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2022 MVP Health Care Payment Policies (Section excerpts)
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This document governs MVP Health Care's 2022 reimbursement and billing policies (selected sections in this excerpt) and affects providers submitting claims to MVP for covered services. It includes rules for after-hours codes, allergy testing and serum preparation, and evaluation & management services, plus notification/prior authorization information.
Policy Summary
PayerMVP Health Care
Policy2022 MVP Health Care Payment Policies (Section excerpts)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateDec 1, 2022
Last ReviewMar 1, 2022
Next Review DateMar 1, 2022
Key ActionProviders must check member eligibility and consult MVP's Member Benefits Display and Utilization Management Guides to determine prior authorization requirements.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
3sections in excerpt
Dec 1, 2022document update
Limits specifiedallergy testing limits
75%audio-only reimbursement
Deniedcontrast materials
Coverage criteria and medical necessity rules
General coverage and specific code criteria
Covered when ALL of the following are met:
Services are medically necessary as defined by MVP/AMA/CMS and documented in the medical record; medical records may be requested to support billed services.
Evaluation and Management (E&M) services are billed in accordance with CMS documentation and coding guidelines (CMS 1995/1997 and CMS 2021 Office and Other Outpatient Services).
After-hours CPT codes (e.g., 99050, 99051, 99053, 99056, 99058, 99060) must be billed with an appropriate E&M; these after-hours codes are considered inclusive with the E&M and are not payable if they are the only CPT on the claim. (99050 is reimbursed unless submitted with preventive visit codes 99381-99397 per contract).
Providers must verify member eligibility and benefits and consult MVP Utilization Management Guides to determine prior authorization requirements; payment policies do not guarantee payment.
When two inpatient physician E&M codes are billed by the same provider for the same/related condition on the same date of service, the second E&M will be denied.
COVERAGE CRITERIA — E&M, consultation, observation, discharge, critical care, scope procedures and billing rules
Covered when ALL of the following billing rules and exclusions are satisfied:
Consultation codes (99241-99245; 99251-99255) are not reimbursed; providers should bill the appropriate E&M codes instead per CMS guidance.
Observation and hospital visit codes may only be billed by the provider who orders the observation; codes must meet CPT component/time requirements and appropriate modifiers (e.g., AI) when applicable.
Discharge service codes (99238-99239; 99217; 99234-99236) are timed/component-based and must meet CPT requirements; do not bill a discharge code and a regular subsequent inpatient/observation E&M on the same day.
Procedures that do not count toward critical care time
Split billing and Audiology coverage criteria
Split billing is permitted ONLY when ALL of the following conditions are met:
Billing entity meets Article 28 requirements (New York) or equivalent state requirements and participates with MVP for Medicare and/or Medicaid/Government programs.
MVP Commercial/ASO and Exchange products are not eligible for split billing arrangements.
Under split billing, provider professional claims must be submitted with a facility place of service (e.g., POS 22) rather than non-facility (e.g., POS 11); the hospital receives technical reimbursement and one combined billing methodology applies per Article 28 (no additional facility payments).
Procedure codes on the MVP In-Office Only list are not reimbursed under split billing unless prior authorization is obtained; if authorized, reimbursement may be allowed for Medicare and Medicaid products.
Audiology specific rules under split/facility contexts: audiologists may not bill E&M codes 99201-99499 and certain cerumen removal codes are restricted (see audiology billing rules).
Audio-only, audiology timing, and supervised non-licensed behavioral health criteria
Audio-only, audiology timing, and supervised non-licensed behavioral health are covered when the listed conditions are met:
Audio-only (telephone) services are covered in Vermont and will be reimbursed when equivalent to in-person services provided via audio-only means.
When billing in-person CPT codes performed via audio-only: use Place of Service = 99 and append Modifier V3 in the required position for Non‑Physician/APRN Behavioral Health as specified by contract; Modifier V3 must be in first position for equivalent-to-in-person audio-only billing in behavioral health.
Non-Physician/APRN Behavioral Health Providers are not eligible to bill CPT codes 99441-99443; these codes are excluded for those provider types per policy.
Reimbursement for covered audio-only physician services in applicable settings will be at 75% of the physician fee schedule when so specified by MVP (state-specific reimbursement rules apply).
In Vermont only: Qualified Non-Licensed Psychotherapists may bill under direct supervision of a Qualified Licensed Psychotherapist when rostered per VT statute; supervising clinician must meet degree-level requirements and specific CMS 1500 form fields and modifiers (HO for Master's level, HP for Doctorate level) must be used. MVP Medicare Advantage members are excluded from supervised non-licensed provider reimbursement.
Services performed by non-licensed providers who cannot practice independently and are not actively working toward licensure are non-reimbursable; MVP Medicare members may not receive services from non-licensed providers even under supervision.
Providers must verify eligibility and prior authorization requirements via MVP resources (Member Benefits Display, Utilization Management Guides, Benefit Interpretation Manual); MVP policies do not guarantee payment.
Contrast materials not separately reimbursable
Contrast materials are not separately reimbursable for the listed products when ALL of the following apply:
Non-licensed provider services — exclusion
Excluded — services performed by non-licensed providers are not reimbursable:
Services performed by non-licensed providers who cannot practice independently and are not actively working toward licensure are non-reimbursable under MVP; Medicare Advantage members are specifically excluded from receiving such services even under supervision.
COVID-19 diagnostic and antibody testing coverage
COVID-19 diagnostic and antibody testing is covered when ALL of the following are met:
Testing is medically appropriate for diagnosis and treatment of COVID-19 as determined by the ordering provider.
Testing ordered solely for pandemic control, employer/school/common carrier screening, or the member's self-assessment of immune status is not covered unless required by law or regulation.
Claims submitted with specified administrative/encounter or otherwise inappropriate primary diagnosis codes will be denied; examples of such codes are listed in the policy appendix and related chunks.
