Neighborhood Health Plan RI Physician Services Coverage

Coverage Criteria and Policy Rules

Autologous fat grafting — coverage with diagnosis restriction

Autologous fat grafting coverage conditions

Coverage for CPT 15771 & 15772: CPT codes 15771 and 15772 are covered only when billed with a diagnosis code in the range C50.011–C50.929, N65.0, N65.1, Z42.1, Z92.21, or Z92.3 for post-mastectomy breast cancer patients.

Chronic Care Management

Chronic Care Management coverage for INTEGRITY

CCM coverage for INTEGRITY: Chronic Care Management (CCM) is covered and reimbursable for INTEGRITY only per CMS guidelines; billing requires at least 20 minutes of care coordination services per month and only one practitioner may bill CCM per patient per month.>= 20 minutes per month

Applicable practitioner types: physicians, physician assistants, clinical nurse specialists, nurse practitioners, and certified nurse midwives.

General coverage rules

Provider- and service-specific coverage rules

Provider reimbursement rules: Physician Assistant reimbursement for Commercial & Medicaid is at 85% of the contracted rate; Nurse Practitioners reimbursed at 100% of the contracted rate. Medicaid and INTEGRITY are covered with no diagnosis restrictions per policy.85% (PA), 100% (NP)

Critical care billing: Critical care is payable when the physician provides direct care for 30 minutes or more for a critically ill or injured patient; services less than 30 minutes should be billed with the appropriate E/M code. Designated components of critical care (for example: arterial puncture, endotracheal intubation, ventilator management, etc.) are considered part of critical care and are not separately reimbursable.>= 30 minutes

List of non-reimbursable components specified in policy.

Inpatient/Observation billing rules: Services less than 15 minutes are not billable. Observation codes 99234–99236 require an observation period of at least 8 hours and less than 24 hours; admitting and discharge notes must be written by the billing physician when required. Prolonged services may be billed in addition to the base E/M where permitted.

Pediatric Developmental Screening

Covered when billed with BOTH an appropriate diagnosis code and the procedure code from the table:

Pediatric Developmental Screening: Service is covered when billed with diagnosis code Z00.121 or Z00.129 AND procedure code 96110 (developmental screening with standardized instrument and scoring).

Pediatric Autism Screening

Covered when billed with BOTH an appropriate diagnosis code and the procedure code from the table with modifier where specified:

Pediatric Autism Screening: Service is covered when billed with diagnosis code Z00.121 or Z00.129 AND procedure code 96110 with modifier U1 as specified.

Modifier U1 required per policy.

Pediatric Fluoride Varnish

Covered when billed with the specified diagnosis code and procedure code from Table 4:

Pediatric Fluoride Varnish: Service is covered when billed with diagnosis code Z29.3 AND procedure code 99188 or D1206 (topical fluoride varnish) from Table 4.

Prenatal Pediatrician Office Visit

Prenatal pediatrician office visits require billing with the specified diagnosis code and an office visit E/M code from Table 5:

Prenatal Pediatrician Office Visit: Service is covered when billed with diagnosis code Z76.81 AND an appropriate office/consultation E/M code from Table 5 (examples include 99201–99203 and 99241–99242 as listed).

Newborn Services

Newborn services are covered when billed with a liveborn infant diagnosis code and an appropriate newborn procedure code from Table 6:

Newborn Services: Service is covered when billed with diagnosis code Z38.00–Z38.8 AND an appropriate newborn code from Table 6 (for example 99460–99465 or 99184).

All Other Physician Services

Other physician services are covered when billed with the appropriate CPT/HCPCS code from Table 7 and any required diagnosis linkage per payer rules:

All Other Physician Services: Services billed with codes listed in Table 7 (examples include 11719, 36415, 95249–95251, 96127, 96160–96161, 98925–98929, 99050–99091, 99174–99177, 99201–99215, 99221–99232) are covered when billed with any required diagnosis linkage as specified in the policy.

Providers must pair procedure codes with required diagnosis codes per documentation guidance.

Routine venipuncture (blood draw) performed by the same provider on the same day as a laboratory test or an evaluation and management (E/M) service is not separately reimbursable. Providers should not bill the venipuncture separately when it is performed in conjunction with same-day laboratory or E/M services by the same clinician.

Certain services in this policy require submission with the specific diagnosis and procedure pairings listed in their sections. Claims submitted without the required diagnosis-to-procedure linkage (for example, developmental screening billed without diagnosis Z00.121 or Z00.129 and code 96110, or fluoride varnish billed without diagnosis Z29.3 and code 99188/D1206) are outside the covered criteria and may be denied.

Submit claims with the exact diagnosis and CPT/HCPCS code combinations shown in the applicable tables; absence of the required pairing removes the coverage basis described in this policy.

