Reimbursement Policy: Coding Edit Rules

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 1 of 110

Review Date: 8/15/2024

Number: RP20210017

Reimbursement Guideline Disclaimer: EmblemHealth has policies in place that reflect billing or claims payment processes unique to our health

plans. Current billing and claims payment policies apply to all our products, unless otherwise noted. EmblemHealth will inform you of new policies

or changes in policies through updates to the Provider Manual and/or provider news. The information presented in this policy is accurate and

current as of the date of this publication.

The information provided in EmblemHealth’s policies is intended to serve only as a general reference resource for services described and is not

intended to address every aspect of a reimbursement situation. Other factors affecting reimbursement may supplement, modify or, in some cases,

supersede this policy. These factors may include, but are not limited to: legislative mandates, physician or other provider contracts, the member’s

benefit coverage documents and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same

way on the different electronic claims processing systems used by EmblemHealth due to programming or other constraints; however,

EmblemHealth strives to minimize these variations.

EmblemHealth follows coding edits that are based on industry sources, including, but not limited to; CPT® guidelines from the American Medical

Association, specialty organizations, and CMS including NCCI and MUE. In coding scenarios where there appears to be conflicts between sources,

we will apply the edits we determine are appropriate. EmblemHealth uses industry-standard claims editing software products when making

decisions about appropriate claim editing practices. Upon request, we will provide an explanation of how EmblemHealth handles specific coding

issues. If appropriate coding/billing guidelines or current reimbursement policies are not followed, EmblemHealth may deny the claim and/or

recoup claim payment.

Overview:

EmblemHealth utilizes internal and third-party code editing vendors to apply procedure and diagnosis code

editing to professional and outpatient facility claims, including but not limited to, ambulance, DMEPOS

providers and drugs.

The edits may be sourced from the Centers for Medicare and Medicaid Services (CMS), regional carrier

LCDs and Articles, the American Medical Association (AMA) Current Procedural Terminology (CPT®), CPT®

Assistant, HCPCS, ICD-10 publications, the Food and Drug Administration (FDA), National Comprehensive

Cancer Network (NCCN), the American Society of Anesthesiology (ASA) manual, and specialty organizations

i.e. ACOG, ACR, as well as EmblemHealth Reimbursement Policies.

Health Plan Policies are applied based on EmblemHealth’s interpretation of the intent of the use of the

procedure code(s). The edits are to ensure accuracy of claims data, to be HIPAA compliant, to address

potential Fraud, Waste and Abuse, and to ensure accurate and fair reimbursement for members and

providers.

Code editing applies to all claims for a member. This includes claims submitted by the same provider in

the same provider Tax ID group, or different provider in another group for the same or different date of

service depending on the edit.

REVISION HISTORY

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 2 of 110

Coding Edits:

Claim Type: Facility (F), Professional (P)

Claim Type

Medical Policy

Rule Description

Effective Date

Add-on Code Policy

Codes designated as "Add-on" codes are not payable

with modifier -51.

1/01/2018

F, P

Add-on Code Policy

Add-on codes are not payable when the primary code is

absent or has been denied for other reasons.

1/01/2018

Add-on Code Policy

Procedure codes billed with modifier 51 are not payable

when submitted with an add-on procedure code.

1/01/2018

Allergy Testing

CPT code 86003 (Allergen specific IgE) is limited to 30

units within a five-year period when billed by any

provider.

9/15/2021

F, P

Allergy Testing

CPT code 86003 (Allergen specific IgE) is limited to 30

units per year when billed by any provider.

1/01/2018-

Terminated

effective

2/28/2023

Updated to include

Facility (HMOC &

HMOMR) effective

11/16/2021

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

F, P

Allergy Testing

CPT code 86003 (Allergen specific IgE) is limited to 40

units per year when billed by any provider.

3/1/2023

Allergy Testing

CPT codes 95024, 95027, 95028 (Intradermal tests with

allergenic extracts) or 95044 (Patch tests) are limited to

40 units in a five-year period when billed by any

provider.