Claims are subject to post-payment review and audit; commercial members may be held liable for denied claims and providers bear responsibility for denials for Medicare Advantage and Medicaid Managed Care members.
COVID-19 testing coverage criteria — applicable rules and limits
COVID-19 testing is covered ONLY when the following specific coverage criteria are satisfied:
Test is ordered/performed based on a clinician determination that it is medically appropriate for diagnosing or treating the individual member.
Testing performed solely for public health surveillance, employer/school/common carrier requirements, or member-requested immune status assessment is not covered unless required by law.
Claims using administrative/encounter primary diagnosis codes (examples: Z02.0, Z02.1, Z02.4, Z02.5, Z02.79, Z02.89 and additional codes listed in the policy) will be denied for COVID-19 testing reimbursement.
Claims are subject to post-payment review; providers and members may be financially responsible for services denied under this policy.
Nutritional counseling and DSME coverage criteria
Nutritional counseling and Diabetes Self-Management Education (DSME) are reimbursable when ALL of the following are met:
Service is medically necessary for a chronic disease where dietary adjustment has a therapeutic role and is prescribed by a physician or qualified non-physician practitioner.
Services are furnished by qualified/licensed professionals recognized under the plan (e.g., registered dietitian, licensed nutritionist, registered nurse trained in nutrition, certified diabetes educator).
DSME documentation includes assessment of education needs, individual goals, education/intervention provided, and evaluation of attainment of goals.
Reimbursable CPT/HCPCS codes include 97802-97804 and G0270-G0271; for Medicare MSA plans only these codes are restricted to specified ICD-10 diabetes diagnoses listed in the policy appendix — other plans have no diagnosis code restrictions for these codes.
Providers must verify member eligibility, benefits, and prior authorization requirements via MVP resources; policy alone does not guarantee payment.
ICD-10 diagnosis listing (informational)
Informational — ICD-10 diagnosis codes associated with nutritional counseling and diabetic management (no new coverage rules in this block):
The policy appendix enumerates multiple ICD-10 diagnosis codes across E08–E13 and O24 series that are associated with nutritional counseling and diabetic management; refer to the Appendix for the full list when billing these services.
Nutritional counseling & diabetic management coverage notes — reimbursable services and exclusions
Reimbursable services and exclusions — conditions for diabetic management and nutritional counseling:
Nutritional counseling is not reimbursed for commercial diet plans, gym memberships, holistic therapy, services offered by health resorts/recreational programs, skill/relaxation/lifestyle programs, supplemental fasting, or physical therapy for weight loss; such exclusions must be observed when submitting claims.
Reimbursement guidance — reference to fee schedules/agreements
Reimbursement specifics are determined outside this policy:
Providers must consult their provider fee schedule or IPA agreement for specific reimbursement rates and contractual payment provisions; this policy does not replace contractual terms.
Diagnosis-to-procedure matching requirement — claims must include appropriate diagnoses per LCD/NCD or society guidance
Diagnosis-to-procedure matching requirement — claims must meet the following:
Submitted diagnosis must match the applicable Medicare Local Coverage Determination (LCD), National Coverage Determination (NCD), or referenced clinical society guidance for the procedure or laboratory test; MVP will deny claims for lack of medical necessity if the correct diagnosis is not submitted.
Examples of procedure groups requiring diagnosis matching
- Transthoracic echocardiography codes (e.g., 93303-93304, 93306-93308, 93308, 93350-93352) require the correct diagnosis per the referenced LCD or claim will be denied.
- Facet joint injections, nerve conduction studies/EMG, corneal pachymetry, visual fields, herpes simplex antibody assays, vitamin D assays, ESR, and other listed laboratory/ophthalmology codes require correct diagnosis per the referenced LCD/NCD or clinical guidance or the claim will be denied.
Providers should consult the CMS Medicare Coverage Database, Novitas LCDs, and the policy Appendix for the appropriate reimbursable diagnosis codes associated with each listed procedure or test.
Diagnosis-submission coverage requirements for listed laboratory tests
For the laboratory tests listed below, coverage requires submission of an appropriate diagnosis code consistent with the referenced guidance:
CPT 82607 (Cyanocobalamin – Vitamin B12): correct diagnosis must be submitted per Novitas Solutions Inc. LCD or the claim will be denied for medical necessity.
CPT 83001 (Gonadotropin Follicle Stimulating Hormone): correct diagnosis must be submitted per the American Society for Reproductive Medicine guidance or the claim will be denied for medical necessity.
Refer to the Appendix for reimbursable ICD-10 diagnosis codes associated with these laboratory services; claims submitted without an appropriate diagnosis consistent with the Appendix will be denied.
Diagnosis code lists by item (reference)
Reference lists of ICD-10 diagnosis codes by item (informational — use when validating diagnosis-to-procedure matching):
Follicle Stimulating Hormone (FSH) – see Appendix listing of ICD-10 codes for billing reference (chunk 234).
Herpes Simplex Virus antibody assays – see Appendix listing of ICD-10 codes and descriptor strings (chunks 235, 236–238).
Gammaglobulin IGE and related allergen-specific IGE assays – see Appendix for allergy/immune diagnosis codes (chunk 239 and following).
Erythrocyte Sedimentation Rate (ESR) – Appendix lists primarily oncology/hematology diagnosis codes appropriate for ESR billing (chunks 249, 252, 271).
ESR diagnosis code list (reference)
ICD-10 diagnosis codes associated with ESR (informational reference):
The Appendix enumerates multiple ICD-10 oncology/hematology and related codes (e.g., C8100, C8110, C8330 and many others) that are associated with ESR testing; refer to the Appendix when submitting ESR claims to ensure an appropriate diagnosis code is present.