This section does not list additional explicit exclusions. Content focuses on code descriptions, typical history/exam/MDM expectations, and time-based thresholds used to support E/M selection rather than enumerating further excluded services.

All services must be medically necessary to qualify for reimbursement. Neighborhood may reference National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), industry-accepted criteria such as InterQual, EOHHS recommendations, and Clinical Medical Policies when making medical necessity determinations. Services deemed not medically necessary under those criteria will not be reimbursed.

This placeholder indicates other physician services described in the policy are listed with code-specific descriptors and documentation/time expectations. Refer to the relevant code tables and accompanying guidance elsewhere in the policy for billing details and documentation requirements.

Coding Tables, Time Thresholds, and Code Lists

Autologous fat grafting — covered only with listed diagnosesCPTCovered

15771	Autologous fat grafting (covered only with specified diagnoses)
15772	Autologous fat grafting (covered only with specified diagnoses)

Inpatient/Observation coding guidanceCPT

99234-99236

Observation or Inpatient Care Services (Including Admission and Discharge Services)

Pediatric Preventive Visit CPTsCPTCovered

99382	Initial comprehensive preventive medicine evaluation and management, new patient; infant (younger than 1 year)
99383	Initial comprehensive preventive medicine evaluation and management, new patient; early childhood (1 through 4 years)
99384	Initial comprehensive preventive medicine evaluation and management, new patient; late childhood (5 through 11 years)
99385	Initial comprehensive preventive medicine evaluation and management, new patient; adolescent (12 through 17 years) and 18-39 years
99391	Periodic comprehensive preventive medicine reevaluation, established patient; infant (younger than 1 year)
99392	Periodic comprehensive preventive medicine reevaluation, established patient; early childhood (1 through 4 years)
99393	Periodic comprehensive preventive medicine reevaluation, established patient; late childhood (5 through 11 years)
99394	Periodic comprehensive preventive medicine reevaluation, established patient; adolescent (12 through 17 years)
99395	Periodic comprehensive preventive medicine reevaluation, established patient; 18-39 years

Pediatric Developmental/Autism ScreeningmixedCovered

Z00.121	Encounter for routine child health examination with abnormal findings
Z00.129	Encounter for routine child health examination without abnormal findings
96110	Developmental screening with scoring and documentation, per standardized instrument

Pediatric Fluoride VarnishmixedCovered

Z29.3	Encounter for prophylactic vaccination and inoculation (used here for topical fluoride varnish billing)
99188	Application of topical fluoride varnish by a physician or other qualified health care professional
D1206	Topical fluoride varnish; therapeutic application for moderate to high caries risk patients

Prenatal Pediatrician Office Visit CodesmixedCovered

Z76.81	Encounter for health supervision of infant or child (listed for prenatal pediatrician office visit)
99201	Office or other outpatient visit for the evaluation and management of a new patient; problem focused; typically 10 minutes
99202	Office or other outpatient visit for the evaluation and management of a new patient; expanded problem focused; typically 20 minutes
99203	Office or other outpatient visit for the evaluation and management of a new patient; detailed history/exam; typically 30 minutes
99241	Office consultation for a new or established patient; problem focused; typically 15 minutes
99242	Office consultation for a new or established patient; expanded problem focused; typically 30 minutes

Newborn ServicesmixedCovered

Z38.00-Z38.8	Codes for liveborn infants according to place of birth (range used for newborn services)
99184	Initiation of selective head or total body hypothermia in the critically ill neonate
99460	Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant
99461	Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center
99462	Subsequent hospital care, per day, for evaluation and management of normal newborn
99463	Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on same date
99464	Attendance at delivery and initial stabilization of newborn
99465	Delivery/birthing room resuscitation, positive pressure ventilation and/or chest compressions

All Other Physician Services codes (broad list)CPTCovered

11719	Trimming of nondystrophic nails, any number
11720	Debridement of nail(s) by any method(s); 1 to 5
11721	Debridement of nail(s) by any method(s); 6 or more
36415	Collection of venous blood by venipuncture
95249	Ambulatory continuous glucose monitoring, patient-provided equipment, sensor placement, etc.
95250	Ambulatory continuous glucose monitoring, office provided equipment
95251	Ambulatory continuous glucose monitoring analysis, interpretation and report
96040	Medical genetics and genetic counseling services, each 30 minutes face-to-face
96127	Brief emotional/behavioral assessment with scoring and documentation
96160	Administration of patient-focused health risk assessment instrument with scoring and documentation

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Selected Office/Inpatient Initial E/M codesCPTCovered

