CommercialMay 31, 2023
Correction: Federal Employee Program® Quality Reimbursement program update
In April 2023, the Provider News newsletter contained this article, explaining the program and the revisions that have taken effect on May 12, 2023. A revision that was missed in the communication was Medicare primary members are not included in the program, and the $10 reimbursement for these CPT® category II codes will not be applicable.
The Federal Employee Program® (FEP) rolled out the Quality Reimbursement program for providers in April 2022, where coding for CPT category II codes for A1c results, blood pressure readings, and the first prenatal visit are reimbursed at $10 per code.
Over the past year, the program has been a success in improving HEDIS® scores and reducing administrative burden. Effective May 12, 2023, the FEP Quality Reimbursement program for PPO providers will undergo the revisions listed below.
Revisions to CPT category II code requirements for $10 reimbursement:
- Only professional CMS-1500 billing providers
- Only these six places of service (POS) codes are applicable:
- 02: telehealth not home
- 10: telehealth home
- 11: office
- 12: home
- 17: walk in clinic
- 20: urgent care
- Only a specific diagnosis code that coordinates with the applicable CPT category II code
Submitting the claim:
- Submit the CPT category II code in field 24 of the CMS-1500 and a charge of $10.
- Use the applicable CPT category II code, place of service code, and diagnosis code according to the information below.
Blood pressure — systolic and diastolic readings:
- Reimbursable ICD-10-CM diagnosis codes: I10, I11.9, I12.9, I13.10, I15, I15.1, I15.8, I15.9, I16.0, I16.1, I16.9
- CPT category II codes:
- 3074F: Most recent systolic blood pressure less than 130 mm Hg
- 3075F: Most recent systolic blood pressure 130 to 139 mm Hg
- 3077F: Most recent systolic blood pressure greater than or equal to 140 mm Hg
- 3078F: Most recent diastolic blood pressure less than 80 mm Hg
- 3079F: Most recent diastolic blood pressure 80 to 89 mm Hg
- 3080F: Most recent diastolic blood pressure greater than or equal to 90 mm Hg
Hemoglobin A1c:
- Reimbursable ICD-10-CM diagnosis codes: E10.8, E10.9, E11.8, E11.9
- CPT category II codes:
- 3044F: Most recent hemoglobin A1c (HbA1c) level less than 7.0%
- 3046F: Most recent hemoglobin A1c (HbA1c) level greater than 9.0%
- 3051F: Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0%
- 3052F: Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0%
First prenatal visit — The first prenatal visit date of service must be on the claim (field 24A, CMS-1500) with the appropriate code:
- Reimbursable ICD-10-CM diagnosis codes: maternity related diagnosis code
- CPT category II codes:
- 0500F: Initial prenatal care visit (report at first prenatal encounter with health care professional providing obstetrical care. Report also date of visit, and in a separate field, the date of the last menstrual period LMP) (Prenatal)
- 0501F: Prenatal flow sheet documented in medical record by first prenatal visit (documentation includes at minimum blood pressure, weight, urine protein, uterine size, fetal heart tones, and estimated date of delivery). Report also: date of visit and, in a separate field, the date of the last menstrual period LMP (Note: If reporting 0501F Prenatal flow sheet, it is not necessary to report 0500F Initial prenatal care visit) (Prenatal)
For additional information about the FEP Quality Reimbursement program, email us at FEPproviderGIC@anthem.com.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
MULTI-BCBS-CM-024791-23
PUBLICATIONS: June 2023 Provider Newsletter
To view this article online:
Or scan this QR code with your phone