Codes, code groups, and coding guidance
After-Hours CodesCPT
| 99050 | Service(s) provided in the office at times other than regularly scheduled office 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 an E&M; not separately reimbursed for Commercial and Medicare; Medicaid/HARP reimbursed at Medicaid rate. |
| 99053 | Services provided between 10:00 pm and 8:00 am at 24-hour facility; must be billed with an E&M; not reimbursed separately. |
| 99056 | Services typically provided in office but delivered out of office at patient request; must be billed with an E&M; not reimbursed separately. |
| 99058 | Services provided on an emergency basis in the office which disrupt scheduled services; must be billed with an E&M; not reimbursed separately. |
| 99060 | Service(s) provided on an emergency basis, out of the office, which disrupts other scheduled office services; must be billed with an E&M; considered inclusive to the E&M and not reimbursed separately. |
Allergy Testing and Serum Preparation CodesCPTCovered
| 95165 | Supervision of preparation and provision of antigens for allergen immunotherapy; number of units/doses must be specified; first year/subsequent year unit limits apply. |
| 95004 | Allergen testing — number of tests must be specified; reimbursement limited to 80 units per calendar year. |
| 95024 | With allergenic extracts, immediate type reaction including interpretation and report; reimbursement limited to 40 units per calendar year. |
| 95027 | Allergen testing entry with number of tests specified; reimbursement limited to 40 units per calendar year. |
| 95028 | Intracutaneous (intradermal) tests with allergenic extracts, delayed type reaction, including reading; reimbursement limited to 30 units per calendar year. |
E&M, consultation, observation, discharge, and critical care codesCPTCovered
| 99201-99499 | Evaluation and Management codes; rules include denial of second inpatient E&M same day by same provider and urgent care exclusions when billed with well child/routine services. |
| 99050-99060 | After-hours E&M-related procedure codes; must be billed with an E&M; see After-Hours policy (99050 reimbursed unless submitted with preventive visit codes). |
| 99241-99245; 99251-99255 | Consultation codes — MVP follows CMS guidance and does not reimburse consultation codes. |
| 99218-99220; 99234-99236; 99217 | Hospital observation codes — only ordering provider may bill; codes are component/time-based per CPT guidelines. |
| 99221-99223; 99211-99215 | Initial hospital and outpatient visit codes — rules about AI modifier, one visit per provider per day, documentation and time/component requirements. |
| 99238-99239; 99217; 99234-99236 | Discharge service codes — timed/component-based; cannot bill discharge code and regular subsequent inpatient/observation code on same day. |
| 99291-99292 | Critical care E&M — minimum 30 minutes for 99291; incremental 99292 units for specified minute ranges. |
Non-GI scope procedure families and multiple procedure payment rulemixedCovered
| (various non-GI scope families per Medicare RBRVS; see list) | Arthroscopic, endoscopic, and other non-GI scope procedure code families: highest RVU procedure reimbursed; secondary procedures reduced per Medicare multiple-procedure methodology (applies to listed families). |
Audiology coding rulesCPTCovered
| 99201-99499 | Evaluation and Management codes — audiologists may not bill these. |
| 69209 | Cerumen removal — audiologists may not bill; included in diagnostic test RVU. |
| 69210 | Cerumen removal — audiologists may not bill; included in diagnostic test RVU. |
| G0268 | Physician code for cerumen removal when physician performs removal same day as diagnostic test. |
Timed audiology and telephone E/M codesCPT
| 92620 | Evaluation of central auditory function, with report; initial 60 minutes — timed code billed only if testing is ≥51% of the code's designated time. |
| 92621 | Evaluation of central auditory function, with report; each additional 15 minutes — additional timed units per CPT time rules. |
| 92626 | Evaluation of auditory rehabilitation status; first hour — timed code billed only if testing is ≥51% of the code's designated time. |
| 92627 | Evaluation of auditory rehabilitation status; each additional 15 minutes. |
| 92640 | Diagnostic analysis with programming of auditory brainstem implant, per hour. |
| 99441 | Telephone E/M service; 5-10 minutes. |
| 99442 | Telephone E/M service; 11-20 minutes. |
| 99443 | Telephone E/M service; 21-30 minutes. |
Contrast material HCPCSHCPCSNot Covered
| A9579 | Injection, gadolinium-based magnetic resonance contrast agent, per ml (considered inclusive to the primary procedure fee). |
| Q9951 | Low osmolar contrast material, 400+ mg/ml iodine concentration, per ml (not separately reimbursable). |
| Q9965 | Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml (not separately reimbursable). |
| Q9966 | Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml (not separately reimbursable). |
| Q9967 | Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml (not separately reimbursable). |
| Q9958 | High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml (not separately reimbursable). |
| Q9959 | High osmolar contrast material code (listed as not separately reimbursable). |
COVID-19 test codesmixed
| Applicable COVID-19 CPT/HCPCS codes per AMA and CMS | Applicable COVID-19 test CPT and HCPCS codes as published by AMA and CMS (providers should use current AMA/CMS code lists). |
Denied/ inappropriate primary diagnosis codesICD-10Not Covered
| Z02.0 | Encounter for examination for admission to educational institution — will be denied as primary diagnosis for COVID-19 testing. |
| Z02.1; Z02.4; Z02.5; Z02.79; Z02.89 | Administrative/encounter examination codes (examples listed) that will be denied when submitted as primary diagnosis for COVID-19 testing — policy lists additional inappropriate codes. |
Reimbursable nutritional counseling codesCPTCovered
| 97802 | Medical nutritional therapy; initial assessment and intervention, individual, face-to-face, each 15 minutes. |
| 97803 | Medical nutritional therapy; re-assessment and intervention, individual, face-to-face, each 15 minutes. |
| 97804 | Medical nutritional therapy; group session. |
| G0270 | MDT related code listed as reimbursable. |
| G0271 | MDT related code listed as reimbursable. |
Sample diabetes-related ICD-10 codesICD-10Covered
| E09.3293 | Drug or chemical induced diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral. |
| E10.3211 | Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye. |
| E11.3213 | Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateral. |
| E13.3293 | Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral. |
Listed ICD-10 diabetes diagnosis groupsICD-10Covered
| E08.* | Diabetes mellitus due to underlying condition (multiple complication codes listed). |
| E09.* | Drug or chemical induced diabetes mellitus (multiple complication codes listed). |
| E10.* | Type 1 diabetes mellitus (selected complication codes listed). |