99215	Office or other outpatient visit for the evaluation and management of an established patient; comprehensive history/exam and high complexity MDM; typically 40 minutes
99221	Initial hospital inpatient or observation care; straightforward or low level MDM; time-based selection requires 40 minutes
99222	Initial hospital inpatient or observation care; moderate level MDM; time-based selection requires 55 minutes
99223	Initial hospital inpatient or observation care; high level MDM; time-based selection requires 75 minutes

Inpatient subsequent and discharge E/M codesCPTCovered

99231	Subsequent hospital inpatient or observation care; straightforward/low MDM; time selection requires 25 minutes
99232	Subsequent hospital inpatient or observation care; moderate MDM; time selection requires 35 minutes
99233	Subsequent hospital inpatient or observation care; high MDM; time selection requires 50 minutes
99234	Hospital inpatient/observation care including admission and discharge same date; straightforward/low MDM; time selection requires 45 minutes
99235	Hospital inpatient/observation care including admission and discharge same date; moderate MDM; time selection requires 70 minutes
99236	Hospital inpatient/observation care including admission and discharge same date; high MDM; time selection requires 85 minutes
99238	Hospital discharge day management; 30 minutes or less
99239	Hospital discharge day management; more than 30 minutes

Emergency and critical care codesCPTCovered

99281	Emergency department visit; problem focused history/exam; straightforward MDM; usually self-limited or minor
99282	Emergency department visit; expanded problem focused history/exam; low complexity MDM
99283	Emergency department visit; expanded problem focused history/exam; moderate complexity MDM
99284	Emergency department visit; detailed history/exam; moderate complexity MDM; usually high severity
99285	Emergency department visit; comprehensive history/exam; high complexity MDM; immediate significant threat
99291	Critical care, first 30-74 minutes
99292	Critical care, each additional 30 minutes

Domiciliary/rest home visit codesCPTCovered

99324	Domiciliary/rest home visit for a new patient; problem focused; typically 20 minutes
99325	Domiciliary/rest home visit for a new patient; expanded problem focused; typically 30 minutes
99326	Domiciliary/rest home visit for a new patient; detailed history/exam; typically 45 minutes
99327	Domiciliary/rest home visit for a new patient; comprehensive history/exam; typically 60 minutes
99328	Domiciliary/rest home visit for a new patient; comprehensive history/exam; high complexity; typically 75 minutes
99334	Domiciliary/rest home visit for an established patient; problem focused; typically 15 minutes
99335	Domiciliary/rest home visit for an established patient; expanded problem focused; typically 25 minutes
99336	Domiciliary/rest home visit for an established patient; detailed interval history; typically 40 minutes
99337	Domiciliary/rest home visit for an established patient; comprehensive interval history; typically 60 minutes

Home visit codesCPTCovered

99341	Home visit for a new patient; problem focused; typically 20 minutes
99342	Home visit for a new patient; expanded problem focused; typically 30 minutes
99343	Home visit for a new patient; detailed history/exam; typically 45 minutes
99344	Home visit for a new patient; comprehensive history/exam; typically 60 minutes
99345	Home visit for a new patient; comprehensive history/exam; high complexity; typically 75 minutes
99347	Home visit for an established patient; problem focused interval history; typically 15 minutes
99348	Home visit for an established patient; expanded problem focused interval history; typically 25 minutes
99349	Home visit for an established patient; detailed interval history; typically 40 minutes
99350	Home visit for an established patient; comprehensive interval history; typically 60 minutes

Prolonged and standby service codesCPTCovered

99354	Prolonged E/M or psychotherapy service in office/outpatient; first hour (add-on)
99355	Prolonged E/M or psychotherapy service in office/outpatient; each additional 30 minutes (add-on)
99356	Prolonged service in inpatient/observation; first hour (add-on)
99357	Prolonged service in inpatient/observation; each additional 30 minutes (add-on)
99358	Prolonged E/M service before/after direct patient care; first hour
99359	Prolonged E/M service before/after direct patient care; each additional 30 minutes
99360	Standby service, requiring prolonged attendance, each 30 minutes

Team conference and supervision codesCPTCovered

99367	Medical team conference with interdisciplinary team, patient/family not present; 30 minutes or more; physician participation
99368	Medical team conference with interdisciplinary team, patient/family not present; 30 minutes or more; nonphysician participation
99374	Supervision of a patient under care of home health agency (patient not present) requiring complex multidisciplinary care; 15-29 minutes per month
99375	Supervision of a patient under care of home health agency (patient not present); 30 minutes or more per month
99377	Supervision of a hospice patient (patient not present); 15-29 minutes per month
99378	Supervision of a hospice patient (patient not present); 30 minutes or more per month
99379	Supervision of a nursing facility patient (patient not present); 15-29 minutes per month
99380	Supervision of a nursing facility patient (patient not present); 30 minutes or more per month

