2022 Payment Policies (Reimbursement and Billing Guidelines)
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This document compiles MVP Health Care's 2022 payment and reimbursement policy guidelines covering multiple service areas (e.g., after-hours, allergy testing, E&M), describing billing rules, reimbursement limits, and prior authorization/notification expectations for providers.
No material clinical or coverage changes in this revision.
Coverage Criteria and Payment Rules
Allergy testing and serum preparation coverage rules
Allergy testing and serum preparation are reimbursable but subject to per-claim and per-calendar-year unit limits by code.
ALL of the following
- 95165 — Units/doses must be specified on the claim; First Year: limited to 40 units/doses per claim and 160 units/doses per calendar year; Subsequent Years: limited to 30 units per claim and 120 units/doses per calendar year.
- 95004 — Number of percutaneous tests must be specified on the claim; reimbursement limited to 80 units per calendar year.
- 95024 — Number of intracutaneous (intradermal) tests must be specified on the claim; reimbursement limited to 40 units per calendar year.
- 95027 — Number of intracutaneous sequential incremental tests must be specified on the claim; reimbursement limited to 40 units per calendar year.
- 95028 — Number of intracutaneous delayed type reaction tests must be specified on the claim; reimbursement limited to 30 units per calendar year.
After-hours reimbursement stance
After-hours service codes require an accompanying E&M and are generally considered inclusive to the billed E&M (not separately reimbursed) except where product-specific rules apply.
ALL of the following
- After-hours CPT codes (99050-99060) must be billed with an E&M; they are not payable if they are the only CPT on the claim.
- Exception: 99051 may be reimbursed at Medicaid/HARP rate per product-specific rules; check contractual agreement for applicability.
Evaluation and Management coverage criteria
Evaluation and Management (E&M) services are reimbursed when medically necessary and documented per CMS/AMA guidelines.
ALL of the following
- E&M services are covered when medically necessary per MVP; MVP follows AMA CPT definitions and CMS 1995/1997 documentation guidelines and the CMS 2021 E&M Coding Guidelines (Office and Other Outpatient Services).
- Documentation supporting the level of service billed must be maintained; MVP may request medical records to verify documentation and appropriateness.
- Member eligibility and benefit specifics should be verified prior to providing services.
E&M coverage criteria and billing rules
MVP reimburses medically necessary E&M services following AMA/CMS guidance, with specific bundling, modifier, global period, and special-case rules as listed below.
ALL of the following
- Medical necessity required — E&M services must meet MVP/AMA/CMS medical necessity definitions and documentation should support the level billed; records may be audited.
- Preventive services — If primary reason is preventive (99381-99387 or 99391-99397), claims reimbursed per state/federal rules; many office procedures are not reimbursed same day as preventive visits.
- One E&M per day limit — Allow one E&M CPT code per day per physician group per specialty (exceptions may apply per modifiers or special rules).
- Immunization administration — Immunization administration codes are reimbursed only when billed with diagnosis code Z23.
- Modifier 25 and procedure linkage — Allergy injections and certain procedures require an accompanying E&M/Inpatient/ER visit with modifier 25 for separate reimbursement; follow MVP Modifier Payment Policy for same-day multiple E&M rules.
- Global period/Modifier 24 — No separate reimbursement for E&M during a major surgery global period unless a significant, unrelated problem arises; append Modifier 24 for unrelated E&M during postoperative period. Minor-procedure 10-day global period E&M not reimbursed separately.
- Prenatal visits — First prenatal E&M visit is global to OB delivery charges; antepartum billing must indicate number of prenatal visits for reimbursement.
- Inpatient duplicate E&M — When two inpatient physician E&M codes are billed same date for same/related condition by the same provider, the second E&M code will be denied.
- After-hours codes — Refer to After-Hours Payment Policy for 99051-99060; 99050 reimbursed except when submitted with preventive visit codes; check contract applicability.
Extracted coverage rules
Key coverage stances and rules extracted from this segment:
ALL of the following
- Inpatient duplicate E&M denial — 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.
- Urgent care exclusion — Urgent care E&M codes will not be reimbursed when billed with well-child care, routine diagnoses, or routine services such as immunizations.