| E13.* | Other specified diabetes mellitus (multiple complication codes listed). |
Sample E09 series entriesICD-10
| E09.43 | Drug or chemical induced Diabetes mellitus with neurological complications with diabetic autonomic (poly) neuropathy. |
| E09.44 | Drug or chemical induced Diabetes mellitus with neurological complications with diabetic amyotrophy. |
| E09.49 | Drug or chemical induced Diabetes mellitus with neurological complications with other diabetic neurological complication. |
Sample E10 series retinal/ophthalmic entriesICD-10
| E10.3211 | Type 1 Diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye. |
| E10.3513 | Type 1 Diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral. |
| E10.37X1 | Type 1 Diabetes mellitus with diabetic macular edema, resolved following treatment, right eye. |
Sample E11 series entriesICD-10
| E11.00 | Type 2 Diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (NKHHC). |
| E11.3211 | Type 2 Diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye. |
| E11.621 | Type 2 Diabetes mellitus with foot ulcer. |
E13 and O24 series entriesICD-10
| E13.311 | Other specified Diabetes mellitus with unspecified diabetic retinopathy with macular edema. |
| O24.014 | Gestational/pre-existing diabetes in pregnancy (example O24 series entries). |
Transthoracic echocardiography groupsCPTCovered
| 93303-93304 | Transthoracic echocardiography for congenital cardiac anomalies; Group 2. |
| 93306-93308 | Real time transthoracic echocardiography; Group 1. |
Additional transthoracic echo codesCPTCovered
| 93308 | Echocardiography, transthoracic, real-time with image documentation (2D); Group 3. |
| 93350-93352 | Echocardiography during rest and cardiovascular stress test; Group 4. |
Facet joint injections / neurotomyCPTCovered
| 64490-64495 | Diagnostic or therapeutic agent injections with image guidance; cervical/thoracic/lumbar/sacral. |
| 64625; 64633-64636 | Destruction by neurolytic agent / facet radiofrequency neurotomy codes. |
Laboratory and ophthalmology codes with diagnosis-match rulesCPTCovered
| 76514 | Corneal pachymetry. |
| 92081-92083 | Visual field examination with interpretation and report. |
| 86695-86696 | Herpes Simplex virus antibody assays (type 1 and 2). |
| 82306 | Vitamin D 25 hydroxy test. |
| 82652 | Vitamin D 1,25 hydroxy test. |
| 85652 | Erythrocyte sedimentation rate; automated. |
| 82785; 86003; 86008 | Gammaglobulin IGE and allergen-specific IGE assays. |
| 82746 | Folic acid assay. |
| 82607 | Cyanocobalamin (Vitamin B12) assay. |
| 83001 | Gonadotropin Follicle Stimulating Hormone assay. |
B12 assayCPTCovered
| 82607 | Cyanocobalamin - Vitamin B12 (requires correct diagnosis per Novitas LCD or claim will be denied). |
FSH assayCPTCovered
| 83001 | Gonadotropin Follicle Stimulating Hormone (requires correct diagnosis per ASRM or claim will be denied). |
T3 assayCPTCovered
| 84481 | Assay of Triiodothyronine (T3) — refer to Appendix for appropriate diagnosis codes; correct diagnosis required or claim will be denied. |
Sample codes for Follicle Stimulating Hormone listICD-10
| I4891 | Unspecified atrial fibrillation (listed in FSH appendix). |
| I959 | Hypotension, unspecified (listed in FSH appendix). |
| J449 | Chronic obstructive pulmonary disease, unspecified (listed in FSH appendix). |
Example Herpes Simplex Virus-related codesICD-10
| R051 | Acute cough (example HSV-related code listed in appendix). |
| R509 | Fever, unspecified (example HSV-related code listed in appendix). |
| B009 | Herpesviral infection, unspecified (example HSV-related code listed in appendix). |
Sample Gammaglobulin IGE-related codesICD-10
| J301 | Allergic rhinitis due to pollen (listed in Gammaglobulin IGE appendix). |
| J449 | Chronic obstructive pulmonary disease, unspecified (listed in Gammaglobulin IGE appendix). |
| T7800XA | Anaphylactic reaction due to unspecified food, initial encounter (listed in Gammaglobulin IGE appendix). |
Erythrocyte Sedimentation Rate — oncology-related codesICD-10
| C169 | Malignant neoplasm of stomach, unspecified (listed in ESR appendix). |
| C3411 | Malignant neoplasm of upper lobe, right bronchus or lung (listed in ESR appendix). |
| C8330 | Diffuse large B-cell lymphoma, unspecified site (listed in ESR appendix). |
Sample ICD-10 codes referenced for ESRICD-10
| C8100 | Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site. |
| C8110 | Nodular sclerosis Hodgkin lymphoma, unspecified site. |
| C8330 | Diffuse large B-cell lymphoma, unspecified site. |
| C9000 | Multiple myeloma not having achieved remission. |
| D630 | Anemia in neoplastic disease. |
| D649 | Anemia, unspecified. |
Additional ICD-10 codes across systemsICD-10
| E1121 | Type 2 diabetes mellitus with diabetic nephropathy (listed among additional ICD-10 examples). |
| G35 | Multiple sclerosis (listed among additional ICD-10 examples). |
| H348130 | Central retinal vein occlusion, bilateral, with macular edema (listed among additional ICD-10 examples). |
Allergy testing and serum preparation annual unit limits - first year and subsequent year caps
First-year annual capUp to 160 units/doses per calendar year (maximum 40 units/doses per claim)
Subsequent-year annual capUp to 120 units/doses per calendar year (maximum 30 units/doses per claim)
95004 per-year capReimbursement limited to 80 units per calendar year
95024 per-year capReimbursement limited to 40 units per calendar year
95028 per-year capReimbursement limited to 30 units per calendar year
Critical care minimum time — 30 minutes
Minimum billable time for critical care (99291)30 minutes (code not reimbursed if time < 30 minutes)
Time counting rulesCritical care time is per calendar day and must be documented; time need not be continuous and includes bedside and related activities
Non-countable activitiesCertain procedures and family discussions do not count toward critical care time
Timed-code billing threshold — 51% minimum of code-designated time to bill a timed code
Timed-code billing thresholdA timed code may be billed only when testing comprises at least 51% of the code's designated time
Applicability to audiology codesApplies to CPT audiology timed codes (e.g., 92620, 92621, 92626, 92627, 92640)
Exclusions from test timeNon-test activities such as counseling or goal setting are not counted toward the timed testing proportion
15-minute unit timing — unit minute ranges for 15-minute codes
1 unit (15-minute code)8 minutes to < 23 minutes
2 units (15-minute code)23 minutes to < 38 minutes
3 units (15-minute code)38 minutes to < 53 minutes
Higher-unit examplesE.g., 4 units = 68 minutes to < 83 minutes; 6 units = 83 minutes to < 98 minutes (per policy examples)
Timed code billing thresholds — combined threshold and unit timing for audiology codes
Audiology timed-code requirementTimed audiology codes billed only if testing is ≥51% of the code-designated time
15-minute unit conversionUnits for 15-minute designated codes follow minute ranges (1 unit = 8 to <23 min; 2 units = 23 to <38 min; 3 units = 38 to <53 min, etc.)
