Oxford Billing: Time Span CPT Codes 93268, 93272, 94005 Explained

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Oxford Billing: Time Span CPT Codes 93268, 93272, 94005 Explained

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Introduction to Time Span CPT Billing with Oxford

For medical billers, coders, and healthcare providers working with Oxford plans, understanding payer-specific guidelines for **time-based CPT billing** is critical for accurate reimbursement. This comprehensive guide delves into Oxford’s specific time span code billing guidelines, focusing on CPT codes 93268, 93272, and 94005, along with other relevant time-based services like CPT 95250 and End-Stage Renal Disease (ESRD) codes (90951-90962). We’ll clarify Oxford’s **reimbursement policy**, **CPT code frequency guidelines**, and address common billing scenarios to help ensure compliant and successful claims. While these guidelines are based on Oxford’s interpretation, it’s essential to remember that policies can vary significantly between payers. Always verify specific reimbursement rules with other insurance providers.

What Are Time Span CPT Codes?

A Time Span Code is a CPT or HCPCS code that specifies a time period for which it should be reported (e.g., weekly, monthly). In medical billing, these codes represent services that are typically provided over a defined period, rather than a single encounter. Accurate **time-based CPT billing** is crucial for appropriate payment, as payers like Oxford have strict **CPT code frequency guidelines** for these services to prevent duplicate billing and ensure medical necessity.

Oxford’s General Reimbursement Policy for Time Span Codes

Oxford will reimburse a CPT or HCPCS Level II code that specifies a time period for which it should be reported (e.g., weekly, monthly), once during that time period. The designated time period is primarily determined by information sourced from the **American Medical Association (AMA)** or **Centers for Medicare & Medicaid Services (CMS)**, including: the CPT or HCPCS code description, CPT book parentheticals, and other coding guidance found in AMA or CMS publications. For services that may be repeated following a month with fewer than 31 days, Oxford may allow reimbursement of monthly time span codes when these codes are reported with dates of service at least 28 days apart.

CPT coding guidelines emphasize that physicians or other qualified healthcare professionals must select the procedure or service name that accurately identifies the services performed.

CPT Code 95250: Continuous Glucose Monitoring CPT Billing

CPT code 95250 specifically describes “Ambulatory continuous glucose monitoring of interstitial tissue fluid via subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording.” For this service, the CPT book provides crucial parenthetical instructions stating, “Do not report 95250 more than once per month.”

Following this guidance, Oxford’s **continuous glucose monitoring CPT** policy limits reimbursement for CPT Code 95250 to only once per month for the same member, when services are provided by the Same Group Physician and/or Other Health Care Professional. To accommodate months with fewer than 31 days, Oxford’s **CPT code frequency guidelines** for CPT 95250 specifically allow for reimbursement when these services are reported with dates of service at least 28 days apart.

Billing Scenario Example for CPT 95250:

  • A patient receives continuous glucose monitoring (CPT 95250) on January 15th. The earliest Oxford would consider reimbursement for the next service for the same patient by the same group would be February 12th (28 days later).
  • If CPT 95250 is performed on February 5th (assuming February has 28 days in a non-leap year), the next allowable date of service would be March 5th (28 days later). This ensures compliance with the “once per month” rule while accommodating shorter months.

End-Stage Renal Disease (ESRD) Services: CPT Codes 90951-90962

The ESRD CPT codes (90951-90962) are structured based on the patient’s age and the number of face-to-face physician or other qualified healthcare professional visits provided per month (e.g., 1, 2-3, or 4 or more visits). Oxford’s **ESRD billing rules** state that only the single most comprehensive outpatient ESRD code submitted per age category will be reimbursed once per month. The age categories are: under 2 years of age, 2-11 years of age, 11-19 years of age, and 20 years of age and older.

This approach aligns with **AMA CPT coding guidance**, which specifies that age-specific ESRD codes should be reported once per month for all physician or other healthcare professional face-to-face outpatient services. It’s crucial for billers to ensure the most appropriate and comprehensive code is selected to avoid denials under **Oxford reimbursement policy**.

Billing Scenario Example for ESRD Codes:

  • A 45-year-old patient receives 4 physician visits for ESRD services in April. The appropriate CPT code (e.g., 90962 for 20 years and older, 4+ visits) is billed. Oxford will only reimburse this single comprehensive code for April.
  • If a less comprehensive ESRD code for the same patient and month is submitted by the same group, it will be denied as inclusive to the more comprehensive service already billed.

Comprehensive vs. Component Time Span Codes: Focus on CPT 93268, 93272

When related time span codes that share a common portion of a code description are both reported during the same time span period by the Same Group Physician and/or Other Health Care Professional for the same patient, Oxford’s policy is to reimburse only the code with the most comprehensive description. The other code is considered inclusive and will not be reimbursed as a separately billable service. It is important to note that **no modifiers will override this denial** for these specific scenarios under Oxford’s **CPT code frequency guidelines**.

