Tufts Health Plan sets frequency limits on certain procedures based on medical necessity. The following are policies that fall within frequency limitations.
Colorectal Screening
In accordance with CMS4, Tufts Health Plan will not compensate for:
** Fecal occult blood tests (82270, 82274) more than once every 12 months for patients over the age of 50.
** A sigmoidoscopy or barium enema more than once within 48 months.
** A colonoscopy or a barium enema on individuals at high risk more than once within 23 months.
** A diagnostic, non-high risk colonoscopy more than once within a 10-year period unless a colorectal cancer screening; sigmoidoscopy has been billed in the previous 4 years.
Effective for dates of service on or after October 1, 2015, Tufts Health Plan will limit coverage of colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 AND BMP3) to one visit within three (3) years, consistent with clinical guidelines
Mutually Exclusive
National Correct Coding Initiative (CCI) has identified procedures that are considered mutually exclusive. Mutually exclusive procedures are those procedures that cannot be reasonably performed in the same operative session. When the same provider bills mutually exclusive procedures for the same date of service, then the procedure with the lowest allowed amount is compensated.