Please refer to the state Medicaid manual for any coverage provisions pertaining to this payment policy. Note: For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs and
INPATIENT ONLY PROCEDURES (AMBETTER). Page 6 of 7. 4. Centers for Medicare and Medicaid Services, CMS Manual System and other ...
Payment Policy: Inpatient Only Procedure (Ambetter Only) Reference Number: MP.PP.018 Product Types: Ambetter Effective Date: 01/01/2013 Coding Implications Last Review Date: 11/01/2020 Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Policy Overview The Centers for Medicare and Medicaid Services (CMS) has determined that certain procedures should only be performed in an inpatient setting and therefore, are not appropriate to be conducted in an outpatient facility setting. According to CMS, Inpatient only services are generally, but not always, surgical services that require inpatient care because of the nature of the procedure, the typical underlying physical condition of patients who require the service or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged. Inpatient only procedures (IOP) are not payable under the Outpatient Prospective Payment System (OPPS). CMS designates IOP with an OPPS status indicator of "C" in the OPPS Addendum B. For the most current list, see https://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-BUpdates.html?DLSort=2&DLEntries=10&DLPage=1&DLSortDir=descending Application This policy applies to Ambetter. Reimbursement Claims Reimbursement Edit The Health Plan's code auditing software will deny procedures that CMS determines should be performed in an inpatient only setting when billed in the outpatient setting. State-specific rules, health plan contracts or health plan policies, may supersede this edit. Rationale for Edit Because of the invasive nature of certain procedures, the need for at least 24 hours of postoperative recovery time or monitoring before a patient can be safely discharged, or the underlying physical condition of the patient requiring surgery, CMS has determined that certain procedures are safest when performed in an inpatient setting. Page 1 of 7 PAYMENT POLICY INPATIENT ONLY PROCEDURES (AMBETTER) Procedure Codes Which Will Deny According to the Policy Please see the following link for inpatient only procedures which are not allowed in an outpatient setting: https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/index. Coding and Modifier Information This payment policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT® codes and descriptions are copyrighted 2020, American Medical Association. All rights reserved. CPT codes and CPT descriptions are included for informational purposes only. Codes referenced in this payment policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. The following codes are not subject to the Inpatient Only rules and will be reimbursed in an outpatient setting. CPT/HCPCS Code 22855 00192 00670 00846 00944 01214 11005 15757 19260 19307 19361 21343 21365 21422 21620 21899 22600 22630 22633 22818 22846 22852 Descriptor Remove spine fixation device Anesth facial bone surgery Anesth spine cord surgery Anesth hysterectomy Anesth vaginal hysterectomy Anesth hip arthroplasty Debride abdom wall Free skin flap microvasc Removal of chest wall lesion Mast mod rad Breast reconstr w/lat flap Open tx dprsd front sinus fx Opn tx complx malar fx Treat mouth roof fracture Partial removal of sternum - THIS COULD BE WOUND CLOSURE, SOFT TISSUE, DEBRIDEMENT ONLY Neck/chest surgery procedure Neck spine fusion Lumbar spine fusion Lumbar spine fusion combined Kyphectomy 1-2 segments Insert spine fixation device Remove spine fixation device Page 2 of 7 PAYMENT POLICY INPATIENT ONLY PROCEDURES (AMBETTER) CPT/HCPCS Code 22855 22856 23472 23472 24999 26989 27036 27075 27130 27130 27134 27170 27222 27447 27447 27470 27472 27486 27514 27535 27535 27536 27599 27703 27724 29999 29999 30999 33477 33967 35301 37182 37215 37618 37799 38724 39220 42426 43279 43282 Descriptor Remove spine fixation device Cerv artific diskectomy Reconstruct shoulder joint Reconstruct shoulder joint Upper arm/elbow surgery Hand/finger surgery Excision of hip joint/muscle Resect hip tumor Total hip arthroplasty Total hip arthroplasty Revise hip joint replacement Repair/graft femur head/neck Treat hip socket fracture Total knee arthroplasty Total knee arthroplasty Repair of thigh Repair/graft of thigh Revise/replace knee joint Treatment of thigh fracture Treat knee fracture Treat knee fracture Treat knee fracture Leg surgery procedure Reconstruction ankle joint Repair/graft of tibia Arthroscopy of joint Arthroscopy of joint Nasal surgery procedure Implant tcat pulm vlv perq Insert i-aort percut device Rechanneling of artery Insert hepatic shunt (tips) Transcath stent cca w/eps Ligation of extremity artery Vascular surgery procedure Removal of lymph nodes neck Resect mediastinal tumor Excise parotid gland/lesion Lap myotomy heller Lap paraesoph her rpr w/mesh Page 3 of 7 PAYMENT POLICY INPATIENT ONLY PROCEDURES (AMBETTER) CPT/HCPCS Code 43283 43774 44005 44055 44110 44188 44204 44602 44602 44799 44800 44960 44970 45400 46999 47100 47120 47379 47380 47600 48510 49203 49203 49204 49255 49329 49659 50040 50060 