Exclusion of non-test timeTime spent on counseling, goal setting, or other non-diagnostic activities must be excluded when determining testing proportion
Coverage inclusion — contrast materials considered inclusive to procedure fee (not separately reimbursable)
Contrast materials are inclusive to procedure feeNon-ionic and ionic contrast materials are considered part of the underlying exam and are not separately reimbursable
Applies to listed HCPCS codesContrast HCPCS codes (e.g., A9579, Q9951, Q9965–Q9967, Q9958, Q9959) are denied as separate charges
RationaleMVP considers both ionic and non-ionic contrast inclusive because costs and routine use now align
Coding guidance — follow CDC ICD-10-CM Official Coding Guidelines
Coding guidance — diagnosis selectionProviders should follow CDC ICD-10-CM Official Coding Guidelines when selecting a diagnosis code
COVID-19 codes sourceApplicable COVID-19 CPT/HCPCS codes as published by AMA and CMS
Use reliable testsMVP encourages use of reliable FDA-authorized COVID-19 tests (per policy guidance)
Diagnosis code restriction for Medicare MSA for nutritional counseling codes
Medicare MSA diagnosis restriction (97802-97804, G0270-G0271)For Medicare MSA plans only, codes 97802-97804 and G0270-G0271 are limited to specified ICD-10-CM diabetes-related diagnoses listed in the policy
Other plansAll other plans have no diagnosis code restrictions for these nutritional counseling codes
Provider verificationProviders must verify member eligibility and plan-specific requirements prior to billing
G0108/G0109 diagnosis limitation for Medicare MSA
G0108/G0109 diagnosis limitation (Medicare MSA)For Medicare MSA plans only, codes G0108 and G0109 are limited to specified ICD-10 diagnoses; other plans reimburse within ICD-10 ranges E08–E09
Code descriptionsG0108 = Diabetes outpatient self-management training, individual, per 30 minutes; G0109 = group session per 30 minutes
Plan varianceVerify plan (MSA vs commercial) as coding restrictions differ by product
No thresholds specified in this coding segment
Thresholds in this segmentNone specified
ContextThis section lists ICD-10 diabetes diagnosis codes for reference; no additional numeric thresholds provided here
Billing implicationUse appropriate diagnosis mapping per policy; refer to other sections for reimbursement rules
Diagnosis match required — claim denial if correct diagnosis per LCD/NCD not submitted
Diagnosis-to-procedure match requiredClaims must include the correct diagnosis in accordance with the applicable Medicare LCD or NCD or the claim will be denied for lack of medical necessity
Applies to listed procedures/testsRequirement applies to transthoracic echo, facet injections, NCS/EMG, corneal pachymetry, visual fields, HSV antibody, vitamin D, ESR, gammaglobulin IGE, folic acid, B12, FSH, thyroid tests, etc.
Reference sourcesProviders should refer to cited LCD/NCD documents and clinical society guidance noted in the policy (e.g., Novitas LCDs, NCD ID #100-3)
No thresholds listed for this document segment
Thresholds in this segmentNone specified
ContentThis segment provides ICD-10 diagnosis codes for ESR billing reference; no numeric thresholds listed
Use guidanceRefer to appendix and diagnosis-matching edits for appropriate coding to avoid denial
Prior authorization, documentation and claim submission actions
Prior Authorization
Verify member eligibility and consult UM guides
Providers must check member eligibility and the Member Benefits Display and review MVP's Utilization Management Guides (and the Benefit Interpretation Manual) via mvphealthcare.com to determine whether prior authorization is required; payment policies are not a guarantee of payment.
Prior Authorization
Check member eligibility and UM guides before services
Providers must confirm Member eligibility, review the Member Benefits Display, and consult MVP's Utilization Management Guides (accessible via provider sign‑in at mvphealthcare.com) to determine prior authorization requirements; MVP payment policies do not guarantee payment.
Prior Authorization
Confirm eligibility and prior‑auth requirements
Providers are required to check member eligibility and the Member Benefits Display and consult MVP's Utilization Management Guides and the Benefit Interpretation Manual (sign‑in to mvphealthcare.com required) to determine if prior authorization is required; policy statements are not guarantees of payment.