This rule specifically applies to a common set of codes for external electrocardiographic rhythm derived event recording: CPT code 93268 (the comprehensive code) and its component codes 93270, 93271, and 93272. CPT code 93268 is defined as: “External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; includes transmission, physician review and interpretation.” The related components are:

  • 93270: Recording (includes connection, recording, and disconnection)
  • 93271: Transmission and analysis
  • 93272: Review and interpretation by a physician or other qualified health care professional

When CPT code 93270, 93271, or 93272 are reported alongside CPT 93268 within the same 30-day period by the Same Group Physician and/or Other Health Care Professional for the same patient, only CPT code 93268 is the reimbursable service. The individual component codes will be denied as inclusive.

Billing Scenario Example for CPT 93268 and 93272:

  • A patient receives a 30-day external event recording service, and the full comprehensive service (93268) is billed. If, within that same 30-day period, the physician also attempts to bill separately for the review and interpretation (93272), Oxford will only reimburse for 93268. CPT 93272 will be denied as inclusive.
  • This rule applies even if different modifiers (e.g., 59, 76) are appended to the component codes; Oxford’s policy specifically states these modifiers will not override the denial in this context.

CPT Code 94005: Home Ventilator Management Care Plan Oversight

CPT code 94005 refers to “home ventilator management care plan oversight of a patient (patient not present) in home, domiciliary or rest home (e.g., assisted living) requiring review of status, review of laboratories and other studies and revision of orders and respiratory care plan (as appropriate), within a calendar month, 30 minutes or more.”

Oxford defines “Calendar Month” as the time span referring to an individually named month of the year (e.g., January, February). For CPT 94005, reimbursement is permitted once per calendar month.

Billing Scenario Example for CPT 94005:

  • A Same Group Physician and/or Other Health Care Professional bills CPT code 94005 for a patient on March 13th. They then bill the same code for the same patient on April 5th. Both claims are considered eligible for reimbursement because the services were provided in different calendar months.
  • If the same group were to submit CPT 94005 for the same patient on March 25th after billing it on March 13th, the second claim would be denied as it falls within the same calendar month.

Key Definitions for Oxford Reimbursement

To ensure clarity and compliance with Oxford’s **reimbursement policy**, the following definitions are important:

  • Calendar Month: Oxford defines Calendar Month as the time span referring to an individually named month of the year, (e.g., January, February) and includes codes with Calendar Month in their description.
  • Same Group Physician and/or Other Health Care Professional: All physicians and/or other health care professionals of the same group reporting the same Federal Tax Identification number.
  • Time Span Code: A CPT or HCPCS code that specifies a time period for which it should be reported (e.g., weekly, monthly).

Practical Billing Scenarios and Frequently Asked Questions (FAQs)

This section addresses common questions medical billers and coders might have regarding **Oxford reimbursement policy** for time span codes.

Q1: How does Oxford determine the “time span” for codes with a description of calendar month, per month, or monthly?

A: The date of service (DOS) is the primary reference point for determining the frequency of code submission and subsequent reimbursement during that period. As noted, Oxford generally adheres to a “once per month” rule, but for services that may be repeated following a month with fewer than 31 days, Oxford may allow reimbursement of monthly time span codes when these codes are reported with dates of service at least 28 days apart.

Example (Per Month/Monthly): HCPCS code A4595 [Electrical stimulator supplies, 2 lead, per month, (e.g., TENS, NMES)] is submitted August 31st. The Same Group Physician and/or Other Health Care Professional reports this code for the same patient on September 30th. Both codes are considered eligible for reimbursement as the services are in different monthly periods or satisfy the 28-day rule.

Q2: Does Oxford recognize modifiers (e.g., 59, 76) through the Time Span Codes Policy to allow reimbursement for additional submissions of a code within the designated time span?

A: No. As a general rule, reimbursement for codes included in Oxford’s Time Span Codes Policy is strictly based on the time span parameter specified in the code description, CPT book parentheticals, and/or other coding guidance from the AMA or CMS. Oxford’s policy explicitly states that modifiers will not override denials for services billed within the restricted time span.

Q3: What documentation is required to support time-span billing?

A: Comprehensive and clear documentation is always crucial. For time-span codes, ensure the patient’s medical record clearly indicates the start and end dates of the service period, the services provided during that period, and medical necessity. For codes like 95250, documentation of sensor placement, removal, training, and data printouts is essential. For oversight codes like 94005, the documentation should reflect the 30 minutes or more of physician effort, including review of status, lab results, and revisions to the care plan. Specific requirements for each CPT code and service should be carefully reviewed with Oxford’s guidelines.

Q4: How are emergency or unexpected repeat services handled under time span code rules?

A: Oxford’s general policy regarding time span codes typically enforces strict frequency limits, and exceptions for “emergency” or “unexpected repeat services” are generally not recognized through the use of modifiers to override these limits. If an urgent, medically necessary repeat service is required within a period that would normally lead to a denial, providers should consult Oxford directly for specific guidance on how to bill such rare occurrences. Such scenarios often require specific authorization or appeal processes rather than standard modifier application.

Important Disclaimer: Verify Latest Policies

The information provided in this article is for general informational purposes only and is based on our understanding of Oxford’s policies. While we strive for accuracy, payer policies, especially **Oxford reimbursement policy**, frequently change. It is always the responsibility of the medical biller, coder, and healthcare provider to verify the most current reimbursement policies directly with Oxford and other payers for all mentioned CPT codes before submitting claims. You can typically find the most up-to-date guidelines on Oxford’s official provider website or by contacting their provider services.


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