Physicians should use CPT or HCPCS codes for all services. In the case of non-specific CPT or HCPCS codes, please include a description of the service. For drugs, non-specific HCPCS codes should be accompanied by the applicable National Drug Classification (NDC) number.
If a participating provider is unable to provide services due to temporary circumstances (e.g., vacation, illness, etc.), a covering physician may evaluate and/or treat the member. To avoid a potential delay in payment, please indicate 'Covering for (provider’s name)' including the first and last name of the physician for whom your physician is covering in Field 19 of the CMS 1500 form if billing on a paper claim. If billing electronically, please indicate this same information in the Notes field.
Physician Extenders include, but are not limited to Nurse Practitioners and Physician Assistants, acting within the scope of their licensure.
Services rendered by credentialed physician extenders should be billed using the physician extender’s own individual (type 1) NPI, as well as group (Type 2) NPI.
CRNA services must be billed on a separate claim with the appropriate modifier.
Generally, supplies and materials provided in the physician’s office (e.g., syringes, gauze, tubing, etc.) are included in the payment for the office visit or in-office procedure.
MHP reimburses physicians for surgical trays when used in support of a Medicare qualifying procedure (see Medicare guidelines for a comprehensive listing).
The following guidelines affect billing for all drugs (e.g., injectables, infusables, pharmaceuticals, chemotherapy agents, blood, and blood products).
Providers must bill with the applicable CPT/HCPCS code (e.g., "J" codes). For the administration of multiple drugs, the applicable HCPCS code for each drug must be listed. If billing on a UB-04, the applicable Revenue Code must also be noted.
Please include the "units" administered and the unit measurement in field 24g (CMS 1500) or field 46 (UB-04) as it correlates to that which is specified by the particular HCPCS code used (e.g., J9000 Doxorubicin HCI, 1 unit equals 10 mg; or J7100 dextran 40 infusion, 1 unit equals 500 ml).
A miscellaneous or non-specific HCPCS or CPT code should only be utilized for drugs that do not have an applicable code. When a miscellaneous or non-specific code is used, include the NDC number and enter the product quantity in the Units field.
When a member receives multiple home IV infusion therapies, please use the modifier '-SH' (second concurrently administered infusion therapy) and, when applicable, modifier '-SJ' (third or more concurrently administered infusion therapy). For example, if a member has two infusions (e.g., antibiotic and enteral) and are billing supplies (e.g., A4222) for the infusion pumps, please bill the second supply/nursing visit, etc., with an '-SH' modifier.
If a physician utilizes a non-participating vendor for services in connection with office services, he/she should reimburse the third party vendor before billing MHP for the services under his/her own name. MHP will not directly reimburse those vendors, as MHP does not have a participation agreement with them.
Billing guidelines for chiropractic care follow standard procedures found in the CPT coding manual. MHP reimburses for an Evaluation and Management code for the initial visit only. Successive visits must be billed using standard chiropractic manipulative treatment (CMT) codes 98940 - 98943. MHP denies any additional evaluation and management code submitted on the same claim since CMT codes, by their definition, include pre-manipulation patient assessments. These denied codes should not be billed to the member unless the denial is due to the member exceeding their benefit limit.