Prior Authorization
Obtain authorization for In‑Office Only codes under split billing
Procedure codes listed on MVP's In‑Office Only list will not be reimbursed under a split‑billing arrangement unless an authorization is obtained; if authorized, reimbursement may be allowed for Medicare and Medicaid products.
Note
Consult member and UM resources prior to billing
Providers must consult the Member Benefits Display, verify member eligibility, and review MVP's Utilization Management Guides and the Benefit Interpretation Manual (via provider account) to determine benefit coverage and prior authorization needs.
Prior Authorization
Obtain required prior authorization for select services
Obtain prior authorization for services identified in MVP's Utilization Management Guides; when an authorization is required it applies to all technical, professional, global and facility claims for the service.
Denial Risk
Risk of administrative denial for missing prior approval
If services requiring prior authorization are provided without prior approval, MVP will apply administrative denial to all associated technical, professional, global and facility claims for those services.
Documentation Required
Consult UM Guides and Benefit Interpretation Manual for clinical guidance
Providers should consult MVP's Utilization Management Guides and the Benefit Interpretation Manual for clinical guidelines and resources; access requires signing into mvphealthcare.com.
Prior Authorization
Verify eligibility and UM requirements before service
Providers must verify member eligibility, review the Member Benefits Display, and consult MVP's Utilization Management Guides (and Benefit Interpretation Manual) via their provider account to determine whether prior authorization is required; payment policies do not guarantee payment.
Prior Authorization
Participating providers must verify eligibility and prior‑auth needs
Participating providers must check member eligibility and the Member Benefits Display and consult MVP's Utilization Management Guides to determine if prior authorization is required; MVP payment policies are not a guarantee of payment.
Documentation Required
Reference ICD‑10 codes for Nutritional Counseling
The policy provides ICD‑10 diagnosis codes associated with Nutritional Counseling and diabetic complications for provider reference when billing nutritional counseling/DSME services.
Billing Rule
Bill G0108/G0109 per guidance and note Medicare MSA diagnosis limits
Codes G0108 (individual, per 30 minutes) and G0109 (group, per 30 minutes) are reimbursable for diabetes outpatient self‑management training; for Medicare MSA plans these codes are limited to specified diagnoses (other plans reimburse ICD‑10 in range E08–E09).
Billing Rule
Refer to provider fee schedule or IPA agreement for reimbursement
For specific reimbursement amounts and payment methodology, providers must consult their provider fee schedule or IPA agreement.
Prior Authorization
Participating providers must verify eligibility and prior‑auth requirements
Participating providers must check member eligibility, review the Member Benefits Display, and consult MVP's Utilization Management Guides and Benefit Interpretation Manual to determine if prior authorization is required; MVP payment policies do not guarantee payment.
Denial Risk
Submit diagnosis that matches applicable LCD/NCD or risk denial
Providers must submit the correct diagnosis with the claim in accordance with the applicable Medicare Local Coverage Determination (LCD) or National Coverage Determination (NCD); claims will be denied for lack of medical necessity if the diagnosis does not match.
Denial Risk
Include correct diagnosis for B12 assay (82607) per Novitas LCD
For CPT 82607 (Cyanocobalamin/Vitamin B12), MVP requires the correct diagnosis to be submitted with the claim per the Novitas Solutions Inc. Local Coverage Determination; claims will be denied if the diagnosis criterion is not met.
Denial Risk
Include correct diagnosis for FSH assay (83001) per ASRM guidance
For CPT 83001 (Gonadotropin FSH), MVP requires the correct diagnosis be submitted with the claim in accordance with the American Society for Reproductive Medicine; claims will be denied if clinical guidance is not met.
Denial Risk
Submit appropriate diagnosis for thyroid testing per NCD/LCD
For thyroid panel tests (codes 84443, 84436, 84439, 84479), MVP requires the correct diagnosis be submitted with the claim in accordance with Medicare NCD/LCD guidance; claims will be denied if the diagnosis criterion is not met.
Denial Risk
Include correct diagnosis for T3 assay (84481) or claim denied
For T3 assay (84481), MVP requires the correct diagnosis be submitted with the claim or the claim will be denied for lack of medical necessity; refer to the Appendix for appropriate diagnosis codes.
Documentation Required
Use appendix ICD‑10 list for FSH billing reference
The appendix of the policy lists ICD‑10 diagnosis codes associated with Follicle Stimulating Hormone testing for provider billing reference.
Documentation Required
Refer to appendix ICD‑10 codes for HSV testing
The policy appendix provides ICD‑10 diagnosis codes and descriptors for Herpes Simplex Virus‑related testing and encounters for provider reference.
Documentation Required
Use appendix ICD‑10 codes for Gammaglobulin IGE testing
Refer to the Appendix for the list of ICD‑10 diagnosis codes and descriptors associated with Gammaglobulin IGE testing (allergy/immune diagnoses and adverse reaction codes).
Documentation Required
Refer to appendix ICD‑10 codes for ESR testing
The policy appendix lists ICD‑10 diagnosis codes (primarily malignant neoplasms and lymphomas) that are associated with Erythrocyte Sedimentation Rate (ESR) testing for billing reference.
Documentation Required
ESR diagnosis code reference (appendix)
See the policy Appendix and referenced CMS/LCD documents for an expanded ICD‑10 diagnosis code reference applicable to ESR claims and billing.
