January 2025 Provider Pulse

178 New CCN SEOCs Implemented January 15

The Department of Veterans Affairs (VA) continues to demonstrate its commitment to providing industry-leading care by identifying opportunities to ensure better clinical outcomes under the Community Care Network (CCN).

Following a comprehensive analysis of the available Standardized Episodes of Care (SEOC), VA has 178 new or updated SEOCs underway as part of a nationwide rollout.

VA created the SEOC model to authorize procedures to ensure Veterans receive-care that meets their needs.

For a list of current SEOCs and their billing codes visit VA’s Community Care web page, then press “ACCEPT”. For clarification, contact TriWest at 877-CCN-TRIW (226-8749).

Please note: These updates do not impact Veterans’ eligibility for community care. Veterans can still choose their own care options at a VA facility, from a community provider, or by using one of VA’s virtual care options. These changes will also not impact any SEOC currently in effect as part of a Veteran’s treatment plan.

Learn More about VA Clinical Determinations and Indications

Clinical Determinations and Indications (CDIs) define clinical criteria and parameters to help you determine whether a service is medically necessary for a Veteran receiving community care. These guidelines ensure community providers deliver care that is both evidence-based and appropriate for the Veteran’s needs. Referencing CDIs before providing care will help VA process requests faster. Also, in a change from previous policy, VA may use CDI criteria as a factor in determining the appropriate reimbursement for services.

All current CDIs are available online in the VA CDI library. When you visit the website, accept the user agreement to access the content. After accepting, you will see CDIs listed by categories of care. Bookmark the webpage and check back often for updates. To submit a question about a published CDI, please use the CDI Question Submission Form located at the bottom of the the CDI website.

There are currently 26 published CDIs available online:

• Autologous Chondrocyte Implantation
• Bioimpedance Devices for the Detection of Lymphadema
• Cataract Extraction and Intraocular Lens Implant
• Cryoablation for Malignant Breast Tumors
• Extracorporeal Shock Wave Therapy for Musculoskeletal Condition
• Fecal Microbiota Products for Clostridioides difficile Infections
• Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
• Intranasal Esketamine for Treatment Resistant Depression
• Intravenous Ketamine for Treatment Resistant Depression
• Ketamine for Chronic Pain
• Lutetium-177 (Lu177) PSMA-617, Vipivotide Tetraxetan (Pluvicto)
• Magnetic Resonance-Guided Focused Ultrasound (MRgFUS) Thalamotomy
• Osseoanchored Prostheses for the Rehabilitation of Amputees (OPRA)
• Pneumatic Compression Devices for Lymphedema
• Prostate-Specific Membrane Antigen Positron Emission Tomography Scan for Prostate Cancer
• Proton Beam Therapy
• Sacral Neuromodulation
• Thermal Evacuation Therapy and Intense Pulsed Light Therapy for MGD
• Thread Carpal Tunnel
• Total Artificial Heart
• Transcranial Magnetic Stimulation (TMS)
• Transurethral Water Vapor Thermal Therapy for Lower Urinary Tract Symptoms and Benign Prostatic Hyperplasia
• Transurethral Waterjet Ablation for BPH
• Tumor Treating Fields (TTF) Therapy
• Ultrasound-Guided Radiofrequency Ablation for Symptomatic Uterine Fibroids
• Wearable Cardioverter Defibrillator

For more information on CDIs, please check out the CDI Overview webinar on VHA TRAIN. If you have not already, you will need to create an account to access this webinar.

2025 VA Fee Schedule Now Available

The annual VA Fee Schedule is now published and available on the VA Fee Schedule web page.

The goal of the annual fee schedule is to ensure fair reimbursement for all providers when Medicare maximum allowable rates are not available. VA continues to modernize the reimbursement methodology to ensure maximum allowable VA fee schedule rates are consistent with industry reimbursement benchmarks and ensure that most services have maximum allowable rates.

VA reimburses medical services, hospital care and extended care services up to the maximum allowable rate. The maximum allowable reimbursement rate is generally the applicable Medicare rate published by the Centers for Medicare and Medicaid Services (CMS). When there is no Medicare rate available, VA reimburses the lesser of the VA fee schedule or billed charges. Reimbursement rates are subject to change.

VA CCN Provider Handbook Updates

The following section will be added to the Billing and Claims page and covers billing requirements for Unlisted and Not Otherwise Classified (NOC) Codes.

Billing Requirements for Unlisted and NOC Codes

Unlisted and NOC codes are used when no specific Current Procedural Terminology (CPT)/Healthcare Common Procedural Coding System (HCPCS) code adequately describes the service or procedure rendered. To ensure accurate and timely claims processing for services billed with these codes, providers must adhere to the following requirements:

• Before submitting a claim with an Unlisted or NOC code, ensure that no existing code fits the service provided. Unlisted/NOC Codes should only be used when there is no specific CPT or HCPCS code available.
• Unlisted CPT/HCPCS codes unit value must be reported as one (1). Claims will be rejected if more than one unit is billed.
• When billing an Unlisted CPT or HCPCS code, a short description that supports the service or item provided is required.
• For Unlisted codes, include:
  • Description of the procedure
  • How it was performed
  • Area treated
• For NOC codes, include:
  • Name of drug
  • Strength and dosage
  • Amount wasted
• Upon claim receipt, TriWest may request additional information. Submit documentation that supports the service or item provided. Information requested may include:
  • The name of the service or item
  • Why the service/item is necessary
  • Relevant clinical details to support the item or service such as provider’s time, effort and equipment necessary to provide the service
• Appropriate information must also be included in box 80 of the CMS-1450 or in box 19 of the CMS-1500. Claims will be rejected if there is no description with an Unlisted or NOC code. A description of the services rendered must be billed as follows:

For more information, please see chapter 26 of the Medicare Claims Processing Manual, Billing (NOC) HCPCS Codes, Unlisted code billing and the appropriate use of NOC Codes.