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Coding Corner: “Initial” vs. “subsequent” vs. “sequela” in ICD-10-CM coding

July 15, 2021


United Healthcare (UHC) has delayed implementation of its Designated Diagnostic Provider (DDP) program for laboratory services in California. Previously scheduled to begin July 1, 2021, the DDP program is now tentatively scheduled to be implemented on January 1, 2022, pending regulatory approval. The program will create a tiered network for laboratory services for its fully insured commercial lines of business and will limit outpatient laboratory service coverage to only Designated Diagnostic Provider labs, which are freestanding or hospital outpatient labs that have met certain quality and efficiency requirements.

The delay follows questions raised by the California Medical Association (CMA) and other stakeholders regarding implementation of the DDP program, including concerns with how physicians and patients will identify DDP labs in the UHC provider directory, confusion identifying patients with coverage limited to DDP laboratories, potential concerns with timely access to lab services for UHC enrollees and increased patient out-of-pocket costs when they mistakenly receive services from an out-of-network lab provider.

Citing the need to reduce outpatient diagnostic laboratory costs, UHC had planned to implement DDP as part of its new patient benefit designs for 2021, pending state regulatory approval. Originally, the DDP program would have required patients under these new benefit designs to only access DDPs for outpatient diagnostic lab services.  Patients who utilized any other provider would have had services denied as non-covered and could be held financially liable for the charges. UHC has, however, recently altered the program to now cover patients for outpatient diagnostic lab services at a lower cost share when delivered by a DDP with patients paying a greater cost share for care rendered by non-DDPs.

Once implemented, the DDP benefit designs will not apply to lab services rendered as part of inpatient admissions, emergency room visits or outpatient surgery pre-operation testing that is billed as part of a global surgical package.

UHC plans to expand the DDP benefit designs and limited provider network to major radiology services (MR, CT, PET/Nuclear Medicine) beginning January 1, 2022.  However, UHC has advised that the delay for laboratory services will likely impact the implementation timeline for radiology services as well.

Providers with questions or concerns regarding the DDP program can email United Healthcare at ddp_lab@uhc.com. For more information on the DDP program, see UHC’s Frequency Asked Questions or visit uhcprovider.com . 

To see a map of the current status of the DDP rollout, click here.

 

 

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