Defined terms used in this policy
Medically Necessary / Medical Necessity definition — MVP follows AMA and CMS definitions
MVP alignment with AMA/CMS definitionsMVP follows AMA and CMS definitions: services a prudent physician would provide to prevent, diagnose, or treat disease and that are clinically appropriate and documented
Documentation expectationDocumentation should support the level of service billed; medical records may be requested for audit
Medical necessity as payment criterionMedical necessity is the overarching criterion for payment in addition to CPT-specific documentation requirements
Critically ill or injured Member — definition snippet
Definition — critically ill or injured MemberA critical illness or injury that acutely impairs one or more vital organ systems indicating a high probability of imminent or life‑threatening deterioration
ExamplesIncludes central nervous system failure, circulatory failure, shock, renal/hepatic/metabolic/respiratory failure
Time principlesCritical care time billed per calendar day and must be documented; time need not be continuous
Split billing — definition
Split billing — definitionA billing structure with two separate charges: professional (physician/practice) and technical (facility)
Professional componentBillable services provided by physicians (e.g., consultation, interpretation) and paid to the provider group
Technical componentFacility-based services (e.g., labs, imaging, procedures) reimbursed to the hospital
Global reimbursementOne combined bill that covers both professional and technical components when applicable
Billing structures — split billing professional vs technical definitions
Professional vs Technical — billing structuresProfessional = physician-provided services billed to provider group; Technical = facility services billed to hospital; Global = single combined payment covering both
Facility-based (split) billingHospital receives technical component reimbursement while physicians receive professional fee consistent with facility-based RVUs
Global (non-facility) billingOne global payment compensates providers operating in private practice and covers overhead and technical expenses
Facility-based vs Global — split billing explanation
Facility-based vs Global — explanationFacility-based (split billing) separates technical and professional components with facility receiving technical reimbursement; Global billing uses one combined payment covering both components
Payment flowIn facility-based, reimbursements for physician services use facility-based RVUs; in global, payments generally go to physician practice unless employed by hospital
ImplicationChoice of billing structure affects who receives technical reimbursement (hospital) versus professional payments (provider group)
Audiological diagnostic testing — definition
Audiological diagnostic testing — definitionTests of auditory and vestibular systems including hearing, balance, auditory processing, tinnitus, and diagnostic programming of certain prosthetic devices performed by qualified audiologists
Timed audiology codesCertain audiology CPT codes include explicit time designations and have billing rules (see timed-code 51% threshold)
Non-test time exclusionActivities such as counseling and goal setting are excluded from test-time calculations when billing timed codes
CPT — Current Procedural Terminology definition
CPT definitionCurrent Procedural Terminology (CPT) is the medical code set used to report medical, surgical, and diagnostic procedures and services
Use caseCPT codes are used for reporting services to payers and accreditation organizations
Relation to E/ME/M services are reported using CPT codes in the 99202-99499 range
E&M Codes — Evaluation & Management code definition
E&M codes — definitionEvaluation & Management (E&M) CPT codes (e.g., 99202–99499) represent services involving evaluating and managing patient health
Documentation guidanceMVP follows CMS 1995/1997 documentation guidelines and 2021 E&M coding guidance for office/outpatient services
Medical necessity linkageE&M reimbursement requires services to meet medical necessity and documentation criteria
Qualified Licensed Practitioner — definition
Qualified Licensed Practitioner — definitionA provider who is licensed and credentialed by MVP and acting within the scope of his/her practice
Billing implicationLicensed practitioners can bill for services they provide within scope and may supervise non-licensed practitioners where allowed
Supervision roleSupervising clinician must meet degree/licensure requirements when supervising non-licensed practitioners (per VT guidance)
Qualified Non-Licensed Practitioner — definition
Qualified Non-Licensed Practitioner — definitionA provider actively working toward licensure as specified by their profession; may bill under direct supervision where permitted (Vermont-specific rules apply)
Supervised billing requirementsWhen billing under supervision, the supervising clinician's NPI/taxonomy and name/degree must be listed on CMS 1500 fields as specified
LimitationsMVP Medicare members are not eligible to receive services from non-licensed providers even under supervision
Supervised Billing — definition
Supervised Billing — definitionLicensed practitioner bills for covered clinical services provided by a qualified non-licensed practitioner under direct supervision
CMS 1500 form requirementsBox 24j list supervising NPI/taxonomy; Box 31 list supervising provider name/degree; append HO or HP modifier per degree level in Vermont
Degree paritySupervising clinician must have same degree level (Masters or Doctorate) as the non-licensed clinician when required
Contrast material reimbursement rationale — non-ionic vs ionic contrast
Contrast material reimbursement rationaleNon-ionic contrast historically costlier but now similarly priced; MVP treats ionic and non-ionic contrast as inclusive to the exam fee and not separately reimbursable
Policy change rationaleRoutine use and comparable costs of non-ionic contrast justify inclusion in procedure fee
Billing outcomeSeparate claims for contrast material (listed HCPCS) will be denied for Commercial, Exchange, and Medicaid products
Services performed by non-licensed providers — non-reimbursable statement
Services by non-licensed providers — reimbursement stanceServices performed by non-licensed providers who cannot practice independently and are not actively working toward licensure are non-reimbursable
Medicare restrictionMVP Medicare members are not eligible to receive services performed by non-licensed providers even under supervision
Supervision exception limitedState-specific supervised billing (e.g., Vermont) may allow conditions for billing under licensed supervisor, but federal Medicare rules still restrict
COVID-19 diagnostic testing definition
COVID-19 diagnostic testing — definitionA virus/antigen detection (diagnostic) test that determines if a person is currently infected with COVID-19
Antibody (serology) testing — definitionA test that may determine if a person has been exposed to COVID-19; per FDA it should not be used to diagnose current infection
Code sourcesApplicable COVID-19 CPT and HCPCS codes as published by AMA and CMS
COVID-19 antibody/serology testing definition
COVID-19 antibody/serology testing definitionA test that may determine exposure to COVID-19; FDA advises it should not be used to diagnose current infection