Preventive, counseling, and prolonged clinical staff codesCPTCovered

99386	Initial comprehensive preventive medicine E/M; new patient; 40-64 years
99387	Initial comprehensive preventive medicine E/M; new patient; 65+ years
99396	Periodic comprehensive preventive medicine reevaluation; established patient; 40-64 years
99397	Periodic comprehensive preventive medicine reevaluation; established patient; 65+ years
99401	Preventive medicine counseling/risk factor reduction; approx 15 minutes
99402	Preventive medicine counseling/risk factor reduction; approx 30 minutes
99403	Preventive medicine counseling/risk factor reduction; approx 45 minutes
99404	Preventive medicine counseling/risk factor reduction; approx 60 minutes
99406	Smoking/tobacco cessation counseling; intermediate >3 up to 10 minutes
99407	Smoking/tobacco cessation counseling; intensive >10 minutes

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All Other Physician Services codes (extended list)mixed

99401	Preventive medicine counseling and/or risk factor reduction intervention(s); ~15 minutes
99402	Preventive medicine counseling and/or risk factor reduction intervention(s); ~30 minutes
99403	Preventive medicine counseling and/or risk factor reduction intervention(s); ~45 minutes
99404	Preventive medicine counseling and/or risk factor reduction intervention(s); ~60 minutes
99406	Smoking and tobacco use cessation counseling; intermediate >3 up to 10 minutes
99407	Smoking and tobacco use cessation counseling; intensive >10 minutes
99408	Alcohol/substance abuse structured screening and brief intervention; 15–30 minutes
99409	Alcohol/substance abuse structured screening and brief intervention; >30 minutes
99411	Preventive medicine counseling to individuals in a group setting; ~30 minutes
99412	Preventive medicine counseling to individuals in a group setting; ~60 minutes

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inv-32: Critical care minimum time

Minimum billable time>= 30 minutes

When <30 minutesBill with appropriate E/M code (not critical care)

Clinical requirementHigh complexity medical decision-making for support of vital organ systems

Provider Responsibilities, Documentation, and Authorization

Prior Authorization

Verify eligibility and prior authorization

Verify member eligibility, coverage, and authorization requirements prior to rendering services. Neighborhood may apply National Coverage Determinations (NCD), Local Coverage Determinations (LCD), InterQual (or similar industry-accepted criteria), Rhode Island EOHHS guidance, and Neighborhood Clinical Medical Policies when determining medical necessity. Contact Provider Services at 1-800-963-1001 or refer to Neighborhood's Prior Authorization Reference page and Clinical Medical Policies for plan-specific authorization rules.

All services must be medically necessary and supported by applicable coverage criteria (NCD, LCD, InterQual, EOHHS, CMP).
Verify member eligibility and any required prior authorization before providing care.
Provider Services: 1-800-963-1001; see plan Prior Authorization Reference page for details.

Prior Authorization

Potential prior authorization for specialized neonatal procedure (99184)

Certain specialized neonatal procedures (for example CPT 99184 initiation of therapeutic hypothermia) may require prior authorization or review for medical necessity. Ensure appropriate clinical documentation (selection review, imaging/laboratory data, temperature probe confirmation, aEEG evaluation, supervision notes) is available to support claims.

Background and Scope

This policy covers a broad range of physician services including routine physical examinations, sick visits, specialty office visits, observation care, inpatient care, and home visits. It defines coverage rules, required diagnosis-to-procedure linkages, and time/MDM requirements used to support E/M and related service levels.

Providers are responsible for verifying member eligibility and applicable prior authorization or payer-specific requirements before rendering services; payments remain subject to eligibility, coding edits, documentation standards, and audit.

Definitions and Term Explanations

inv-55: Care Plan Oversight (CPO)

DefinitionCare Plan Oversight (CPO) is physician supervision of a patient under home health, hospice, or nursing facility care involving review of reports, participation in care conferences, and development/revision of care plans and medical therapy

IncludesTime spent reviewing patient status reports and participating in care conferences

SettingApplies to home health, hospice, and nursing facility patients

inv-56: Chronic Care Management (CCM)

DefinitionChronic Care Management (CCM): care coordination services outside regular office visits for patients with two or more chronic conditions expected to last >=12 months or until death

Billing requirementsCovered and reimbursable for INTEGRITY only per CMS guidelines; requires >=20 minutes clinical staff time per month (99490) and only one practitioner may bill per patient per month

OpenPayer

Physician Services Coverage Criteria

Coverage Criteria and Policy Rules

Coding Tables, Time Thresholds, and Code Lists

Provider Responsibilities, Documentation, and Authorization

Background and Scope

Definitions and Term Explanations

Policy Revision History