- Consultation nonpayment — MVP follows CMS guidance and does not reimburse consultation codes (office or inpatient); use alternative E&M codes with appropriate documentation.
- Scope-procedure family payment — When multiple arthroscopic/endoscopic/non-GI scope procedures within same code family occur same day, the highest RVU procedure is reimbursed; additional procedures reduced per Medicare methodology.
- Split billing eligibility — Split billing arrangements recognized only for Article 28 providers participating in Medicare and/or Medicaid/Government Programs; Commercial/ASO and Exchange products are not eligible.
- Prior authorization note — Payment policies are not a guarantee of payment; providers must verify eligibility and prior authorization requirements via MVP resources.
Split billing coverage criteria
Eligibility and scope for split billing arrangements
ALL of the following
- Eligible providers — Split billing is permitted only when billing entity meets Article 28 requirements (or equivalent) and participates with MVP Medicare and/or Medicaid/Government Programs.
- Ineligible products — MVP Commercial, ASO, and Exchange products are not eligible for split billing arrangements.
- Facility and claim responsibilities — Under split billing the hospital incurs practice-related expenses and receives technical reimbursement; provider claims should use a facility place of service (e.g., POS 22) rather than office POS 11.
- In-Office Only procedures — Procedure codes on MVP's In-Office Only list are not reimbursed under split billing unless prior authorization is obtained; with authorization reimbursement may be allowed for Medicare and Medicaid products.
Audiology coverage criteria
Audiology service billing criteria and limits
ALL of the following
- E&M billing restriction — Audiologists may not bill E&M CPT codes 99201-99499.
- Hearing aid reimbursement — Reimbursement for hearing aids includes the initial evaluation and all follow-up tests and adjustments required for fitting.
Audio-only, Audiology timing, Behavioral health and Supervised billing criteria
Summary of coverage and billing conditions present in this document segment.
ALL of the following
- Timed audiology codes — Timed audiology CPT codes billed only when testing comprises >=51% of the code's designated time; activities such as counseling, goal-setting, or evaluation for remediation are excluded from testing time.
- 15-minute unit mapping — For CPT codes designated as 15 minutes, units map to CPT minutes-per-unit guidance (e.g., 1 unit = 8 to <23 minutes, 2 units = 23 to <38 minutes, etc.).
- Audio-only coverage (Vermont) — MVP covers telephone (audio-only) services in Vermont and reimburses telephone-only services equivalent to in-person codes when provided via audio-only methods.
- Place of service and modifier for audio-only — In-person CPT codes delivered via audio-only should use Place of Service = 99 and Modifier = V3; for behavioral health non-physician/APRN claims Modifier V3 is required in first position and those providers are not eligible to bill 99441-99443.
- Audio-only reimbursement rate — Reimbursement for covered services delivered by audio-only is at 75% of the medical provider physician fee schedule (where specified).
- Supervised billing in Vermont — Qualified Non-Licensed Psychotherapists may bill under direct supervision of a Qualified Licensed Psychotherapist (excludes MVP Medicare Advantage); supervised billing requires specific CMS 1500 box entries and use of modifiers HO (master's) or HP (doctorate).
- Non-licensed provider exclusions — Services by non-licensed providers who cannot practice independently and are not actively working toward licensure are non-reimbursable; MVP Medicare members are ineligible to receive services from non-licensed providers even under supervision.
Coverage and billing rules
Key coverage positions and administrative billing rules
ALL of the following
- Contrast materials inclusion — Contrast materials (ionic and non-ionic, including gadolinium) are considered inclusive to the primary exam fee; MVP will deny separate claims for contrast materials for Commercial, Exchange, and Medicaid products.
- Prior authorization requirements — When prior authorization is required and not obtained, all associated technical, professional, global and/or facility claims for the service will be administratively denied; applies to outpatient surgical services and radiology as specified.
- Non-licensed provider non-reimbursable — 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 performed by non-licensed providers even under supervision.
- COVID-19 testing coverage — COVID-19 diagnostic/viral and antibody testing are covered when medically appropriate for diagnosis and treatment; see additional exclusions for surveillance-only or administrative testing.