Provider guidanceUse reliable FDA-authorized tests and follow CDC ICD-10-CM coding guidelines
ApplicabilityPolicy applies to participating and non-participating practitioners, facilities, labs and pharmacies and all lines of business
COVID-19 testing policy scope definition
COVID-19 testing policy scopeDefines coverage, reimbursement and billing guidelines for COVID-19 viral and antibody testing for participating and non‑participating providers and all lines of business
Coverage conditionTesting covered when medically appropriate for diagnosis and treatment; not covered when solely for public health/employer screening unless required by law
Claims reviewClaims are subject to post-payment review; inappropriate primary diagnosis codes will be denied per examples in policy
Nutritional counseling definition and furnishing provider types
Nutritional counseling — definitionReimbursable when medically necessary for chronic diseases; must be prescribed by a physician or qualified practitioner and furnished by recognized licensed providers (e.g., registered dietitian, licensed nutritionist, trained nurses)
Provider typesExamples of furnishing providers: registered dietitian, licensed nutritionist, certified diabetes educator, registered nurse
Service contentMedical nutrition therapy includes assessment of nutritional status and individualized diet/counseling to treat chronic illness
Diabetic Management / Medical Nutrition Therapy definition
Diabetic Management / Medical Nutrition Therapy — definitionIncludes diabetes education and management for all diabetes types; medical nutrition therapy by a registered dietitian involves assessment and individualized nutrition therapy to treat chronic illness
DSME documentationDocumentation should include assessment of education needs, specific goals, interventions, and evaluation of attainment
Provider qualificationsServices must be provided by licensed health professionals, e.g., registered dietitian, RN, or certified diabetes educator
Diabetes self-management education (DSME) definition and required documentation elements
Diabetes self-management education (DSME) — definitionAn interactive, collaborative ongoing process to help persons with or at risk for diabetes develop knowledge and skills to meet self-defined diabetes goals
Required documentation elementsAssessment of education needs, individual's diabetes self-management goals, education/behavioral interventions, and evaluation of attainment
Standards referenceBased on AADE national standards and supporting guidance cited in policy
Nutritional Counseling (duplicate definition)
Nutritional Counseling — duplicate definition noteNutritional counseling reimbursable when medically necessary and must be provided by recognized licensed providers; CPT/HCPCS codes 97802-97804 and G0270-G0271 are considered reimbursable
Medicare MSA limitationFor Medicare MSA plans these codes are limited to specified diabetes diagnoses; other plans have no diagnosis restriction
Billing requirementServices must be prescribed by a physician or qualified non-physician practitioner
G0108/G0109 — Diabetes outpatient self-management training services definition
G0108/G0109 — definitionG0108 = Diabetes outpatient self-management training services, individual, per 30 minutes; G0109 = group session (2+) per 30 minutes
Medicare MSA restrictionFor Medicare MSA plans these codes are limited to specified diagnoses; other plans reimburse ICD-10 in range E08–E09
Documentation implicationDSME services must be prescribed and documented per policy requirements
Diabetic Management codes — ICD-10 diagnosis codes for diabetes and complications
Diabetic Management codes — definitionICD-10 diagnosis codes for diabetes and related complications (E08–E13, O24 series) referenced for billing and coverage
MSA-specific limitsCertain CPT/HCPCS codes for diabetic management and nutritional counseling are limited to specific ICD-10 codes for Medicare MSA plans
Reference guidancePolicy references CMS NCDs and Novitas LCDs for diagnosis-to-procedure matching
Medical Necessity — CMS Medicare's definition and documentation expectations
Medical Necessity (CMS) — definitionMedical necessity is the overarching payment criterion; documentation must support the billed service and not rely on documentation volume alone
MVP documentation expectationMVP may request medical records to verify appropriate documentation and accuracy of billed services
AMA definition alignmentMVP aligns with AMA/CMS definitions emphasizing appropriateness, necessity, and conformity with accepted standards
Diagnosis Matching Edits definition — requirement to submit correct diagnosis with claims
Diagnosis Matching Edits — definitionRequirement that correct diagnosis be submitted with claims in accordance with LCD/NCD or specialty society guidance; failure leads to denial for lack of medical necessity
ApplicabilityApplies to all lines of business and all claims including physicians, hospitals, and ASCs
ReferenceProviders should consult the CMS Medicare Coverage Database and the referenced LCD/NCD documents cited in the policy
National Coverage Determination reference (NCD) citation
NCD reference — identifierNational Coverage Determination Publication ID #100-3 Manual Section #190.22
Use caseReferenced for thyroid testing and related diagnosis-matching edits in the policy
Access guidanceProviders directed to CMS website for the NCD details
Local Coverage Determination reference (Novitas Solutions Inc.)
Local Coverage Determination referenceNovitas Solutions Inc. Local Coverage Determinations are referenced for specific codes (e.g., 82607, transthoracic echo groups)
Denial consequenceClaims will be denied if diagnosis does not match Novitas LCD requirements for the cited procedures/tests
Provider actionConsult the referenced Novitas LCD document IDs provided in the policy for appropriate diagnoses
diagnosis-to-item mapping — lists of ICD-10 codes associated with items
Diagnosis-to-item mapping — definitionPolicy lists ICD-10 diagnosis codes associated with items/tests in appendices to guide appropriate claim submission
Examples providedAppendix contains codes for FSH, HSV, Gammaglobulin IGE, ESR and numerous ICD-10 entries for each item
Use instructionProviders must use these mappings to meet diagnosis-matching edits and avoid denials
Erythrocyte Sedimentation Rate definition and reference
Erythrocyte Sedimentation Rate (ESR) — definitionESR entry in the policy provides a listing of diagnosis codes (primarily oncology/hematology) referenced for billing/coverage
Reference guidanceAppropriate diagnoses should follow American Society for Clinical Pathology guidance and appendix listings to avoid denial
Appendix locationSee Appendix entries (chunks referenced) for the full list of reimbursable ICD-10 codes associated with ESR
Policy Summary
PayerMVP Health Care
Policy2022 MVP Health Care Payment Policies (Section excerpts)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateDec 1, 2022
Last ReviewMar 1, 2022
Next Review DateMar 1, 2022
Key ActionProviders must check member eligibility and consult MVP's Member Benefits Display and Utilization Management Guides to determine prior authorization requirements.
SourceLink
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