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Commercial Reimbursement Policy Updates - UHC

The new molecular pathology policy will be effective for dates of service on and after Sept. 1, 2019.

Correct Coding Initiative (CCI) Editing, Professional

Effective with dates of service on or after July 1, 2019, the CCI Editing policy will allow modifiers 59, XE, XP, XS and XU to be appended to either code in Column I/Column II procedure to procedure edits, when a modifier override is allowed.

  • This will align with the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) transmittal update.

New: Molecular Pathology Policy, Professional

  • American Medical Association (AMA) guidance provides Claim Designation codes in the Molecular Pathology Gene Table that represent specific genes that are being tested.
  • UnitedHealthcare will require care providers to append the AMA ClaimDesignation to identify the specific gene when submitting a Tier 2 Molecular Pathology code. If there is not a Claim Designation assigned, the provider should submit the abbreviated gene name. This information can be found in the CPT Molecular Pathology Gene Table or the specific analyte is listed after each Tier 2 code descriptor.
  • Genomic Sequencing Procedures (GSP) panel codes account for specific combinations of genes for testing.
  • Individual Molecular Pathology Tier 1 and Tier 2 codes should not be submitted separately in addition to a GSP code. If Tier 1 or Tier 2 codes are submitted separately they will be denied.
  • UnitedHealthcare may deny Tier 1 and Tier 2 codes when there is a more appropriate GSP code available.
  • Unlisted code, 81479, should only be submitted when the unique procedure is not adequately addressed by another CPT code. It should only be submitted once per patient, per specimen and date of service.
  • UnitedHealthcare will require the submission of a unique test ID provided through the National Institutes of Health Genetic Testing Registry (GTR) when 81479 is submitted to identify the test and validate the unlisted code is the appropriate code to submit for the test performed
  • The AMA Claim Designation code and the GTR unique test ID should be reported in Loop 2400 or SV101-7 field for electronic claims and in Box 19 for paper claims.
  • Claims that have complied with notification or prior authorization requirements in UnitedHealthcare’s Genetic Testing and Molecular Prior Authorization Program satisfy the policy’s requirements without further provider action if they meet UnitedHealthcare’s Genetic Test Lab Registry requirements.

INDUSTRY NEWS TAGS: Payor


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