Indiana providers billing Anthem Medicaid plans for multiple instances of the same surgical procedure for the same date of service by the same provider will need to make some adjustments to their claims in order to get paid correctly.
At issue is Anthem’s policy of reducing payment when two or more covered surgical procedures are performed during the same operative session for patients covered by Anthem’s Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect plans. The following adjustments typically apply:
- 100% of the global fee for the most expensive procedure
- 50% of the global fee for the second most expensive procedure
- 25% of the global fee for the remaining procedures
In order to process the claim reductions correctly, all surgeries performed on the same day by the same rendering physician must be billed on the same professional claim form. Otherwise, subsequent claims may be denied, and the original claim must be adjusted for any additional payment.
According to a recent Indiana Anthem Medicaid provider webinar, however, the payer’s claims processing system is not currently able to correctly apply discounts for multiple procedures when they are billed on the same claim line.
Anthem is working to correct the problem, but in the meantime, the payer recommends that providers submit all surgical procedures on separate lines for Anthem Medicaid claims, even if the same surgical procedure is performed multiple times. This will avoid potential overpayments and the need for subsequent refunds.
The example offered in the webinar was billing for the treatment of three fractured toes. Rather than bill Anthem Medicaid for the following:
- 28510-51 – 3 units
Providers would instead submit a claim with the following:
- 28510-T1 – 1 unit
- 28510-51 -T2 – 1 unit
- 28510-51 -T3 – 1 unit
For more information about Anthem Medicaid’s multiple procedure policy, review the IHCP Surgical Services Provider Reference Module or check out Anthem’s First quarter 2019 billing updates for Hoosier Healthwise, Healthy Indiana Plan and Hoosier Care Connect. For specific information regarding Anthem’s system problem with applying discounts for multiple procedures when they are billed on the same claim line, providers should contact their Anthem Indiana Medicaid provider representative.
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