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REIMBURSEMENT POLICY

CMS-1500 Policy Number 2020R0060J

Proprietary information of UnitedHealthcare Community Plan. Copyright 2020 United HealthCare Services, Inc. 2020R0060J

Maximum Frequency Per Day Policy, Professional

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT®*), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plan’s reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the physician or other provider contracts,

the enrollee’s benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publicat ion. *CPT Copyright American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

Application

This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid products. This policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. This policy does not apply to: network home health services and supplies/home health agencies; anesthesia management; ambulance services; network physicians and other qualified health care professionals contracted at a case rate (in some markets known as a flat rate) unless the code description for the service or supply indicates it should be reported only once daily . For HCPCS codes reported with rental modifiers (KH, KI, KJ, KR, or RR) or the Maintenance and Service modifier (MS) by a participating network and non-network durable medical equipment (DME), orthotics or prosthetics vendor, please refer to UnitedHealthcare Community Plan’s Durable Medical Equipment, Orthotics and Prosthetics Multiple Frequency Policy.

Table of Contents

Application Policy

Overview Reimbursement Guidelines

MFD Determination Part I Part II

Reimbursement Modifiers

Anatomic Modifiers State Exceptions




Questions and Answers Attachments Resources History

Policy

Overview

The purpose of this policy is to ensure that UnitedHealthcare Community Plan reimburses physicians and other qualified health care professionals for the units billed without reimbursing for obvious billing submission, data entry errors or incorrect coding based on anatomic considerations, HCPCS/CPT code descriptors, CPT coding instructions, established UnitedHealthcare Community Plan policies, nature of a service/procedure, nature of an analyte, nature of equipment, and unlikely clinical treatment. The term “units” refers to the number of times services with the same Current Procedural Terminology (CPT ®) or Healthcare Common Procedure Coding System (HCPCS) codes are provided per day by the same individual physician or other qualified health care professional. To do this, UnitedHealthcare Community Plan has established maximum frequency per day (MFD) values, which are the highest number of units eligible for reimbursement of services on a single date of service. Reimbursement also may be subject to the application of other UnitedHealthcare Community Plan Reimbursement policies. This policy applies whether a physician or other qualified health care professional submits one CPT or HCPCS code with multiple units on a single claim line or multiple claim lines with one or more unit(s) on each line. It is common coding practice for some CPT and HCPCS codes to be submitted with multiple units. MFD values will be evaluated and/or updated quarterly to reflect new, changed, and deleted codes. Review of MFD values for existing CPT and HCPCS codes based on criteria within this policy will be completed quarterly. For the purpose of this policy, the same individual physician or other qualified health care professional is the same individual rendering health care services reporting the same Federal Tax Identification number.

Reimbursement Guidelines

MUE Editing **NOTE: MUE values always supersede MFD values listed in this policy except in Arizona. **

UnitedHealthcare Community Plan will follow the CMS MUE values before any other MFD criteria is applied. If there is not a CMS MUE value or the CMS MUE value is not exceeded, then the following criteria has been used to establish MFD values. See UnitedHealthcare Community Plan’s Medically Unlikely Edits Policy.

Part I The following criteria are first used to determine the MFD values for codes to which these criteria are applicable:

• Where the criteria above have not defined an MFD value, the CMS Medically Unlikely Edits (MUE) value, where available, will be utilized to establish an MFD value.

• When the service is classified as bilateral (Indicators 1 or 3 on the CMS National Physician Fee Schedule

[NPFS]) or the term 'bilateral' is included in the code descriptor and when no MUE value has been established for these codes, the MFD value is 1. There are some codes that describe more than one anatomical site or vertebral level that can be treated bilaterally where the MFD value may be more than 1.

• Where the CPT or HCPCS code description/verbiage references reporting the code once per day, the MFD value is 1.

• The service is anatomically or clinically limited with regard to the number of times it may be performed, in which case the MFD value is established at that value.

• The CPT or HCPCS code description/verbiage indicates the number of times the service can be performed, in which case the MFD value is set at that value.

• CMS Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Local Coverage

Determination (LCD) assigns an MFD value in which case the MFD value is set at that value. • Where no other definitive value has been established based on the criteria above, drug HCPCS codes will have

an MFD value of 999 which indicates they are exempt from the MFD policy.




