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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

October 2018

Hospital-Based Clinic and Treatment Room Commercial Payment Policy Updates

In a hospital-based clinic setting, Harvard Pilgrim reimburses the physician for the evaluation and management (E&M) services, and any facility charges should be billed under a clinic revenue code in the 051X or 052X series. Payment for clinic services is based on the contracted professional fee rate for the facility; for providers reimbursed for clinic services at a global rate, facility charges are not separately reimbursable. This is reflected in our current commercial Hospital-Based Clinic and Treatment Room payment policies.

Consistent with these policies, effective for dates of service beginning Jan. 1. 2019, Harvard Pilgrim will no longer reimburse E&M codes (CPT 99201-99499, 92002-92004, 92012-92014) when they are billed with any of the following revenue codes:

  • 028X (Oncology) — used to report the treatment of tumors and related diseases, such as chemotherapy
  • 0760, 0761, 0769 (Treatment Room) — used to report a procedure or treatment
  • 0770, 0771 (Preventive Care Services) — used to report preventive screening services, such as screening for glaucoma or screening for a pelvic exam

This change is in keeping with appropriate billing and reimbursement practices indicated by the Uniform Billing Editor, and will help avoid payment retractions that occur when Harvard Pilgrim is billed for the same service for the same patient by both the physician and facility.

For more information, please refer to Harvard Pilgrim’s updated commercial Hospital-Based Clinic Payment Policy and Treatment Room Payment Policy.

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