Currentpriority healthPolicy N/A

FREQUENCY OF CARE COORDINATION SERVICES AND ESRD PROCEDURES

This policy governs reimbursement guidelines for care coordination services billed during the same service period as End-Stage Renal Disease (ESRD) procedures for Priority Health members.

Policy Summary

Payerpriority health

PolicyFrequency of Care Coordination Services and ESRD Procedures

Policy CodePolicy N/A

Change TypeNo material change

Effective DateAug 1, 2025

Next Review DateApr 1, 2026

Key ActionFor indications not meeting NCD, LCD or policy criteria, a Pre-Service Organization Determination (PSOD) is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPT 99375, G0181, 99495-99496 bundledBundling rule

91526Medical policy ref

04/2026Next review

RequiredDocumentation

Coverage and Billing Rules

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

Care Plan Oversight (CPT 99375 or G0181) and Transitional Care Services (CPT 99495-99496) are considered part of the monthly capitated payment and will not be separately reimbursed when billed during the same calendar month as a monthly ESRD services code.

Providers must follow CMS NCCI and standard billing/coding guidelines; modifiers should be applied only when supported by documentation. Incorrect modifiers may result in claim denials.

Provider must maintain complete and thorough documentation to substantiate the procedure performed; failure to document adequately may result in denial or recoupment.

Place of service / authorization: Coverage is considered for services furnished in an appropriate setting to the patient’s medical needs and condition; authorization may be required based on place of service and medical necessity.

Applicable CMS and state (e.g., MDHHS) guidelines apply unless superseded by contract or statutory mandates.

Relevant Codes and Bundling Rules

Covered/Not Separately Reimbursed CodesCPT | HCPCS | mixedNot Covered

99375	Care plan oversight
G0181	Care plan oversight (other)
99495	Transitional care management
99496	Transitional care management (high complexity)

ESRD Procedure Referencemixed

91526

End Stage Renal Disease (ESRD) - policy reference

inv-03: Same calendar month bundling

Policy ruleCare Plan Oversight (CPT 99375 or G0181) and Transitional Care Services (CPT 99495-99496) are considered part of the monthly capitated payment and will not be separately reimbursed when billed during the same calendar month as a monthly ESRD services code.

Affected codesCPT 99375, G0181, 99495, 99496 are not separately reimbursed when billed in the same calendar month as a monthly ESRD service.

ScopeApplies to care plan oversight and transitional care services billed in the same calendar month as a monthly ESRD services code for Priority Health members.

Payment implicationThese services are considered part of the monthly capitated payment and will not receive separate reimbursement in the specified scenario.

Authorization and Pre-Service Determination

Prior Authorization

Pre‑Service Organization Determination (PSOD) required

For Medicare indications that do not meet NCD, local LCD, or specific medical policy criteria, complete a Pre‑Service Organization Determination (PSOD) before providing the service.

Prior Authorization

Authorization may be required based on place of service

Determine whether authorization is needed based on the place of service and the member's medical necessity; obtain prior authorization when required.

Key Definitions

inv-06: Care Coordination Services with ESRD procedures

DefinitionCare Coordination Services rendered during the same service period as End-Stage Renal Disease (ESRD) procedures.

Examples of servicesCare Plan Oversight and Transitional Care Services when provided during the ESRD service period (see related CPT codes in coding section).

RelevanceThis definition frames the policy guidance on reimbursement and billing when coordination services overlap with ESRD procedures.

Documentation noteProviders must maintain complete documentation to substantiate services rendered during the same service period as ESRD procedures (see documentation requirements).