• Where no other definitive value has been established based on the criteria above, unlisted CPT and HCPCS

codes will have an MFD value of 999 which indicates they are exempt from the MFD p olicy. • Where no other definitive value has been established based on the criteria above, new CPT codes released by

the American Medical Association and new HCPCS codes released by CMS since the last MFD value update (not covered by any of the above criteria), will have an MFD value of 100.

Part II When none of the criteria listed in Part I apply to a code, data analysis is conducted to establish MFD values according to common billing patterns.

• When a code has 50 or more claim occurrences in a data set, the MFD values are determined through claim data analysis and are set at the 100th percentile (i.e. the highest number of units billed for that CPT or HCPCS code in the data set). If the 100th percentile exceeds the 98th percentile by a factor of four, the MFD value will be set at the 98th percentile.

• When a code has less than 50 claim occurrences in a data set, the MFD values will be set at the default of 100 until the next annual analysis.

• In any case where, in UnitedHealthcare Community Plan's judgment, the 98th percentile does not account for the clinical circumstances of the services billed, the MFD for a code may be increased so as to capture only obvious billing submission and data entry errors.

The "MFD CPT Values" and the "MFD HCPCS Values" lists below contain the most current MFD values.

UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) HCPCS Policy List

Reimbursement

The MFD values apply whether a physician or other qualified health care professional submits one CPT or HCPCS code with multiple units on a single claim line or multiple claim lines with one or more unit(s) on each line. It is common coding practice for some CPT and HCPCS codes to be submitted with multiple units. However, when reporting the same CPT or HCPCS code on multiple and/or separate claim lines, the claim line may be classified as a duplicate service and/or subject to additional UnitedHealthcare Community Plan reimbursement policies.

Services provided are reimbursable services up to and including the MFD value for an individual CPT or HCPCS code. In some instances, a modifier may be necessary for correct coding and corresponding reimbursement purposes. See Q & A #3, 4 and 5.

Bilateral payment via the use of modifiers LT or RT is inappropriate for procedures, services, and supplies where the concept of laterality does not apply. UnitedHealthcare Community Plan will pay up to the maximum frequency per day value for codes with "bilateral" or "unilateral or bilateral" in description or for codes where the concept of laterality does not apply, whether submitted with or without modifiers LT and/or RT by the same individual physician or other qualified healthcare professional on the same date of service for the same member. Use of modifiers LT and/or RT on the codes identified in the "Codes Restricting Modifiers LT and RT" list will be considered informational only. UnitedHealthcare Community Plan Codes Restricting Modifiers LT and RT

There may be situations where a physician or other qualified healthcare professional reports units accurately and those units exceed the established MFD value. In such cases, UnitedHealthcare Community Plan will consider additional reimbursement if reported with an appropriate modifier such as modifier 59, 76, 91, XE, XS or XU. Medical records are not required to be submitted with the claim when modifiers 59, 76, 91, XE, XS or XU are appropriately reported. Documentation within the medical record should reflect the number of units being reported and should support the use of the modifier.




Modifiers

59 76 91 XE XS XU

Anatomic Modifiers

E1 E2 E3 E4 F1 F2

F3 F4 F5 F6 F7 F8

F9 FA T1 T2 T3 T4

T5 T6 T7 T8 T9 TA

LC LD LM LT RC RI

RT

State Exceptions

Arizona Arizona Health Care Cost Containment System (AHCCCS) publishes a unit limit list specific to Arizona Medicaid. Arizona does not exclude network home health services and supplies/home health agencies; anesthesia management; ambulance services. Arizona unit values are allowed even if they are greater than the CMS MUE values. If Arizona has not published a unit limit for a code, the MUE value will be followed.

California California is exempt from MFD for code 90471. California has an MFD exception for codes: Codes 96150 and 96151 has a limit of 1 unit per day Codes 96152, 96153 and 96154 has a limit of 2 units per day Codes 96367 and 96375 has a limit of 3 units per day Code G0277 has a limit of 4 units per day Code G9008 with modifier U1-U7 may be billed with up to 96 units; however, only 1 unit is reimbursable. Code 86235 has a limit of 5 units per day Code 96370 has a limit of 8 units per day Code A4217 has a limit of 12 units per day Code T1014 has a limit of 90 units per day Code T1019 has a limit of 96 units per day

Florida Per state regulations, a different unit value is allowed for the following codes: CPT 92507 and 92508 = 4 units allowed HCPCS H0031 (MMA) = 80 units allowed HCPCS T1019 = 96 units per day HCPCS T1030 and T1031 = 4 units allowed HCPCS H2010, T1020, T1021, T1024 and T2033 = no unit limit HCPCS T1005 = 96 units per day

Iowa Per Iowa Medicaid requirements: • 92507, 92508, A4253, G9012, S4993, T2018 and T2036 are excluded from the MFD listed limits. • J0571-J0575 = units based on milligrams per dose administered (i.e. two 8 mg sublingual films administered at separate visits on the same date - 2 units submitted using J0574). • T1019 has a daily limit of 96 units • T2018 has a daily limit of 24 units

Kansas Per State Regulations: • HCPCS codes H0005 and H0006 are exempt from MFD limits.

