Payment Reduction for Repeat Services
Reduction of Payment for Duplicate Service Rendered on the Same Day
DESCRIPTION:
Duplicate Services are identified as same procedure code/modifier, same charge, and same provider on the same date of service.
POLICY:
The service will be denied when a claim for a Duplicate Service is submitted and the member’s claim records reflect that the Duplicate Services was previously submitted and processed.
Reduction of Payment for Subsequent Service Same Day
DESCRIPTION:
Subsequent, multiple or repeated services rendered on the same calendar day may be clinically appropriate depending upon the unique indications of the patient. Subsequent, multiple or repeated services may involve different procedures or a repeat of the same service.
POLICY:
WellChoice generally follows the designations of the AMA’s CPT book and/or CMS for bilateral, unilateral and units reporting. For example, services identified as bilateral by CPT code should be reported only once when provided bilaterally; procedure codes designated as per hour in the CPT book should be reported with the number of hours incurred.
CPT Modifiers 76/77 identify repeat procedures.
Multiple surgical procedures on the same anatomical site will be reimbursed according to the member’s WellChoice New Jersey benefit contract. The allowed procedure with the highest reimbursement rate will be paid and the minor procedures will be denied as incidental. Multiple surgical procedures on different anatomical sites will generally be reimbursed at the allowed amount for the primary procedure and at fifty percent of the allowed amount for the lesser procedures
Multiple Evaluation and Management (E&M) on the same day will be reimbursed at the higher reimbursement rate for the allowed service and the other E&M services will be denied as incidental.
Multiple radiology procedures of the same anatomical site will be reimbursed at the highest reimbursement rate for the allowed service and the other radiology procedures will be denied as incidental.
Multiple pathology procedures will be reimbursed separately based on clinical appropriateness.
Reimbursement of all services is subject to the terms, conditions and limitations of the individual member’s coverage as specified in the governing benefit contract and/or certificate and clinical appropriateness standards as set forth in the WellChoice New Jersey Physician and Hospital/Facility SourceBook and related medical policies.
Submission of all information listed above is subject to review by WellChoice as part of the claim payment adjudication process to confirm that medical necessity criteria have been met.
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