COVID-19 testing coverage stance
Coverage is provided when tests are medically appropriate for diagnosis and treatment; testing solely for pandemic control, administrative reasons, or asymptomatic screening for non-clinical purposes is not covered.
ALL of the following
- Covered when medically appropriate — COVID-19 diagnostic/viral and antibody testing are covered when ordered because they are medically appropriate for the diagnosis and treatment of an individual member.
- Not covered for surveillance/administrative-only reasons — Tests ordered or performed solely for pandemic control, re-opening, employer/school screening, travel, or member self-assessment (asymptomatic screening without clinical indication) are not covered.
- Claims subject to audit — COVID-19 testing claims may be reviewed post-payment and are subject to audit; providers are responsible for denials when tests do not meet the medical appropriateness criteria or applicable law exceptions.
Default Pricing reimbursement rule
Default Pricing applies when no reimbursement rate is assigned.
ALL of the following
- Default Pricing rule — When a reimbursement rate has not been assigned by MVP, contract, CMS, or NYS Medicaid, MVP will establish a rate based on an acceptable industry gap-pricing method; if none exists, Default Pricing applies.
- Default Pricing amount — Under Default Pricing MVP will pay up to 30% of billed charges unless otherwise provided for in the executed contract or by CMS/NYS Medicaid.
Coverage criteria for nutritional counseling and diabetic management
Coverage is provided when services are medically necessary, prescribed by an authorized practitioner, furnished by qualified providers, and billed appropriately. Prior authorization rules must be checked separately.
ALL of the following
- Eligibility and authorization — Provider must verify member eligibility and benefits via Member Benefits Display and determine prior authorization requirements via MVP Utilization Management Guides.
- Qualified providers — Nutritional counseling/diabetic management must be furnished by recognized providers (e.g., licensed nutritionist, registered dietitian, registered nurse trained in nutrition, or certified diabetes educator) and services must be prescribed by a physician or qualified non-physician practitioner.
- Medical necessity — Nutritional counseling reimbursable when medically necessary for chronic disease where dietary adjustment has a therapeutic role; diabetic self-management education (DSME) is medically necessary when member has diabetes and services are prescribed.
- Billing rule — Services provided by a nutritionist, dietitian, or certified diabetes educator must be billed under their individual provider number.
- Diagnosis restrictions for Medicare MSA — Codes 97802-97804 and G0270-G0271 are limited to specified ICD-10 diagnoses for Medicare MSA plans only; other plans have no diagnosis code restrictions for these CPT/HCPCS codes.
Coverage stance for nutritional counseling (codes only)
No explicit coverage rules or criteria are provided in this excerpt; the content is a listing of ICD-10 diagnosis codes to be used with nutritional counseling services.
Nutritional Counseling and Diabetic Management coverage criteria
Coverage stance and limitations for nutritional counseling and diabetic management services in this section:
ALL of the following
- Included diagnoses — Extensive ICD-10 diagnosis codes (including E08–E13, O24 series, Z48.22, etc.) are provided as acceptable diagnoses for nutritional counseling and diabetic management reimbursement (see Appendix/listings).
- Excluded services — Nutritional counseling is not reimbursed for commercial diet plans, gym memberships, holistic therapy, services offered by resorts/camps/wilderness programs, skill/relaxation/lifestyle programs, supplemental fasting, or treatment by a physical therapist for weight loss.
Coding guidance (diagnosis selection)
Use the listed ICD-10 codes when documenting the corresponding diabetic condition or complication on claims.
ALL of the following
- Diagnosis specificity — Select the most specific ICD-10 code that reflects the patient's diabetes type and complication (include laterality and macular edema status where applicable).
- Coding actions — Apply the listed ICD-10 codes corresponding to Type 1 (E10), Type 2 (E11), drug/chemical-induced (E09), and other specified diabetes (E13) series as appropriate to support nutritional counseling and diabetic management claims.
Diagnosis matching and medical necessity criteria
Claims must include the correct diagnosis that matches the procedure per the applicable Medicare LCD/NCD; failure to submit correct diagnoses will result in denial for lack of medical necessity.
