REIMBURSEMENT POLICY

UB-04

Proprietary information of UnitedHealthcare Community Plan. Copyright 2018 United HealthCare Services, Inc.

Revenue Codes Requiring Procedure Code Policy

Policy Number TBD Annual Approval Date TBD Approved By Reimbursement Policy Oversight Committee

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY

You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT

®*), Centers for Medicare and

Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on UB-04 forms and, when specified, to those billed on 1500 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan’s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider

contracts, the enrollee’s benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. UnitedHealthcare Community Plan uses a customized version of the Optum Claims Editing System known as iCES Clearinghouse to process claims in accordance with UnitedHealthcare Community Plan reimbursement policies.

Application

This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid and Medicare products. This reimbursement policy applies to services reported using the UB-04 form or its electronic equivalent or its successor form. This policy applies to all products, all network and non-network facilities, including but not limited to, non-network authorized and percent of charge contract facilities. Home Health providers and Skilled Nursing Facilities are exempt from this policy. Payment Policies for Medicare & Retirement and Employer & Individual please use this link. Medicare & Retirement Policies are listed under Medicare Advantage Reimbursement Policies. Employer & Individual are listed under Reimbursement Policies-Commercial.

Policy

Overview

This policy describes revenue codes that require procedure codes based on National Uniform Billing Committee (NUBC) guidelines.

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=ca174ccb4726b010VgnVCM100000c520720a____

REIMBURSEMENT POLICY

UB-04

Proprietary information of UnitedHealthcare Community Plan. Copyright 2018 United HealthCare Services, Inc.

Reimbursement Guidelines

Per NUBC, outpatient UB-04 claims must be billed with both a revenue code and a CPT or HCPCS code. A revenue code must be assigned for each line item. If multiple CPT or HCPCS are necessary to reflect multiple, distinct, or independent visits with the same revenue code, repeat the revenue code as required. Absence of a CPT or HCPCs code for any revenue code not listed on this policy may affect claim payment or result in a claim denial. Revenue codes exempt from this requirement are listed in the attachment section. This policy applies to all outpatient claims except for the following bill types:

Skilled Nursing (23X)

Home Health (33X)

Religious Non Medical Healthcare (43X)

Rural Health Care Clinic (71X)

Hospital based Clinic (72X)

Free standing Clinic (73X)

Federally Qualified Health Center Clinic (77X)

Hospice (81X, 82X)

Critical Access Hospital (85X)

State Exceptions

Iowa Hospice bill types and revenue codes 0651, 0652, 0655, 0656, 0657, and 0658

are exempt from this requirement.

Florida Florida Medicaid has a custom list of revenue codes that require HCPCs

Hawaii Revenue code 0912 is allowed to be billed without a HCPC

Massachusetts Revenue code 0912 is allowed to be billed without a HCPC

New Mexico New Mexico Medicaid has a custom list of revenue codes that require HCPCs

Texas Texas Medicaid has a custom list of revenue codes that require HCPCs

Virginia Hospice bill types are exempt from this requirement.

Wisconsin Wisconsin has a bypass list of codes exempt from the global list of revenue