• HCPCS code T1019 limit is 96 units per day. • HCPCS code T2046 limit is 1 per day




Maryland MD has an exception from CMS for the following codes: Allows 76 units per day on code V5266 Allows 96 units per day on code T1019

Michigan MI allows 8 units of 90472 in place of service 71 T1019 is allowed 96 units per day

Mississippi MS Can has exceptions for codes T1025 and L0980 – L3600 T1019 is allowed 96 units per day

Missouri MO utilizes its own list of units allowed per date of service.

Nebraska Per State regulations, Nebraska Medicaid has exceptions to the following codes: Allows 5 units per day on code H0015 Allows 4 units per day on code 99429 when billed with modifier EP Code 90911 to be exempt from MFD Code T1019 is allowed 96 units per day

New Jersey New Jersey has an MFD exemption for codes B4220, B4222. B4224 and S9343; and no limits for the following codes: 97532 when billed with modifier U4 & U5 97535 & 97110 when billed with modifiers U2, U3, U4 or U5 New Jersey allows 8 units per day for code S8990. Due to State Regulations: 96101 has a daily limit of 6 units per day 96102 has a daily limit of 6 units per day 96103 has a daily limit of 6 units per day 96116 has a daily limit of 6 units per day 96118 has a daily limit of 6 units per day 96120 has a daily limit of 6 units per day 96125 has a daily limit of 6 units per day 96127 has a daily limit of 1 unit per day 96110 has a daily limit of 1 unit per day 96150 has a daily limit of 6 units per day 96151 has a daily limit of 4 units per day 96152 has a daily limit of 4 units per day 96153 has a daily limit of 4 units per day 96154 has a daily limit of 4 units per day H0035 has a daily limit of 5 units per day T1019 has a daily limit of 96 units per day

New York New York has an exception for the following codes to be exempt from MFD: J7175, J7178, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7188, J7189, J7190, J7191, J7192, J7193, J7194, J7195, J7198, J7199, J7200, J7201, J7202, J7205, J7207 and J7209 Due to State Regulations, there is no daily limit for H0031 and H0032 Due to State requirements, CPT code 97530 is allowed 8 units per day Due to State requirements, HCPCS code A4575 is allowed 16 units per day H0004 has a daily limit of 4 per day H2011 has a daily limit of 8 per day H0036 has a daily limit of 6 per day H2017 has a daily limit of 8 per day H0038 has a daily limit of 8 per day H2014 has a daily limit of 24 per day T2015 has a daily limit of 2 per day H2015 has a daily limit of 12 per day H2023 has a daily limit of 12 per day S5150 has a daily limit of 16 per day T1019 has a daily limit of 96 per day




0403T has a daily limit of 2 per day

Ohio Ohio Medicaid allows the following unit limits: H0005 and H0006 – 96 units per day H0014 - 1 unit per day H0038 - 16 units per day H2012 – 2 units per day J0571-J0575- based on milligrams administered (i.e. 12 mg administered, 4 units submitted using J0572). T1019 is allowed 96 units per day Ohio MME has an exception from CMS for codes 90792, 90863, H0001, H0007, H0016, and H0020 when billed in a place of service 53 to be exempt from MUE/MFD edit limits.

Pennsylvania PA has an exception from CMS for the following codes: Allows 2 units per day on code T1028 when reported with Modifier HD Allows 96 units per day on code T1019

Rhode Island Rhode Island has an exception from CMS for code S9446 to be exempt from MUE edit limits. Rhode Island has an exception for code 99211 for Behavioral Health.

