Payment Policies for Professional Claims - CMS-1500
This section contains background information for CMS-1500 billers.
In order to assist you with claim line messages, Wellmark has created a table listing the "I" message and the corresponding "G" message and the 835 ANSI message and Remark Code (where it applies).
Download the iCAP-Messages - #S-2318 .
Inpatient Only Procedures
If a service on the inpatient only list is provided in the outpatient setting, please submit a provider inquiry along with medical record documentation for payment consideration.
Download the Wellmark Inpatient Only List - #S-2317 .
Correct Coding Initiative (CCI)
The Centers for Medicare and Medicaid Services (CMS) developed CCI to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment in professional claims. The coding policies developed are based on coding conventions defined by the American Medical Association's (AMA's) Current Procedural Terminology (CPT) Manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practice and review of current coding practice. Wellmark also recognizes modifiers consistent with CMS' modifier use for CCI. Use of modifiers to bypass CCI criteria will be monitored. Documentation is subject to review.
Visit the CMS Web site for information about the Correct Coding Initiative (CCI) .
Wellmark has adopted the CMS global surgery policies.
Preoperative Services. For major procedures (90-day global period), the surgeon's preoperative services the day before and day of the procedure are included in the global period.
The "decision for surgery" reported with modifier -57 is an exception to the preoperative services rule. Preoperative services performed by someone other than the surgeon are payable separately. Report these services with the appropriate E/M service.
For minor procedures (0 or 10-day global period), the preoperative services performed the same day as the procedure are included in the global period. A significant, separately identifiable service reported with modifier -25 is an exception to the preoperative services rule.
Postoperative services. All postoperative services are included in the global period. To report services for consideration outside the postoperative period, the appropriate modifier must be reported. These include modifier -24 for unrelated E/M services and modifiers -58, -78 or -79 for procedural services.
Splitting the global period. Wellmark recognizes modifiers -54 and -55 for procedures with 90-day global periods. Procedures reported with these modifiers will apply the CMS percentage to Wellmark's Maximum Allowable Fee.
Use of modifiers to bypass global surgery criteria will be monitored. Documentation is subject to review.
Assistant, Team and Co-Surgeon Policies
Wellmark has adopted the CMS assistant, team and co-surgeon requirements.
Maximum Unit Policy
Wellmark has assigned a maximum daily unit to each CPT/HCPCS code. Daily maximum units that have been exceeded can be identified with remittance advice message I512/G12, a denial for maximum daily units or I563/G63, a reduction in maximum daily units. Daily maximum units are guidelines that accommodate most “normal” services. For those services exceeding the maximum daily units, please submit a provider inquiry attaching the medical documentation/order to support the units of service.
Wellmark can process up to four modifiers per claim line. You may request any modifier change using one of the following methods:
- Send an electronic request by selecting the Provider Service e-mail line for your situation.
- Submit a Provider Inquiry form:
- Call a Provider/Customer Service representative.
Claims corrections will appear on your remittance advice as an adjustment to the original claim number so you can easily track and reconcile corrections. We will no longer void the first claim, recoup money, and submit a new claim to correct any modifier adjustments as reported before.
Submitting Medical Records
Do not submit medical records when requesting a claim review if your claim needs a coding change. This includes CPT, HCPCS, ICD-9, modifier or date of service changes. Simply make the necessary change on a corrected claim and attach it to a Provider Inquiry Form for Iowa or South Dakota .