Claims Corner — Fee Schedule

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AMA terminology for diagnostic and procedure codes

Consult Codes Removed From Fee Schedule Effective November 1, 2010 2/13/12
Fair Health Replaces HIAA/Ingenix in 2011 2/07/11
Changes to the In-Office Testing List for CompreHealth, HIP and Vytra Plans 10/28/10
GHI Converts to Average Sales Price for Drugs Administered in Your Office

Consult Codes Removed From Fee Schedule Effective November 1, 2010

(HIP/Vytra/CompreHealth Plans)

To be consistent with Centers for Medicare & Medicaid Services guidelines, consultation codes are no longer reimbursable and have been removed from our prevailing plan fee schedule as of November 1, 2010. This change applies to all providers who received a notice, contract amendment, or both on or after July 2010. You may use Office Visit and Hospital Care codes, if applicable, to bill for your services instead of the removed consult codes. The affected consult codes are:

  • 99241 - 99245
  • 99251 - 99255

FAIR Health Replaces HIAA/Ingenix in 2011

In 2011, FAIR Health will replace HIAA/Ingenix or similar language in our Prevailing Provider Fee Schedules, where documented in our provider agreements. In addition, our members have been notified that the FAIR Health database will replace the HIAA/Ingenix database for the purpose of calculating out-of-network claims.

To learn more about FAIR Health, please visit their Web site. We published on our Web site an explanation of FAIR Health for our members to help them understand in plain language what FAIR Health means for them. We invite you to review this explanation as well.

Changes to the In-Office Testing List for CompreHealth, HIP and Vytra Plans

(Applies to CompreHealth, HIP and Vytra benefit plans.)

The In-Office Testing List, as published in the EmblemHealth Provider Manual, has been updated to allow certain in-office tests to be performed by additional types of specialists. It also includes an additional test that all practitioners may perform.

These changes are effective November 1, 2010, and are noted in bold in the list excerpt below:

Excerpt from: In-Office Testing List - CompreHealth/HIP/Vytra Effective November 1, 2010
80100Drug screen; multiplePain Medicine, Addiction Medicine
80101Drug screen; single Pain Medicine, Addiction Medicine
86485Skin test; candidaInfectious Disease, Allergy/Immunology
86702-QWOraQuick rapid HIV-2 antibody test
86735Antibody; mumpsInfectious Disease, Allergy/Immunology

*Please note: Most of the codes on the In-Office Testing List may be performed by all practitioners. However, some codes may only be performed by practitioners in the specialty type(s) listed within the “Specialty” column of the table.

Effective November 1, 2010 the following CPT-4 code will be added to the In-Office Testing List and may be performed by all specialty types:

86702-QW: OraQuick rapid HIV-2 Antibody Test

GHI Is Converting to Average Sales Price for Drugs Administered in Your Office


Effective December 31, 2009, GHI will begin reimbursing practitioners at a rate of approximately 13 percent over the average sales price (ASP). In addition, for many generic or branded equivalents, maximum allowable cost (MAC) reimbursement pricing will be employed and will generally pay more than 30 percent over the ASP for these products.

As generic or branded equivalents are made available for any particular injectable product and the acquisition costs for such products decrease, MAC pricing will adjust reimbursement to reflect changes in market pricing.

GHI's MAC methodology will apply to generics and therapeutic classes such as antiemetics, LHRH (luteinizing hormone-releasing hormone) agonists and certain chemotherapies. Quarterly updates will apply MAC pricing to additional therapeutic classes as new generics and therapeutic equivalents become available. Based on today's availability of generic and therapeutic equivalents, the MAC pricing changes will apply to the following HCPCS codes:

J0640 J1568 J2430 J9045 J9170 J9217
J1260 J1569 J2469 J9060 J9181 J9264
J1459 J1572 J3487 J9062 J9190 J9265
J1561 J1626 J9000 J9130 J9202 J9390
J1566 J2405 J9040 J9140 J9206

Should you have any questions related to this fee schedule change, please e-mail us at mdq&adownstate@emblemhealth.comm if your practice is in New York City, Nassau, Rockland, Suffolk or Westchester counties. All other practices with questions may e-mail us at mdq&

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