Tennessee Tennessee has an exception for codes G9004, G9005, G9006, G9007, G9010, and G9011 when billed with modifiers UB or UA. HCPCS code H0031 and H0032 allows up to 96 units per day Code 95165 is exempt from MFD limits Code 95170 allows up to 40 units per day when billed with modifier U1 Code T1019 allows 96 units per day

Texas Per Texas Medicaid: • Providers are required to bill additional vaccine administration codes on separate lines with only 1 unit. • 81099, 82803, 82948, 84999, 90460, 90461, 90472, 90474, A4281, A4282, A4284, A4286, H0005 and H0020 are exempt from MFD. • 82642, 83722, 86790, 86794, 87015, 87046, 87071, 87075, 87076, 87077, 87081, 87088, 87101, 87102, 87106, 87107, 87140, 87147, 87149, 87150, 87152, 87153, 87181, 87184, 87185, 87186, 87188, 87190, 87206, 87209, 87210, 87252, 87254, 87300, 87634, 87798, 87801, 87809, 87899, 87904, 97799 and A4396 allows 1 unit per day. • 97535 and 97537 allow up to 3 units per day each • A0420 and S5101 allows up to 2 units per day • A4253 and A9275 allow up to a combined total of 2 units per month for insulin dependent diabetics and a combined total of 1 unit per month for noninsulin dependent diabetics. • H0020 when billed with modifier U1 is exempt from MFD • H2014 allows up to 16 units which equals up to 4 hours. • S5151 allows up to 24 units when billed with modifier U3, U7, UC, US or 99 • T1019 allows up to 96 units per day • T1026 allows up to 4 units per day

Virginia VA has an exception for the following codes: Allows 1 unit per day on codes H0006, H0014, H0015 and H2015 Allows 3 units per day on codes H0035 and H2017 Allows 5 units per day on code H0032 Allows 6 units per day on codes G0151, G0152, G0153, G0495, T1015, T1024, T1026 and T1027 Allows 12 units per day on code H2019 Allows 16 units per day on codes H0024, H0025, T1012 and S9445 Allows 24 units per day on codes G0493, G0494, H0004, H0005, S5126, S5150, T1000, T1001, T1002, T1003, T1005, T1019, T1023, T1030 and T1031 Allows 48 units per day on code H2021 VA is exempt from MFD limits on code(s) S0109




Washington Per State regulations, Washington Medicaid has exceptions to the following codes: Code 95870 allows 5 units per day Code A4349 allows 2 units per day Codes S9430 & H0003 does not impose a daily limit Codes H0010 & H0016 do not impose a daily limit for Behavioral Health Code H0020 allows 2 units per day Code T1019 allows 96 units per day The following COVID19 codes does not impose a daily limit: 98966, 98967, 98968, 99001, 99421, 99422, 99423, 99441, 99442, 99443, 99451, G2012

Wisconsin Per State regulations, Wisconsin Medicaid has exceptions to the following codes: Allows 2 units per day on code 99082 Allows 4 units per day on code T1006 Allows 24 units per day on code H0022 Allows 96 units per day on code H0005 Allows 96 units per day on code T1019 Wisconsin Department of Health Services publish separate unit limits specific to Wisconsin Medicaid for specific physical, occupational, and speech therapy services. Please refer to the C&S Physical Medicine & Rehabilitation: Maximum Combined Frequency per Day Policy.

Questions and Answers

1

Q: Why do you exclude network home health services and supplies/home health agencies, anesthesia management, and ambulance providers from this policy?

A: There are many contracts specific to these physicians and other qualified health care professionals that permit codes to be used in a different manner than intended by CPT and HCPCS, which make the application of this policy unworkable. Billing practices may also dictate that the units field is used to report something other than how many times a service was performed (i.e. mileage), which again may make the application of this policy unworkable. These providers were excluded until contract language and/or billing practices can be reviewed and changed.

2

Q: When the f requency of a billed service on a date of service is greater than the established MFD value, will there be additional reimbursement?

A: When a physician or other qualified healthcare professional reports units accurately, yet those units exceed the established MFD value, an appropriate modifier such as 59, 76, 91, XE, XS, or XU may be utilized. The MFD value is a threshold set solely to avoid overpayment due to billing and data entry errors. UnitedHealthcare Community Plan intends to reimburse all services performed and reported with proper coding in accordance with its reimbursement policies and benefit or provider contracts. Medical records do not need to be submitted for the purposes of this policy, unless the processed claim is being submitted on appeal. When reporting the same CPT or HCPCS code on multiple and/or separate claim lines, the claim line may be classified as a duplicate service and subject to additional UnitedHealthcare Community Plan reimbursement policies.

3

Q: Why has UnitedHealthcare Community Plan set the MFD value at 1 for bilateral procedures?

