Category III CPT Codes/Unlisted Category I Surgical and Radiology Codes Physicians Plus Insurance Corporation Guideline Document Number: 0127-GL-DEPT-012-CC Revision #: Rev1-6 Accountable Department: Operations Date Last Updated: 08/05/2013 Author: Jarrett, Jane Status: Approved Owner/Author Accountable Department: Operations Document Owner: Director of Configuration & Claims Cost Containment Author: Jarrett, Jane Contributing Authors: B&P Committee Catherine Inman, M.D. Medical Director Typist: Jarrett, Jane Guideline Description Guideline: This guideline was developed under the guidance of Physicians Plus' Medical Director and approved by the Benefits and Policy Committee. Category III current procedural terminology (CPT) codes are temporary for emerging technology, services and procedures. These CPT codes are used for data collection purposes per the American Medical Association (AMA). Use of unlisted Category I codes in lieu of category III codes is considered inappropriate coding and is subject to fraud, waste and abuse investigation procedures. The inclusion of these Category III codes in the CPT book for services/procedures does not imply coverage, endorsement, clinical efficacy, safety or applicability to clinical practices. Physicians Plus considers all services, procedures, and treatment with category III codes to be experimental, investigational, and or emerging technology. Unlisted Category I surgical procedures and imaging studies used to develop templates or other devices to be used during orthopedic procedures are also considered experimental/investigational/emerging technology. Category III Codes All Category III codes will now require Prior Authorization. Without prior authorization, the claim will deny as provider responsibility. If the member requests to have a Category III surgical procedure performed knowing that an authorization was not obtained (or the authorization was denied), providers may have the member sign an ABN to accept responsibility for the service provided. Once Physicians Plus receives a copy of the signed ABN, the service becomes member liability. Physicians Plus Insurance Corporation Date Originally Created at P+: 05/21/2012 Page 1 of 4 Status: Approved Printed: 08/22/2014 0127-GL-DEPT-012-CC Category III CPT Codes/Unlisted Category I Surgical and Radiology Codes Revision #: Rev1-6 Updated: 08/05/2013 Unlisted Category I Surgical Codes: When a Category III code is unavailable and the most appropriate code choice is an Unlisted Category I Surgical Procedure Code (11021-69990 range), Physicians Plus requires the Unlisted Category I code to be used. If the code represents a service that is considered experimental/investigational/emerging, the same Prior Authorization rules will apply to Category I codes as they do to Category III codes. Physicians Plus defines experimental, investigational, or emerging service, procedure, or treatment to mean one in which the published authoritative medical and scientific literature has not defined or supports further research to define the safety, toxicity, maximum tolerated dose, or efficacy in comparison to the standard means for treatment or diagnosis; or does not demonstrate clinically significant improvement in the efficacy or outcomes for the drug, device, treatment or procedure compared to standard drugs, devices, treatments or procedures. Unlisted Category I Radiology Codes: Imaging studies (for example, x-ray, MRI, CT) used to develop templates or other devices to be used during orthopedic procedures for a specific patient will also require prior authorization. If the member requests to have an unlisted Category I surgical procedure or imaging study as listed above performed knowing that an authorization was not obtained (or the authorization was denied), the provider may have the member sign an ABN to accept responsibility for the service provided. Once Physicians Plus receives a copy of the signed ABN, the service becomes member liability. Providers who wish to have their denied Category III, unlisted Category I surgical or imaging study procedures/services reviewed for coverage consideration may submit a request for technology review with accompanying evidence-based peer review literature supporting the procedure/service. The request should be sent prior to the procedure/service under consideration by the Medical Policy Committee. Technology review takes a minimum of 2 months for a decision by the Medical Policy Committee. Responsibility: Health Services Operations Revision History Rev1-1: 05/21/2012 Document Created Rev1-2: 06/04/2012 added sign off's per Jane. POSSE review and approved. Physicians Plus Insurance Corporation Date Originally Created at P+: 05/21/2012 Page 2 of 4 Status: Approved Printed: 08/22/2014 0127-GL-DEPT-012-CC Category III CPT Codes/Unlisted Category I Surgical and Radiology Codes Revision #: Rev1-6 Updated: 08/05/2013 Rev1-3: 11/13/2012 Additions and deletions made per the direction of Dr. Inman. Rev1-4: 01/03/2013 Updated title to include Unlisted Category I Codes Rev1-5: 01/08/2013 Corrected spelling errors. Rev1-6: 08/05/2013 Status changed from Posse Review to Approved per Dr. Inman's request. Physicians Plus Insurance Corporation Date Originally Created at P+: 05/21/2012 Page 3 of 4 Status: Approved Printed: 08/22/2014 0127-GL-DEPT-012-CC Category III CPT Codes/Unlisted Category I Surgical and Radiology Codes Revision #: Rev1-6 Updated: 08/05/2013 Authorization History Sign-off Approvals: Jane Jarrett Configuration Manager [email protected] Rev1-1 Catherine Inman, MD Medical Director [email protected] Rev1-1 Sign-Off Approvals The author of this guideline assures that it is consistent with the organizations philosophy and strategic direction. Print Name & Title Signature ___/____/______ Date After you have approved this document, please sign and date below. Distribution / Routing List All persons or areas listed below should receive notification that this document has been approved and is available on PlusNet. Medical Policy Committee B&P Committee Review / Approval Management Physicians Plus Insurance Corporation Date Originally Created at P+: 05/21/2012 Page 4 of 4 Status: Approved Printed: 08/22/2014
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