ALL of the following
- Diagnosis matching requirement — Correct diagnosis must be submitted with the claim in accordance with the referenced Medicare Local Coverage Determination (LCD) or National Coverage Determination (NCD); failure to do so may result in claim denial for lack of medical necessity.
- Scope — This requirement applies to all lines of business and all claim types (physicians, hospitals, ambulatory surgery centers, etc.).
- Procedure-specific references — For specified procedure code groups (e.g., transthoracic echocardiography, facet injections, NCS/EMG, corneal pachymetry, visual fields) providers should use the cited Document IDs/LCDs on the CMS website to determine acceptable diagnoses; pediatric cardiology may be excluded from some edits.
Diagnosis and medical necessity criteria
Coverage is conditional on submission of appropriate diagnosis codes aligning with cited Medicare LCD/NCDs or specialty society guidance; claims lacking correct diagnoses will be denied as not medically necessary.
ALL of the following
- Requirement — Submit the correct diagnosis per the referenced LCD/NCD or specialty society guidance; failure to meet this requirement may result in denial for lack of medical necessity.
- Applicable procedures — Applies to listed CPT procedure groups and laboratory/diagnostic codes (e.g., corneal pachymetry 76514, visual fields 92081-92083, herpes simplex antibody 86695/86696, vitamin D 82306/82652, ESR 85652, allergen IgE assays 82785/86003/86008, folic acid 82746, vitamin B12 82607, FSH 83001, thyroid tests 84436/84439/84479/84480/84481).
- References and resources — Providers should consult the CMS Medicare Coverage Database and the specific LCD/NCD document IDs referenced in this policy for diagnosis lists and supporting guidance; specialty society guidance (ASCP, AAFP, AAAAI, ASRM, Endocrine Society) may also govern acceptable indications for certain tests.
Diagnostic code lists (informational)
This window provides diagnostic code lists only; it does not state coverage determinations, criteria, or payment rules.
Codes, Limits, and Coding Guidance
| 99050 | Service(s) provided in the office at times other than regularly scheduled office hours; must be billed with an E&M to be reimbursable; not reimbursable with preventive visit codes. |
| 99051 | Service(s) provided in office during regularly scheduled evening, weekend, or holiday hours; must be billed with an E&M; not separately reimbursed for Commercial and Medicare; Medicaid/HARP reimbursed at Medicaid rate. |
| 99053 | Service(s) provided between 10:00 pm and 8:00 am at 24-hour facility; must be billed with an E&M; not reimbursed separately. |
| 99056 | Office services provided out of the office at patient request; must be billed with an E&M; not reimbursed separately. |
| 99058 | Emergency office services disrupting scheduled office services; must be billed with an E&M; not reimbursed separately. |
| 99060 | Emergency services out of the office disrupting scheduled services; must be billed with an E&M; not reimbursed separately. |
Required Provider Actions and Documentation
Verify member eligibility & check Member Benefits Display
Providers must check member eligibility and the Member Benefits Display and review MVP's Utilization Management Guides and the Benefit Interpretation Manual to determine if prior authorization is required; payment policies are not a guarantee of payment.
Confirm eligibility and consult Utilization Management Guides
Providers must confirm member eligibility, refer to the Member Benefits Display, and review MVP's Utilization Management Guides and Benefit Interpretation Manual to determine whether prior authorization or notification is required; policies do not guarantee payment.
Check eligibility and prior authorization requirements
Providers must check member eligibility and the Member Benefits Display and review MVP's Utilization Management Guides and Benefit Interpretation Manual (available at mvphealthcare.com) to determine prior authorization requirements; payment policies are not a guarantee of payment.
Verify eligibility and Utilization Management Guides
Providers must check member eligibility, consult the Member Benefits Display, and review MVP's Utilization Management Guides to determine if prior authorization is required; payment policies are not a guarantee of payment.
Consult Member Benefits Display and MVP resources for prior auth
Providers must check member eligibility, review the Member Benefits Display, and consult MVP's Utilization Management Guides and Benefit Interpretation Manual (accessible via mvphealthcare.com) to determine prior authorization requirements.