codes requiring HCPCs

Attachments: Please right-click on the icon to open the file

Revenue codes exempt from the HCPC requirement

Revenue Code Description

250 PHARMACY

251 DRUGS/GENERIC

252 DRUGS/NONGENERIC

254 DRUGS/INCIDENT ODX

255 DRUGS/INCIDENT RAD

257 DRUGS/NONPSCRPT

258 IV SOLUTIONS

259 DRUGS/OTHER

260 IV THERAPY GENERAL

261 IV THER/INFSN PUMP

262 IV THER/PHARM/SVC

263 IV THER/DRUG SUPPLY/DELV

264 IV THER/SUPPLIES

269 IV THERAPY/OTHER

270 MED-SUR SUPPLIES

271 NONSTER SUPPLY

272 STERILE SUPPLY

273 TAKEHOME SUPPLY

275 PACE MAKER

276 INTR OC LENS

278 SUPPLY/IMPLANTS

279 SUPPLY/OTHER

280 ONCOLOGY GENERAL

289 ONCOLOGY OTHER

343 NUC MED/DX RADIOPHARM

344 NUC MED/RX RADIOPHARM

370 ANESTHESIA GENERAL

371 ANESTHE/INCIDENT RAD

372 ANESTHE/INCDNT OTHER DX

379 ANESTHE/OTHER

390 BLOOD/STOR GENERAL

392 BLOOD/STORAGE

399 BLOOD/OTHER STOR

500 OUTPATIENT SVS GENERAL

509 OUTPATATIENT/OTHER

521 RURAL/'CLINIC

522 RURAL/'HOME

524 FR/STND RURAL/SNF

525 FR/STND RURDL/SNF/NF/ICF

527 FR/STND RURAL HOME

528 FR/STND RURAL OTHER

583 VISIT/HOME HLTH UNASSGND

621 MED-SUR SUPP/INCDNT RAD

Revenue Codes Exempt from HCPC Requirement

622 MED-SUR SUPP/INCDNT ODX

623 SURG DRESSING

624 FDA INVEST DEVICE

630 DRUGS RESERVED

631 DRUG/SINGLE

632 DRUG/MULT

633 DRUGS/RSTR

637 DRUG/SELF-ADMIN

660 RESPITE/CARE GENERAL

661 RESPITE/SKILLED NURSE

662 RESPITE/HMEAID/HMEMKR

663 RESPITE/UNASSIGNED

669 RESPITE/OTHER

681 TRAUMA LEVEL I

682 TRAUMA LEVEL II

683 TRAUMA LEVEL III

684 TRAUMA LEVEL IV

689 TRAUMA OTHER

700 CAST ROOM GENERAL

710 RECOVERY ROOM GENERAL

720 DELIVEROOM/LABOR

721 LABOR

732 TELEMETRY

762 OBSERVATION RM

801 DIALY/INPT

802 DIALY/INPT/PER

803 DIALY/INPT/CAPD

804 DIALY/INPT/CCPD

809 DIALY/INPT/OTHER

810 ORGAN ACQUISIT GENERAL

815 ALOGNC STM CELL AQ. SVCS

819 OTHER DONOR

821 HEMO/COMPOSITE

824 HEMO/HOME/100%

825 HEMO/HOME/SUPSERV

829 HEMO/HOME/OTHER

860 MEG GENERAL

861 MEG

905 INTENS OP TREAT/PSYCH

906 INTENS OP TREAT/CHEM DEP

907 COMM BEHAVIORAL HEALTH

931 MED REHAB/HALF DAY

932 MED REHAB/FULL DAY

940 OTHER RX SVS GENERAL

942 EDUC/TRAINING

943 CARDIAC REHAB

948 PULMONARY REHABILITATION

990 PT CONVENIENCE GENERAL

991 CAFETERIA

992 LINEN

993 TELEPHONE

994 TV/RADIO

995 NONPT ROOM RENT

996 LATE DISCHARGE

997 ADMIT KITS

998 BARBER/BEAUTY

999 PT CONVENCE/OTHER

1000 BH ACCOM GEN

1001 BH ACCOM RES PSYCH

1002 BH ACCOM RES CHEM/DEP

1003 BH ACCOM GEN SUP LIVING

1004 BH ACCOM HALFWAY HOUSE

1005 BH ACCOM GROUP HOME

2100 ALT THER SVC GENERAL

2101 ALT THER SVC ACCUPUNCT

2102 ALT THER SVC ACCUPRESS

2103 ALT THER SVC MASSAGE

2104 ALT THER SVC REFLEXOLOGY

2105 ALT THER SVC BIOFEEDBACK

2106 ALT THER SVC HYPNOSIS

2109 ALT THER SVC OTHER

3101 ADULT MED/SOC HOURLY

3102 ADULT SOC HOURLY

3103 ADULT MED/SOC DAILY

3104 ADULT SOC DAILY

3105 ADULT FOSTER DAILY

3109 ADULT CARE OTHER

jpetkeFile AttachmentRevenue Codes Exempt from HCPC Requirement.pdf

REIMBURSEMENT POLICY

UB-04

Proprietary information of UnitedHealthcare Community Plan. Copyright 2018 United HealthCare Services, Inc.

Revenue codes requiring HCPCs for Florida Medicaid

Revenue codes requiring HCPCs for New Mexico Medicaid

Revenue codes requiring HCPCs for Texas Medicaid

List of codes exempt from the revenue codes requiring HCPCs list for Wisconsin Medicaid

Custom list of exempt bill types for Wisconsin Medicaid

Resources

Individual state Medicaid regulations, manuals & fee schedules Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Centers for Medicare and Medicaid Services, Healthcare Common Procedure Coding System, HCPCS Release and Code Sets National Uniform Billing Committee (NUBC)

History

4/1/2018 Policy Implemented by UnitedHealthcare Community & State

FLORIDA SPECIFIC REV CODES THAT REQUIRE PROCEDURE CODES

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jpetkeFile AttachmentFLORIDA SPECIFIC REV CODES THAT REQUIRE PROCEDURE CODES.pdf

New Mexico Revenue Codes Requiring HCPCs

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329

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349

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610

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jpetkeFile AttachmentNew Mexico Revenue Codes Requiring HCPCs.pdf

Texas Revenue Codes Requiring HCPCs

220

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569

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619

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779

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924

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929

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jpetkeFile AttachmentTexas Revenue Codes Requiring HCPCs.pdf

Wisconsin Revenue Codes Exempt from the Revenue Codes Requiring HCPCs Requirement

250

251

252

253

258

270

271

272

276

278

370

500

509

521

522

524

525

527

528

583

660

661

662

663

669

710

762

905

906

907

931

932

948

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1000

1001

1002

1003

1004

1005

2100

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2109

3101

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3105

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jpetkeFile AttachmentWisconsin Revenue Codes Exempt from the Revenue Codes Requiring HCPCs Requirement.pdf

WI TOBs Exempt from the HCPC Requirement

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jpetkeFile AttachmentWI TOBs Exempt from the HCPC Requirement.pdf