Supply Code 99070
For reimbursement of covered medical and surgical supplies, an appropriate Level II HCPCS code must be submitted.
The non-specific CPT code 99070 (supplies and materials, except spectacles, provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)) is not reimbursable in any setting.
MATERIALS AND SUPPLIES – CPT CODE 99070
Anthem’s reimbursement for materials and supplies provided by the physician is included in the global reimbursement of the primary service being provided. Materials and supplies are not separately payable. Therefore, CPT code 99070 is nots eparately payable. If a provider bills with CPT code 99070 for a material or supply that is not usually part of the primary service, and CPT code 99070 is denied, the provider may call the Customer Service number listed on the member’s card or Provider Inquiry for a manual review of the claim.
Anthem's reimbursement, if any, is reduced by any applicable deductibles, copayments and/or coinsurance as defined in the member’s contract for benefits and coverage.
Surgical Implant(s) shall be itemized separately from the surgical procedure code(s) and are reimbursed in addition to the surgery.
• The ASC shall be reimbursed for the Surgical Implant(s) at fifty percent (50%) over the acquisition invoice cost;
• The ASC shall be reimbursed for the Associated Disposable Instrumentation required for implantation of the Surgical Implant(s) at twenty percent (20%) over the acquisition invoice cost, if the Associated Disposable Instrumentation is received with the Surgical Implant(s) and included on the same implant acquisition invoice;
• The ASC shall be reimbursed for shipping and handling at the actual cost to the provider if listed on the invoice.
Note
Request for Surgical Implant(s) Reimbursement later in this chapter. : Surgical Implants, Associated Disposable Instrumentation and shipping and handling may be certified for the amount requested for reimbursement pursuant to the percentages stated in this policy.
Surgical Implant(s) shall only be billed using the Workers’ Compensation unique procedure and modifier code: 99070 IM.
Associated Disposable Instrumentation required for implantation of the Surgical Implant(s) shall be billed using the Workers’ Compensation unique procedure and modifier code: 99070 DI.
Shipping and handling shall be billed using the Workers’ Compensation unique procedure and modifier code: 99070 SH.
Note: Instructions contained in 69L-7.602(4)(b)6, F.A.C, the Florida Workers’ Compensation Medical Services Billing, Filing and Reporting Rule, shall be used to bill Surgical Implant(s), Associated Disposable Instrumentation, and shipping and handling in Form Locator 42 of the Form DFS-F5-DWC-90 (UB-04) C claim form. The Workers’ Compensation unique procedure codes and their required modifiers stated above shall be billed on separate lines in Form Locator 44.
CPT 99070 for Reporting Supplies, Materials, Supplements, Remedies, etc. For HCFA1500 claims with dates of service 04/01/2015 and following, Moda Health will deny CPT code 99070 to provider write-off with an explanation code mapped to Claim Adjustment Reason Code 189 (Not otherwise classified or "unlisted" procedure code (CPT/HCPCS) was billed when there is a specific procedure code for this procedure/service.). There is always a procedure code more specific than 99070 available to be used.
Correct coding guidelines require that the most specific, comprehensive code available be selected to report services or items billed. (AMA1 , OptumInsight/CMS2 ) Moda Health accepts HCPCS codes for processing. Therefore, 99070 is never the most specific code available to use to report a supply, drug, tray, or material provided over and above those usually included in a service rendered.
Any HCPCS Level II code in the HCPCS book is more specific than 99070. The HCPCS book also includes a wide variety of more specific unlisted codes that should be used in place of 99070 when the billing office cannot identify a listed HCPCS code to describe the supply or material being billed. The use of more specific HCPCS Level II procedure codes helps to ensure more accurate determination of benefits and processing of the claim.
It is important to note that not all HCPCS codes will be eligible for covered benefits under the member’s contract, and if covered, not all HCPCS codes will be eligible for separate reimbursement.
