Anthem is broadening its moderate sedation reimbursement policy changes to additional states, with Maine set to see the updates take effect Aug. 1, according to a May 1 notice posted on the payer’s website.
Under the new policy, Anthem will no longer reimburse facilities separately for moderate sedation services. Instead, those services will be reimbursed only as part of the primary procedure or overall facility fee. Anthem cited instances of facilities billing separately for services already included in the primary procedure reimbursement, which can allegedly result in duplicate payments and higher out-of-pocket costs for members.
Facilities will be subject to three new billing requirements:
- Separate reimbursement will not be allowed for recovery room services (revenue code 0710) when billed alongside moderate sedation.
- Moderate sedation codes will not be reimbursed when reported on a UB-04 claim form.
- Anesthesia revenue codes 037X must be billed with a HCPCS/CPT code when submitted with radiology or diagnostic revenue codes.
The insurer said the change is consistent with CMS outpatient prospective payment system methodology and is intended to eliminate duplicate payments for services already included in the primary procedure reimbursement. Anthem previously announced the same policy update, effective July 1, for Georgia, Indiana, Missouri, Nevada, New Hampshire and Ohio.
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