Billing for Spine COE reimbursement

(The following information does not apply to PriorityMedicare^SM plans.)

Priority Health will reimburse for the initial evaluation and management (E/M) service performed at a designated Spine Center of Excellence for spine-related problems when these criteria are met:

1. Member is a patient presenting for their initial evaluation service.
2. The E/M code range of 99201-99205 and 99241-99245 is reported based on the documentation within the medical record. 
3. The claim is submitted with one of the diagnosis codes listed in Priority Health medical policy 91531 (link below).
4. The specialist billing the service must be a physiatrist in a practice recognized by Priority Health as a Spine Center of Excellence. 
   

Coding

1. Prior authorization is required for all office visits to orthopedic surgeons or neurosurgeons for spine-related problems.
2. Physiatrists must bill the qualifying E/M code with one of the diagnosis codes for additional reimbursement.  Prior authorization for physiatrist consultations is not required.

Refer to medical policy 91531, Spine Centers of Excellence, for additional coding and policy information associated with these services.