B. For Professional Services
1. Supplies and Services Included in the Practice Expense Allowance
The Centers for Medicare and Medicaid Services (CMS) establishes and determines a relative value unit (RVU) for procedure codes and publishes this information on the Medicare Physician Fee Schedule Database (MPFSDB). Since 2002, the practice expense portion of the RVU includes medical and surgical supplies and equipment commonly furnished and that are a usual part of the surgical or medical procedures. (CMS16 ) Additional charges for routine supplies and/or equipment used for a surgical procedure or during an office visit or office procedure are not appropriate and not eligible for separate reimbursement, regardless of the method used to bill for them (individual HCPCS codes, 99070, a separate line item with modifier SU attached, etc.). Payment is included in the reimbursement for the primary procedure code.
In those cases when supplies and materials are provided which the provider feels are clearly over and above those usually included with the office visit or other services rendered and require separate reporting on the claim:
• CPT code 99070 should not be used to bill Moda Health for those supplies and materials. For claims processed with dates of service 04/01/2015 and following, 99070 will be denied to provider write-off.
• Moda Health expects supplies and materials to be billed with HCPCS Level II codes to ensure that the most specific code available is billed, and to enable accurate claims processing.
• Unlisted codes need to be submitted accompanied by a clear and specific description for the item or service being billed.
Handmaster Plus CPT Procedure Code CPT Supply Code HCPCS II
Codes Hand, Wrist, Forearm, Elbow Exerciser/Exercise *97110 Therapeutic Exercise **99070 A9300 Additional Supplies and Materials Exercise Equipment
A single 15-minute unit (for a timed CPT therapeutic exercise) should be reported for a treatment greater than or equal to 8 minutes (minimum for approval) and less than 23 minutes. This time includes consult and exercise.
Separate coding is usually required when billing for medical supplies and equipment. Always check with payers for reimbursement information and specific coding requirements. Include a letter of medical necessity whenever possible.
Describe the Handmaster Plus as specifically as possible in relation to patient’s needs and limitations (strengthening, re-balancing, stabilizing, stimulating, etc.).
**The use of HCPCS codes is vital in order to obtain accurate and complete reimbursement. Handmaster Plus billed with CPT code 99070 may not be reimbursed unless identified with the specific HCPCS code A9300. Most payers require that 1) the supply be described, 2) medical necessity be established, and 3) some require that an invoice be attached to the claim.
Supply Code 99070
For reimbursement of covered medical and surgical supplies, an appropriate Level II HCPCS code must be submitted. The non-specific CPT code 99070 (supplies and materials, except spectacles, provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)) is not reimbursable in any setting.
Anthem’s reimbursement for materials and supplies provided by the physician is included in the global reimbursement of the primary service being provided. Materials and supplies are not separately payable. Therefore, CPT code 99070 is not separately payable. If a provider bills with CPT code 99070 for a material or supply that is not usually part of the primary service, and CPT code 99070 is denied, the provider may call the Customer Service number listed on the member’s card or Provider Inquiry for a manual review of the claim.
Administered, Injectable Pharmaceuticals and Supplies Dispensed in the Practitioner’s Office
When an injectable drug is administered along with an evaluation and management service, the drug is billed and identified with CPT® 99070 or the appropriate J Code from HCPCS, and the NDC number. The office notes must identify the drug administered. A therapeutic injection administration fee is not paid in conjunction with an office visit. The drug is reimbursed at average wholesale price (AWP).
Supplies dispensed from the practitioner’s office are billed with the appropriate HCPCS code when available. If a HCPCS code does not adequately describe the supply, then 99070 may be used. A report or office notes documenting the service must be attached to the bill. Supplies are reimbursed at the DME/Supply fee schedule (based on Medicare plus 5%).