A: UnitedHealthcare Community Plan has set the MFD value for most bilateral procedures at 1. The preferred method of billing a bilateral eligible procedure is with 1 unit on one claim line with modifier 50. Modifier 50 indicates that one procedure was performed bilaterally. Bilateral eligible procedures may also be billed on two lines with 1 unit each and modifiers RT and LT. There are some codes that describe more than one anatomical site or vertebral level that can be treated bilaterally where the MFD value may be more than 1.

4 Q: Would the MFD value for bilateral procedures remain at 1 unit if it is possible to perform these procedures more than once per day?




A: If the bilateral procedure is provided more than once per day, modifiers 59, 76, XE, XS, or XU may be appropriate to bill depending on the circumstance. Additional reimbursement will be considered with the use of these modifiers.

5

Q: Would the MFD value for hand or foot bilateral procedures remain at 1 unit if it is possible to perform the procedure on multiple digits such as fingers or toes?

A: The MFD value would remain at 1 unit, however, HCPCS modifiers FA or F1-9 may be used to report specific f ingers; TA or T1-9 may be used to report specific toes.

6

Q: Will UnitedHealthcare Community Plan allow more than 1 unit for a CPT or HCPCS code with “per diem” or “per day” in the code description?

A: UnitedHealthcare will allow 1 unit of a procedure code with “per diem” or “per day” or other verbiage describing once daily in the code description. There are no modifiers that will override the MFD value.

For example, if a patient requires home infusion antibiotic therapy twice daily, it would be more appropriate to report 1 unit of HCPCS code S9501 rather than 2 units of S9500. The MFD applies whether a physician or other qualif ied health care professional submits one CPT or HCPCS code with multiple units on a single claim line or multiple claim lines with one or more unit(s) on each line.

• S9500 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 24 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

• S9501 Home infusion therapy, antibiotic, antiviral, or antifungal therapy; once every 12 hours; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.

7

Q: What is an example of a code that is limited because of anatomical or clinical reasons?

A: CPT code 44950- Appendectomy would be set at the MFD value of 1 unit because a person only has one appendix.

8

Q: How should 90460 and/or 90461 be reported when multiple immunizations with face-to-face counseling are performed on the same date of service? For example, if the physician or other qualified health care professional administers immunizations for a 2-month-old infant on the same date of service according to the current immunization schedule, how should the following immunizations be reported?

Immunization Components CPT Code

DtaP intramuscular administration 3 90460

90461 x 2

Rotavirus oral administration 1 90460

Hepatitis B and Hemophilus influenza b intramuscular administration

2 90460

90461

Poliovirus intramuscular administration 1 90460

Pneumococcal conjugate vaccine 1 90460

A: Coding practices may vary by physician or other qualified healthcare professional offices. It is appropriate to report the immunization administration of the first and additional vaccine/toxoid component with face-to-face counseling on one line with multiple units and a link to all associated ICD-10-CM codes or report each component on a separate line. In the example above, the claim could be reported as 90460 with 5 units on one line and 90461 with 3 units on a separate line with the associated ICD-10-CM diagnoses linked to each line.

It is also appropriate to report the administration of each vaccine component on separate lines; e.g. reporting 5 lines for 90460 with 1 unit each and 3 lines for 90461 with 1 unit each. However, when reporting the same CPT or HCPCS code on multiple lines and/or on separate claims, the additional claim line(s) reported with the same procedure code may be denied as a duplicate service.




9

Q: How are MFD values for immunization administration CPT codes 90472 and 90474 determined?

A: UnitedHealthcare Community Plan follows the recommendations from the Center for Disease Control's (CDC) Advisory Committee on Immunization Practices (ACIP) to set the MFD value for additional immunization administration codes.

10

Q: What is an example of a CPT or HCPCS codes where the "description/verbiage" clearly indicates the number of units that can be performed on a single date of service?

A: Two examples are CPT Codes 11102 and 80305. Code 11102-Tangential biopsy of skin, (eg, shave, scoop, saucerize, curette); single lesion. Because the code description includes "single lesion", it should only be billed with 1 unit. Code 80305 - Drug test(s) presumptive, any number of drug classes, any number of devices or procedures capable of being read by direct optical observation only (eg, utilizing immunoassay [eg, dipsticks, cups, cards, or cartridges]), includes sample validation when performed, per date of service. The code description includes "per date of service," therefore it should only be billed with 1 unit per date of service.

11

Q: Why are many new CPT and HCPCS codes set at an MFD value of 100?

