Update on Evaluation Management CPT codes – HighMark insurance

Jul 19, 2011 | Medical billing basics

Highmark Announces Adjustments to UCR and Premier Blue sm
Shield Reimbursement
 As noted in the April 2011 issue of PRN, Highmark filed with, and has now received approval from, the Pennsylvania Insurance Department to implement a broad range of UCR Level II and Premier Blue Shield reimbursement adjustments.
The adjustments impact anesthesia, select surgical, diagnostic and evaluative services, including, but not limited to, musculoskeletal, eye, behavioral health, allergen immunotherapy and routine electroencephalography procedures.
• Increases in allowance will be implemented for dates of service beginning July 1, 2011.
• A minimum number of allowances will be decreased for dates of service on/after Sept. 26, 2011.
Highmark will also implement changes to its payment differential for evaluation and management procedure codes 99201 through 99215 when performed in the facility, compared to services performed in a non-facility setting. Effective Sept 26, 2011, Highmark will calculate payment for the facility service using Medicare’s site-of-service differential, or at a predetermined cap, not to exceed a certain designated percentage. Currently, Highmark applies a 15 percent differential.
In addition, the allowances for CT studies of the abdomen and pelvis combined, procedure codes 74176, 74177 and 74178,will be increasing with this update. The allowances will be based upon additional data collection and analysis and have yet to be finalized.
Fees Available Via NaviNet

You may access the reimbursement adjustment information online in four convenient ways.
1. Visit our Provider Resource Center via NaviNet. Simply hover on Administrative Reference Materials, and click on Fee Updates to view the complete list of fee adjustments. (Fees are not published on the public 

Provider Resource Center.)

When the adjustments are in effect (see effective dates above), you can also use the following online tools.
2. On NaviNet, hover on Allowance and then select Allowance Inquiry to determine pricing for specific procedure codes-by planrproduct type.
3. Also on NaviNet, you can hover on Allowance, and select Frequently Billed Codes. This function initiates a report request that provides you with a quicker means of retrieving the most frequently billed codes/procedure codes based on the specialty represented by the selected billing provider and plan.
4. Via NaviNet’s Resource Center, you can download the full Premier Blue Shield fee schedule. Simply click on
Administrative Reference Materials.
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