Authorization required for In-Office Only procedures under split billing
Procedure codes listed on MVP's In-Office Only list will not be reimbursed under a split billing arrangement unless prior authorization is obtained; if authorized, reimbursement may be allowed for Medicare and Medicaid products.
- In-Office Only codes are excluded from split billing unless authorization is obtained
- Authorized services may be reimbursed for Medicare and Medicaid products
Verify eligibility and prior authorization via MVP resources
Providers must verify member eligibility, consult the Member Benefits Display, and review MVP's Utilization Management Guides and Benefit Interpretation Manual to determine if prior authorization is required; resources are available at mvphealthcare.com.
Prior authorization required — failure to obtain may cause administrative denials
MVP requires prior authorization for select services identified in its Utilization Management Guides; when authorization is required and not obtained, all technical, professional, global and/or facility claims associated with those services will be administratively denied.
- Authorization applies to technical, professional, global and facility claims
- Services provided without prior approval will be administratively denied
Check eligibility and consult Member Benefits Display for prior auth
Providers must check member eligibility, refer to the Member Benefits Display, and consult MVP's Utilization Management Guides to determine whether prior authorization is required; payment policies are not a guarantee of payment.
Verify eligibility and MVP guides for prior auth requirements
Providers must check member eligibility and the Member Benefits Display and review MVP's Utilization Management Guides and Benefit Interpretation Manual to determine benefits and prior authorization requirements; resources are available by signing into mvphealthcare.com.
ICD-10 codes (E09 series) for nutritional counseling documentation
Lists ICD-10 codes under the E09 series (drug/chemical-induced diabetes and related retinopathy/complications) for use with nutritional counseling documentation and billing.
ICD-10 codes (E10 series) for Type 1 diabetes documentation
Lists ICD-10 codes in the E10 series (Type 1 diabetes and related retinopathy/complications) intended for use in nutritional counseling documentation and billing.
ICD-10 codes (E11 series) for Type 2 diabetes documentation
Lists ICD-10 codes in the E11 series (Type 2 diabetes and related complications) for documentation and billing of nutritional counseling services.
Do not bill MVP for non-reimbursable nutritional services
Nutritional counseling is not reimbursed for commercial diet plans, gym memberships, holistic therapy, services offered by resorts/camps/outdoor programs, skill/relaxation/lifestyle programs, supplemental fasting, or treatment by a physical therapist for weight loss.
- Commercial diet plans and weight management program services
- Gym memberships
- Holistic therapy and resort/recreational/outdoor program services
- Skill/relaxation/lifestyle programs and supplemental fasting
- Physical therapy for weight loss
Reference: E09 series ICD-10 codes for diabetic management
Enumerates ICD-10 diagnosis codes for drug/chemical-induced diabetes (E09 series) to be used when documenting diabetic management and related complications.
Reference: E10 series ICD-10 codes (Type 1 diabetes)
Provides ICD-10 diagnosis codes for Type 1 diabetes (E10 series) and its complications for billing and documentation purposes.
Reference: E11 series ICD-10 codes (Type 2 diabetes)
Provides ICD-10 diagnosis codes for Type 2 diabetes (E11 series) and related complications for documentation and billing of nutritional counseling and diabetic management.
Reference: E13 series ICD-10 codes (Other specified diabetes)
Lists ICD-10 diagnosis codes for Other specified diabetes (E13 series) and related complications for use in nutritional counseling and diabetic management documentation.
Verify eligibility and submit correct diagnosis per LCD/NCD
Participating providers must check member eligibility, refer to the Member Benefits Display, and review MVP's Utilization Management Guides to determine prior authorization requirements; MVP requires correct diagnosis submission per Medicare LCD/NCD or claims will be denied for medical necessity.
- Verify eligibility and Member Benefits Display before providing services
- Consult Utilization Management Guides for prior authorization rules
- Submit correct diagnosis per Medicare LCD/NCD to avoid denial for medical necessity
Submit correct diagnosis per Medicare LCD/NCD for listed procedure groups
For specified procedure code groups, MVP requires the correct diagnosis be submitted with the claim in accordance with the applicable Medicare Local Coverage Determination or the claim will be denied due to lack of medical necessity.