A: There is no data or previous claim history for new codes. Setting the MFD value at 100 allows claims to be processed and prevents most overpayments from occurring due to billing errors and data entry errors. Once claims data is available on a code, the MFD value will be established.

12

Q: What is an example of determining the MFD value at the 100th percentile unless the 100th percentile exceeds the 98th percentile by greater than a factor of 4?

A: Statistical calculation: (A) x 4 = (C); if (B) is greater than (C), then the 98th percentile is set for the MFD value. If (B) is less than or equal to (C), then the 100th percentile is set for the MFD value. Here are two examples of determining MFD values based on a factor of 4.

Code (A) Units @ 98th (B) Units @ 100th (C) Factor of 4 Set MFD at:

86902 14 27 56 27

E0676 2 30 8 2

13

Q: What is an example of a clinical circumstance where UnitedHealthcare Community Plan would assign a specific MFD value?

A: A4595-Electrical stimulator supplies, 2 lead, per month, (e.g. TENS, NMES). According to standard criteria, the data showed the 98th percentile at 10 units and the 100th percentile at 72 units. The statistical calculation would have set the MFD value at 10. However, based on the code description allowance of “per month” and subject to the UnitedHealthcare Community Plan Time Span Codes Reimbursement Policy, the MFD value was decreased to one (1).

Attachments: Please right click on the icon to open the file

UnitedHealthcare Community Plan Maximum Frequency Per Day (MFD) CPT Code Policy List

Designates the maximum frequency per day value assignments for CPT codes.

Code Value

0001U 1

0002M 1

0002U 1

0003M 1

0003U 1

0004M 1

0005U 1

0006M 1

0007M 1

0007U 1

0008U 1

0009U 2

0010U 2

0011M 1

0011U 1

0012M 1

0012U 1

0013M 1

0013U 1

0014M 1

0014U 1

0016U 1

0017U 1

0018U 1

0019U 1

0021U 1

0022U 2

0023U 1

0024U 1

0025U 1

0026U 1

0027U 1

0029U 1

0030U 1

0031U 1

0032U 1

0033U 1

0034U 1

0035U 1

United Healthcare Community Plan

Maximum Frequency Per Day (MFD)

CPT Code Policy List

0036U 1

0037U 1

0038U 1

0039U 1

0040U 1

0041U 1

0042T 1

0042U 1

0043U 1

0044U 1

0045U 1

0046U 1

0047U 1

0048U 1

0049U 1

0050U 1

0051U 1

0052U 1

0053U 1

0054T 1

0054U 1

0055T 1

0055U 1

0056U 1

0058T 1

0058U 1

0059U 1

0060U 1

0061U 1

0062U 1

0063U 1

0064U 2

0065U 2

0066U 1

0067U 2

0068U 1

0069U 1

0070U 1

0071T 1

0071U 1

0072T 1

0072U 1

0073U 1

0074U 1

0075T 1

0075U 1

0076T 1

0076U 1

0077U 2

0078U 1

0079U 1

0080U 1

0082U 1

0083U 1

0084U 1

0085T 1

0086U 1

0087U 1

0088U 1

0089U 1

0090U 1

0091U 1

0092U 1

0093U 1

0094U 1

0095T 1

0095U 1

0096U 1

0097U 1

0098T 5

0098U 1

0099U 1

0100T 1

0100U 1

0101T 1

0101U 1

0102T 2

0102U 1

0103U 1

0105U 1

0106T 4

0106U 1

0107T 4

0107U 1

0108T 4

0108U 1

0109T 4

0109U 1

0110T 4

0110U 1

0111T 1

0111U 1

0112U 1

0113U 1

0114U 1

0115U 1

0116U 1

0117U 1

0118U 1

0119U 1

0120U 1

0121U 1

0122U 1

0123U 1

0124U 1

0125U 1

0126T 1

0126U 1

0127U 1

0128U 1

0129U 1

0130U 1

0131U 1

0132U 1

0133U 1

0134U 1

0135U 1

0136U 1

0137U 1

0138U 1

0139U 1

0140U 1

0141U 1

0142U 1

0143U 1

0144U 1

0145U 1

0146U 1

0147U 1

0148U 1

0149U 1

0150U 1

0151U 1

0152U 1

0153U 1

0154U 1

0155U 1

0156U 1

0157U 1

0158U 1

0159U 1

0160U 1

0161U 1

0162U 1

0163T 4

0163U 1

0164T 4

0164U 1

0165T 4

0165U 1

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