationaleThese services are non-covered as they do not meet the policy's definition of medically necessary nutritional counseling
Provider noteProviders should verify member benefits and eligibility prior to providing such services
Diabetic Management reimbursable codes (G0108/G0109)
Reimbursable codes (DSM) G0108 and G0109 are reimbursable for diabetes outpatient self-management training (per 30 minutes)
Medicare MSA restrictionThese codes limited to specified ICD-10 diagnoses for Medicare MSA plans; other plans reimburse broader diabetes code ranges
Documentation requirementServices must be prescribed and provided by qualified licensed professionals and documented per DSME requirements
Diabetic management codes — ICD-10-CM diagnostic code context
ICD-10 contextICD-10-CM diagnostic codes (E08–E13, E09.*, etc.) listed in the appendix provide the diagnosis matching context for diabetic management and nutritional counseling claims
Use in claimsCorrect diagnosis codes must be submitted with claims per referenced LCD/NCDs to avoid denial
Medicare reservationCMS may add or remove diagnosis codes associated with NCDs to implement NCDs efficiently
Medical necessity — definition (reiteration)
Medical necessity (reiteration)Medical necessity is the overarching payment criterion; documentation must support level of service and inappropriate to bill a higher level when lower is warranted
Standards referencedMVP aligns with AMA and CMS definitions and guidance for medical necessity determinations
EnforcementClaims may be subject to post-payment review and denial if documentation or diagnosis matching is not met
Medicare Coverage Database — reference definition
ResourceMedicare Coverage Database (CMS) Advanced Search — used to locate National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)
PurposeReference for diagnosis-matching edits and clinical coverage guidance cited in the policy appendix
Access noteProviders should consult the CMS Medicare Coverage Database for applicable LCD/NCD guidance referenced in the policy
Follicle Stimulating Hormone — definition reference
FSH contextAppendix lists sample diagnosis codes (e.g., E663 overweight; E669 obesity) associated with Follicle Stimulating Hormone testing
UseThese sample ICD-10 codes guide appropriate diagnosis matching for FSH claims
Reference locationAppendix entries under Follicle Stimulating Hormone section
Herpes Simplex Virus — definition reference
HSV contextAppendix provides diagnosis and encounter code listings related to Herpes Simplex Virus presentations (examples include R509 fever, R21 rash)
UseCodes serve as examples for appropriate diagnosis selection for HSV testing and claims
LocationSee Herpes Simplex Virus appendix section
Gammaglobulin IGE — definition reference
IgE contextAppendix lists diagnosis codes associated with Gammaglobulin IgE testing, including allergic conjunctivitis, sinusitis and other allergic conditions
UseAppendix codes guide appropriate diagnosis matching for IgE/allergy testing claims
ReferenceSee Gammaglobulin IGE appendix entries
Erythrocyte Sedimentation Rate — definition reference
ESR contextErythrocyte Sedimentation Rate (ESR) appendix lists malignant and hematologic diagnosis codes (e.g., C169, C3411, C61, C549) relevant to test coverage
UseThese ICD-10 entries are provided to guide diagnosis matching and potential coverage verification for ESR testing
LocationAppendix ESR sections in the policy document
Policy Summary
PayerMVP Health Care
PolicyAfter‑Hours, Allergy Testing and Serum Preparation, and E&M Reimbursement
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateMay 11, 2023
Last ReviewMar 1, 2023
Next Review DateN/A
Key ActionVerify member eligibility, benefits and prior authorization requirements via Member Benefits Display and MVP Utilization Management Guides before billing.
SourceLink
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