Office Visits and Administration of Injectable Medication
An injection administration code for the therapeutic injectable medication is not payable as a separate procedure when billed with an E/M service. The medication administered in the therapeutic injection shall be billed with procedure code 99070 or the appropriate J-code and identified with the NDC code. The drug is reimbursed at the average wholesale price of the drug (AWP). If an E/M service is not billed, then the administration codes may be billed in addition to the drug.
Application of Casts and Strapping
Cast and strapping services (CPT® codes 29000-29799) may be billed and paid when the cast or strapping is a replacement procedure used during or after the follow up care, or when the cast or strapping is an initial treatment service performed without a restorative procedure to stabilize or protect a fracture, injury or dislocation and/or to afford comfort to a patient. (CPT® Assistant Volume 6, Issue 2, February 1996 discusses when the casting codes are appropriately used).
The payment for a cast/strapping code includes the application and the removal of the cast, splint, or strapping. Casting supplies may be billed in addition to the procedure using 99070 or the appropriate HCPCS code.
Injectable Pharmaceuticals
Payment for injection codes includes the supplies usually required to perform the procedure, but not the medication. Injections are classified as subcutaneous, intramuscular, or intravenous. Each of the procedure codes describing a therapeutic injection has an assigned RVU and MAP amount.
When a therapeutic injection is given during an E/M service, the relative value for providing the injection is in the payment for the E/M service and must not be billed orpaid separately. The cost of the injectable pharmaceutical may be billed using procedure code 99070 from CPT® or the appropriate J-Code listed in Medicare’s Level II HCPCS codes.
Extremity Splints
Extremity splints may be prefabricated, off-the-shelf, custom-made, or custom-fit. Prefabricated splints are billed using the appropriate HCPCS code or 99070. If there is no MAP listed for the procedure and if the charge exceeds $35.00 than an invoice shall be included with the bill. The service is reimbursed by the fee schedule or at a mark-up above invoice cost as outlined in R 418.101003b.
Supplies
If a provider dispenses a supply (e.g., lumbar roll, support, or cervical pillow) it shall be billed with the appropriate HCPCS procedure or 99070. Reimbursement is made according to R 418.101003b as described above.
* Items implanted into the body that remain in the body at discharge from the facility may be billed separate from the surgical procedure. The facility shall bill implant items with the unlisted CPT® drug and supply code, 99070. A report listing a description of the implant and a copy of the facility’s cost invoice shall be included with the bill. Some examples of implants are metal plates, pins, screws and mesh.
Outpatient
Hospital Outpatient Wound Care: Use CPT * debridement codes.
Normally, dressings used on the day of service are included within the APC (Ambulatory Payment Classification) payment. However, MDT dressings and supplies are considered non-routine (see AMA’s guidance document, CPT Assistant, September 2008, Vol 18, Issue 9, page 11), and should be billed separately, either by adding their HCPCS codes (if existent and known), or describing them in detail, under a miscellaneous CPT (99070) or HCPCS (A4649) code.
Guildeline from Aetna - All Unlisted/Unspecified Codes
Include a complete written description of the procedure and written report for all unlisted/unspecified codes. See the requirements below for the following specific codes.
All Unlisted Medical Procedures & Supplies
For example: CPT 93799-Unlisted cardiovascular service or procedure; CPT 99070-Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided). Submit complete description of procedure including office notes and report.
All Unclassified Drug Codes
For example: HCPCS J3490-Unlisted drugs
State the NDC code, name of drug, manufacturer's name, dose, number of doses and number of doses administered. Submit complete description of the service including itemized invoice.
All Other Unlisted, Non-specific HCPCS Codes
For example: HCPCS A0999-Unlisted ambulance service or HCPC E1399-Durable medical equipment, miscellaneous or HCPC A4649-Surgical supply, miscellaneous. Submit complete description of the service, including itemized invoice.
All Non-specific ICD-9 Codes
For Example: ICD-9 799.8-ILL-Define condition nec or ICD-9 794.9-ABN Function study nec.
Submit complete description of the diagnosis, including office notes and history and physical
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