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UHC Suspends Prior Auth Requirements for Trichomonas & Candida, Will Adopt CMS Billing Policy for Prostates on January 1, 2021

  • Director of Anatomic Pathology Development

Suspension of Trichomonas and Candida Prior Auth Requirements

Beginning Oct. 1, 2020, for all commercial and UnitedHealthcare Community Plan plans included in the genetic and molecular testing program, UHC will be suspending prior authorization and notification requirements for the following three genetic and molecular CPT codes performed in an outpatient setting:

  • 87480: Infectious agent detection by nucleic acid (DNA or RNA); candida species, direct probe technique
  • 87660: Infectious agent detection by nucleic acid (DNA OR RNA); Trichomonas vaginalis, direct probe technique
  • 87661: Infectious agent detection by nucleic acid (DNA OR RNA); Trichomonas vaginalis, amplified probe technique:

The suspension of prior authorization requirements for these codes, which UHC states are an effort to ease the administrative burden for providers during COVID-19, is indefinite at this time, however, it appears other tests, such as Gardnerella will still be impacted. 

UHC to Adopt CMS Billing Policy on Prostates

Following in lockstep with Cigna’s recent implementation of the G0416 requirement for prostates, UHC announced today the same policy to be effective for their commercial plans beginning January 1, 2021. This policy is already in effect for UHC’s Medicare Advantage plans, which has caught some pathology groups off guard as they’ve been notified of recoupment for overpayments, referencing a CMS-aligned policy established in 2015. By expanding their alignment with CMS’s policy on billing prostates, the continued deterioration of revenue historically generated by these services will nonetheless be felt by practices nationwide.

Per UHC’s Reimbursement Policy Update, October 2020:

  • Effective with dates of service on or after January 1, 2021, UnitedHealthcare will align with CMS and require surgical pathology for prostate needle biopsy specimens, including gross and microscopic examination, be reported with HCPCS code G0416 instead of 88305.
  • According to the CMS National Correct Coding Initiative (NCCI) Manual (Chapter 10), CMS requires that surgical pathology for all prostate needle biopsy specimens, including gross and microscopic examination, be reported with 1 unit of service and code G0416, instead of code 88305 and multiple units of service.
  • Claims for surgical pathology for prostate needle biopsy that do not align with the Laboratory Services Policy enhancement, because they are reported with code 88305, will be denied.

Reference the full update here. For additional information, please contact Diana Richard, Director of Anatomic Pathology Program Development at drichard@xifin.com


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