23-013 Bill Correctly to Get Paid for Pulmonary Testing and Skin Substitute Claims

Date: 01/05/23

New payment policy edits and post-payment edits follow national guidelines

Effective March 15, 2023, Health Net* will implement new edits described below on claim payments to ensure compliance with company standards and national billing guidelines.

Pulmonary function testing claims

Health Net will apply edits to ensure medical necessity guidelines are met for payment. For more information, refer to the policy,  CP.MP.242, Clinical Policy: Pulmonary Function Testing (PDF). 

Skin substitute claims

Health Net will implement retrospective payment edits for skin substitute correct billing review. Claims coding edits align with Medi-Cal and Centers for Medicare & Medicaid Services (CMS) policy guidelines or manuals. 

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• Medi-Cal coding guidelines: Reimbursable only when billed in conjunction with an application CPT code in the range of 15271 through 15278.
• CMS coding guidelines: Guidelines separate skin substitutes into two categories, high- and low-cost:
  • High-cost products should only be billed with an application CPT code in the range of 15271 through 15278.
  • Low-cost product HCPCS costs should only be billed with an application  HCPCS code in the range of C5271 through C5278.

Additional information

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email within 60 days, by telephone or through the Health Net provider website.

 

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.

For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.