This policy provides information about the billing and reimbursement of performance measurement codes.
Coding & Billing Guidelines
Performance measurement codes are developed from the American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) to decrease the need for record abstraction and chart review, minimizing the administrative burden on physicians, other health care professionals, hospitals and entities seeking to measure the quality of patient care.
These codes are to facilitate data collection about the quality of care delivered by coding certain services and test results that support nationally established performance measures, and that have an evidence base on contributing to quality patient care.
CMS has assigned these services a Physician Fee Schedule status indicator of “M” (Measurement codes used for reporting purposes only). These codes are used to aid with identifying performance measurement values. There are no Relative Value Units (RVUs) and no payment amounts for these codes. These codes should be reported with a one-dollar amount but will not be reimbursed.
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
American Medical Association Category II Codes