50405 50545 51840 51900 53415 54430 55866 57280 57308 58140 58150 Descriptor Lap esoph lengthening Lap rmvl gastr adj all parts Freeing of bowel adhesion Correct malrotation of bowel Excise intestine lesion(s) Lap colostomy Laparo partial colectomy Suture small intestine Suture small intestine Unlisted px small intestine Excision of bowel pouch Appendectomy Laparoscopy appendectomy Laparoscopic proc Anus surgery procedure Wedge biopsy of liver Partial removal of liver Laparoscope procedure liver Open ablate liver tumor rf Removal of gallbladder Drain pancreatic pseudocyst Exc abd tum 5 cm or less Exc abd tum 5 cm or less Exc abd tum over 5 cm Removal of omentum Laparo proc abdm/per/oment Laparo proc hernia repair Drainage of kidney Removal of kidney stone Revision of kidney/ureter Laparo radical nephrectomy Attach bladder/urethra Repair bladder/vagina lesion Reconstruction of urethra Revision of penis Laparo radical prostatectomy Suspension of vagina Fistula repair transperine Myomectomy abdom method Total hysterectomy Page 4 of 7 PAYMENT POLICY INPATIENT ONLY PROCEDURES (AMBETTER) CPT/HCPCS Code 58150 58180 58267 58548 58700 58720 58740 58750 58952 59120 60271 60505 60650 61500 61624 62223 63048 63057 63081 63082 63267 63267 63707 63709 63709 64760 64911 64999 66999 75952 G0341 G0343 Descriptor Total hysterectomy Partial hysterectomy Vag hyst w/urinary repair Lap radical hyst Removal of fallopian tube Removal of ovary/tube(s) Adhesiolysis tube ovary Repair oviduct Resect ovarian malignancy Treat ectopic pregnancy Removal of thyroid Explore parathyroid glands Laparoscopy adrenalectomy Removal of skull lesion Transcath occlusion cns Establish brain cavity shunt Remove spinal lamina add-on Decompress spine cord add-on Remove vert body dcmprn crvl Remove vertebral body add-on Excise intrspinl lesion lmbr Excise intrspinl lesion lmbr Repair spinal fluid leakage Repair spinal fluid leakage Repair spinal fluid leakage Incision of vagus nerve Neurorraphy w/vein autograft Nervous system surgery Eye surgery procedure Endovasc repair abdom aorta Percutaneous islet celltrans Laparotomy islet cell transp References 1. Current Procedural Terminology (CPT®), 2020 2. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10CM), 2020 3. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services Page 5 of 7 PAYMENT POLICY INPATIENT ONLY PROCEDURES (AMBETTER) 4. Centers for Medicare and Medicaid Services, CMS Manual System and other CMS publications and services - https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/index. Revision History 03/14/2017 5/31/2017 11/01/2019 11/01/2020 Created an Ambetter specific version of the Inpatient Only policy which excludes a list of codes. Corrected formatting and revised code list. Annual Review completed. Annual Review completed Important Reminder For the purposes of this payment policy, "Health Plan" means a health plan that has adopted this payment policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any other of such health plan's affiliates, as applicable. The purpose of this payment policy is to provide a guide to payment, which is a component of the guidelines used to assist in making coverage and payment determinations and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage and payment determinations and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable plan-level administrative policies and procedures. This payment policy is effective as of the date determined by Health Plan. The date of posting may not be the effective date of this payment policy. This payment policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this payment policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. Health Plan retains the right to change, amend or withdraw this payment policy, and additional payment policies may be developed and adopted as needed, at any time. This payment policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This payment policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. Providers referred to in this policy are independent contractors who exercise independent judgment and over whom Health Plan has no control or right of control. Providers are not agents or employees of Health Plan. This payment policy is the property of Centene Corporation. Unauthorized copying, use, and distribution of this payment policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed Page 6 of 7 PAYMENT POLICY INPATIENT ONLY PROCEDURES (AMBETTER) herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services. Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this payment policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this payment policy. Note: For Medicare members, to ensure consistency with the Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD), all applicable NCDs and LCDs should be reviewed prior to applying the criteria set forth in this payment policy. Refer to the CMS website at http://www.cms.gov for additional information. *CPT Copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. ©2020 Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene® and Centene Corporation® are registered trademarks exclusively owned by Centene Corporation. Page 7 of 7Microsoft Word 2016