HNS Policy 

Providers are responsible for the accuracy of the information submitted on claim forms, including but not limited to the ICD, CPT, and HCPCS codes reported on the claim forms.

ICD Codes
ALL diagnoses must be recorded in the healthcare record including primary, secondary and any additional diagnoses.

All ICD codes reported to an HNS contracted payor must be properly documented, consistent with the patient's chief complaint/clinical findings and treatment plan, and must support the necessity of services provided.

ICD codes reported on insurance claims must be consistent with HNS and HNS Payor Policies, the policies of applicable licensing boards, as well as state and federal laws.

Providers must use the most accurate and appropriate ICD code for services reported on an insurance claim.

The ICD-10 section of the HNS Website has helpful information regarding ICD-10 coding.

CPT Codes
Providers must assure the CPT codes reported on the insurance claim accurately reflect the services provided, are the most appropriate CPTs for the services provided, and that those services are properly documented in the healthcare record.

Only CPT codes that reflect services that are medically necessary, consistent with the patient's chief complaint/clinical findings, diagnoses, and treatment plan should be reported on claims filed through HNS.

CPT codes reported on insurance claims filed through HNS must be consistent with HNS and HNS Payor Policies, the policies of applicable licensing boards, as well as state and federal laws.

Providers must use the most appropriate CPT code for services reported on an insurance claim.

HCPCS Codes
HNS providers must report the most appropriate HCPCS code on all insurance claims filed through HNS.

HCPCS codes should only be billed to an HNS contracted payor if the service is medically necessary, consistent with the patient's chief complaint/clinical findings, diagnoses, and treatment plan. (Exception: Maintenance care. When maintenance care is covered, it must be billed using S8990.)

HCPCS codes can only be billed to an HNS contracted payor if the service is consistent with HNS and HNS Payor Policies, the policies of applicable state licensing boards, and state and federal laws.

All DME provided must be documented in the healthcare record.

Documentation in the healthcare record must include the specific DME recommended, the date the DME was ordered, and the date the DME was delivered to the patient. Proof of purchase of the DME, unless rented, must be available upon request if requested by a contracted payor of HNS. Rental agreements for DME must be available upon request if requested by a contracted payor of HNS.

Documentation in the healthcare record should include all instructions given to the patient regarding the use of any DME. If written standards are maintained for DME that include specific instructions, reference to the written standard is acceptable.

If written standards for DME are utilized, they should include the following statements: 

• The need for any DME billed to a payor is consistent with the patient's chief complaint/clinical findings, diagnoses, and treatment plan.

• The patient's healthcare record clearly establishes the medical necessity for any DME billed to the payor.

For all CPT and HCPCS codes reported on a healthcare claim, providers must assure the accuracy of the number of units reported. The number of units reported must be supported by appropriate documentation in the healthcare record.

Many HCPCS codes are not covered by HNS contracted payors. In addition to verifying benefits, please check the applicable payor corporate medical policy and/or contact your HNS Service Representative if you have questions or need assistance.

Modifiers
When applicable, providers must use appropriate modifiers when reporting and billing chiropractic services to an HNS contracted payor.

The use and/or need for the modifier must be supported by appropriate documentation in the healthcare record.

For information regarding GP and 59 modifiers required as a result of NCCI edits, please click here, or review the information regarding the CPT codes impacted by these edits on this website.