9/15/2021

Allergy Testing

CPT codes 95004 (Percutaneous tests) or 95017-95018

(Allergy testing) are limited to 60 units in a five-year

period when billed by any provider.

9/15/2021

F, P

Allergy Testing

Limit allergy studies (95004, 95017, 95018, 95024,

95027) to 137 units within one year.

3/1/2023

F, P

Allergy Testing

Limit 95165 (Professional services for the supervision of

preparation and provision of antigens for allergen

3/1/2023

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 3 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

immunotherapy; single or multiple antigens) to 137

units per year when billed by any provider.

Ambulance Policy

Additional ambulance services and supplies billed with

modifier QL are not payable.

1/01/2018

F, P

Ambulance Policy

Ambulance services for deceased patients must be

reported at the basic life support level.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Ambulance Policy

Ambulance services billed without an origin modifier

combined with a destination modifier are not payable.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Ambulance Policy

Ambulance transport services not billed in Place of

Service 41 or 42 are not payable.

1/01/2018

Ambulance Policy

Ambulance services submitted with non-covered origin

and destination modifiers are not payable.

1/01/2018

Ambulance Policy

Ambulance mileage (or ambulance mileage when

reported with response and treatment only) is not

payable when an ambulance transport code has not

been billed for the same date of service or has been

denied by another policy.

1/01/2018

F, P

Ambulance Policy

Emergency ambulance services (HCPCS codes A0427,

A0429, A0433) are not payable when billed and the

destination modifier is not H (Hospital), I (Site of transfer

[e.g. airport or helicopter pad] between modes of

ambulance transport), or X (Intermediate stop at

physician's office on way to hospital [destination code

only]).

2/26/2019

Ambulance Policy

Additional ambulance services and supplies are not

payable when billed with modifier QL.

1/01/2018

F, P

Ambulance Policy

Ambulance services are not payable when billed without

an origin modifier combined with a destination modifier.

1/01/2018

Ambulance Policy

Ambulance transport services are not payable if billed

without Place of Service 41 or 42.

1/01/2018

Ambulance Policy

Certain ambulance services are not payable when

submitted with non-covered origin and destination

modifiers.

1/01/2018

Ambulatory Surgical Center

(ASC) Policy

Professional services are not payable when billed with

modifier SG.

1/01/2018

Anesthesia Crosswalk -

Without Anesthesia

procedure code

Identifies claim lines submitted by anesthesiologists for

non-anesthesia Procedure Codes that are not eligible to

be cross walked to an anesthesia Procedure Code.

1/01/2018

Anesthesia Crosswalk -

Without Anesthesia

procedure code

Identifies claim lines submitted by anesthesiologists for

non-anesthesia services that have a one-to-many

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

relationship with anesthesia services. These services

need to be reviewed to

determine the appropriate anesthesia Procedure Code.

Anesthesia Policy

Surgical codes billed by anesthesiologists or CRNAs are

not payable unless crosswalk the surgical procedure

code to the anesthesia service code. Exception: Surgery

codes listed in the ASA Manual.

1/01/2018

Anesthesia Policy

Reimbursement and frequency for multiple general

anesthesia service codes (00100-01999) are limited to

the code with the highest submitted charge amount

when billed with anesthesia modifier QX or QZ (CRNA

services)

1/01/2018

Anesthesia Policy

Reimbursement and frequency for multiple general

anesthesia service codes (00100-01999) when billed

with Revenue Code 0964 (CRNA) to the code with the

highest submitted charge amount.

1/01/2018

F, P

Anesthesia Policy

Anesthesia services (00100-01999) billed by a CRNA

without the appropriate CRNA modifier (QX, or QZ) are

not payable.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Anesthesia Policy

Anesthesiologist's claims billed without medical

supervision/direction modifiers are not payable if a

CRNA claim with medical direction exists.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Anesthesia Policy

Reimbursement and frequency for multiple general

anesthesia service codes (00100-01999) billed for the

same day is limited to the code with the highest

submitted charge amount.

