22-653 Stay Up to Date with Claims Edits for National Coverage Determination Coding
Date: 08/22/22
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
Be sure your billing staff is aware of this change
Wellcare By Health Net (Health Net*) reviews and updates our payment and utilization policies on a regular basis to make sure they follow industry standards. This helps ensure we deliver the best patient experience to our members.
Effective on or after October 26, 2022, the Plan will include new claims edit policies to our claims processing systems. The new claims edits will include national coverage determination (NCD) coding for Medicare. The Plan will add prepay reviews for NCDs to align with the Centers for Medicare & Medicaid Services (CMS) guidelines for correct coding.
This change is needed to ensure compliance with CMS coding updates and changes to the NCDs and local coverage determinations (LCDs) for Medicare. NCD and LCD coding is a CMS billing requirement and applies to all health insurance payers nationally and locally.
Please refer to the chart below for the specific NCDs that will now have claim editing applied.
New National Coverage Determinations Coding
CMS establishes guidelines that identify whether some medical items, services, treatments, diagnostic services or technologies can be paid under the health plan. These rules evaluate diagnosis to procedure code combinations. Below is a list of new NCD edits and payment policies being implemented. CMS will look for these codes to ensure proper billing is applied.
Title/Topic | Edit Description |
|---|---|
Bone Mineral Density Studies | This CMS NCD looks at procedure codes 0508T,0554T,0555T,0556T, 0557T, 0558T, 76977, 77078, 77080, 77081, 77085, G0130 and ensures the correct diagnosis, dictated by Medicare, is billed correctly. |
Implantable Cardiac Defibrillators | This CMS NCD looks at the correct bill type, place of service, for procedure codes 33202, 33203, 33215, 33216, 33217, 33218, 33220, 33223, 33224, 33225, 33230, 33231, 33240, 33241, 33243, 33244, 33249, 33262, 33263, 33264, 33270, 33271, 33272, 33273, & G0448 and it takes into consideration diagnosis. |
Glycated Hemoglobin Glycated Protein | This CMS NCD looks at procedure codes 82985, 83036 and ensures that correct diagnosis is billed. |
Percutaneous Image Guided Breast Biopsy | This CMS NCD looks at procedure codes 19081, 19082, 19083, 19084, 19085, & 19086 and diagnosis relationship. |
Prostate Screening Cancer | This CMS NCD looks at procedure codes G0102 & G0103, place of service, & diagnosis relationship. This is also a bill type and diagnosis for G0102. |
Screening for Hepatitis B Virus HBV Infection | This CMS NCD looks at procedure codes 86704, 8706, 87340, 87341, & G0499 with a diagnosis relationship. |
Screening for Sexually Transmitted Infections (STIs) & High-Intensity Behavioral Counseling (HIBC) to Prevent STIs | Restrict Chlamydia (86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810), Gonorrhea (87590, 87591, 87850), Syphilis (86592, 86593), and Hep B (87340, 87341) screening for certain types of bills, diagnoses, places of service, and specialty. |
Screening for the Human Immunodeficiency Virus HIV Infection | This CMS NCD looks at procedure codes G0432, G0433, G0432, & G0475, place of service and diagnosis relationship. |
Single Chamber and Dual Chamber Permanent Cardiac Pacemakers | This CMS NCD looks at procedure code 33206, 33207, 33208, C1785, C1786, C2619, & C2620 and diagnosis relationship. |
Additional information
Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact the
Provider Services Center within 60 days at 800-929-9224.