- Applies to transthoracic echocardiography, facet injections, NCS/EMG groups and others
- Consult the referenced Document ID/LCD for appropriate diagnoses
Include LCD-specified diagnosis with corneal pachymetry (76514)
MVP requires the correct diagnosis be submitted with corneal pachymetry (CPT 76514) claims in accordance with the Medicare Local Coverage Determination; failure to do so may result in denial for medical necessity.
- CPT 76514 — corneal pachymetry: include the diagnosis required by LCD
Ensure LCD-appropriate diagnosis on visual field testing claims
MVP requires the correct diagnosis be submitted with visual field testing claims (CPT 92081–92083) per the Medicare Local Coverage Determination; claims lacking the appropriate diagnosis will be denied for medical necessity.
Use specialty-guided diagnoses for Herpes Simplex antibody testing
MVP requires that Herpes Simplex antibody testing (CPT 86695, 86696) be submitted with appropriate diagnoses in accordance with specialty guidance (AAFP/USPSTF); failure to include appropriate diagnoses may result in denial for medical necessity.
Submit ASCP-appropriate diagnosis for ESR (85652)
MVP requires the correct diagnosis be submitted with Erythrocyte Sedimentation Rate (CPT 85652) claims per American Society for Clinical Pathology guidance; failure to include appropriate diagnoses may result in denial.
- CPT 85652 — follow ASCP guidance and Appendix for appropriate diagnosis codes
Include appropriate diagnosis for folic acid testing (82746)
MVP requires the correct diagnosis be submitted with Folic Acid testing (CPT 82746) claims in accordance with clinical guidance (ASCP); refer to the Appendix for appropriate diagnosis codes.
- CPT 82746 — include ASCP-appropriate diagnosis per Appendix
Provide ASRM-appropriate diagnosis for FSH testing (83001)
MVP requires the correct diagnosis be submitted with Gonadotropin (FSH CPT 83001) claims in accordance with American Society for Reproductive Medicine guidance; claims lacking the appropriate diagnosis will be denied.
- CPT 83001 — use ASRM-supported diagnosis codes (see Appendix)
Submit LCD/specialty diagnoses for thyroid testing
MVP requires the correct diagnosis be submitted with thyroid testing claims (e.g., CPT 84436, 84439, 84479, 84480, 84481) per Medicare LCDs and specialty society guidance; failure to include the appropriate diagnosis may result in denial for medical necessity.
- Include LCD- or specialty-guided diagnoses on TSH and related thyroid panel claims
Use Appendix ICD-10 codes for FSH-related claims
Appendix lists ICD-10 diagnosis codes associated with Follicle Stimulating Hormone therapies; consult the Appendix and include the appropriate diagnosis when submitting related claims.
Reference Appendix ICD-10 codes for Herpes Simplex Virus claims
Appendix lists ICD-10 diagnosis codes related to Herpes Simplex Virus; providers should reference the Appendix and include appropriate diagnoses when submitting claims for HSV testing or services.
Use Appendix diagnoses for Gammaglobulin IgE and allergy claims
Appendix provides ICD-10 diagnosis codes related to Gammaglobulin IgE testing and allergy-related encounters; include appropriate Appendix-listed diagnoses with related claims.
Include Appendix-listed diagnosis descriptors for Gammaglobulin IgE encounters
Appendix provides detailed ICD-10 code descriptors for gammaglobulin IgE and allergy-related encounters (anaphylactic reactions, venom, latex, food allergies, allergy status codes); consult the Appendix for the correct diagnosis code when billing.
Refer to Appendix ICD-10 codes for ESR (85652) indications
Extensive ICD-10 diagnosis lists for indications of Erythrocyte Sedimentation Rate (ESR) testing are provided in the Appendix; use those Appendix diagnoses to support ESR (CPT 85652) claims.
- Appendix includes neoplasm, hematologic, immune, endocrine, neurologic and other indications
Definitions and Terms
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