1/01/2018

Anesthesia Policy

CRNA services billed with modifier QX or QZ are not

payable when an anesthesia service performed

personally by an anesthesiologist (Modifier AA) has been

billed for the same date of service.

1/01/2018

Anesthesia Policy

An anesthesiologist's claim billed with modifier AA is not

payable when a CRNA service billed with modifier QX or

QZ has been previously paid for the same date of

service.

1/01/2018

Anesthesia Policy

CPT 00100-01999 (Anesthesia services) are not payable

if billed without an appropriate modifier.

1/01/2018

F, P

Anesthesia Policy

Daily hospital management of epidural or subarachnoid

continuous drug administration (01996) is not payable

when billed with anesthesia qualifying circumstance

codes (99100-99140) and billed without an anesthesia

procedure code (00100-01992, 01999).

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Anesthesia Policy

Daily hospital management of epidural or subarachnoid

continuous drug administration (01996) is not payable

when billed with physical status modifiers P1-P6.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 5 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Anesthesia Policy

Anesthesia and moderate sedation services (00300,

00400, 00600, 01935-01936, 01991-01992, 99152-

99153, 99156-99157) when billed with pain

management services, are payable only when billed and

a surgical procedure (CPT 10021-69990) has been billed

by any provider for a patient age 18 or older.

1/01/2018

Updated to include

CNY effective

8/01/2022

Anesthesia Policy

Reimbursement and frequency for multiple general

anesthesia service codes (CPT codes 00100-01999) billed

for the same day will be limited to the code with the

highest submitted charge amount.

1/1/2018

Anesthesia Policy

Any anesthesia code that is billed with multiple

anesthesia modifiers on the same claim line is not

payable.

1/01/2018

Anesthesia Policy

Reimbursement and frequency for multiple general

anesthesia service codes (CPT code 00100-01999) will be

limited to the code with the highest submitted charge

amount when billed with anesthesia modifier QX or QZ

(CRNA services).

1/01/2018

Anesthesia Policy

Reimbursement and frequency for multiple general

anesthesia service codes (CPT codes 00100-01999) will

be limited when billed with Revenue Code 0964 (CRNA)

to the code with the highest submitted charge amount.

1/01/2018

Anesthesia Policy

Anesthesia services (CPT codes 00100-01999) are not

payable when billed by a CRNA without the appropriate

CRNA modifiers (QX, or QZ).

1/01/2018

F, P

Anesthesia Policy

Diagnostic and therapeutic epidural or subarachnoid

injections (CPT codes 62320-62327) to eight times per

region in a year.

1/01/2018

Updated to include

PPOC effective

8/01/2022

Anesthesia Policy

Anesthesiologist claims without medical

supervision/direction modifiers are not payable if a

CRNA claim with medical direction exists.

1/01/2018

Anesthesia Policy

Reimbursement and frequency for multiple general

anesthesia service codes (CPT codes 00100-01999) are

limited to the billed for the same day to the code with

the highest submitted charge amount.

1/01/2018

Assistant Surgeon Policy

CPT 59510 (Global obstetrical care, Cesarean delivery) is

not payable when billed with an assistant surgeon

modifier.

1/01/2018

Assistant Surgeon Policy

CPT 59618 (Global obstetrical care, Cesarean delivery,

following failed VBAC) is not payable when billed with an

assistant surgeon modifier.

1/01/2018

Assistant Surgeon Policy

CPT 59622 (Cesarean delivery only, following failed

VBAC, including postpartum care) is not payable when

billed with an assistant surgeon modifier.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Assistant Surgeon Policy

CPT 59515 (Cesarean delivery only, including

postpartum care) is not payable when billed with an

assistant surgeon modifier.

1/01/2018

Assistant Surgeon Policy

Only one assistant surgeon is allowed for a surgical

procedure.

1/01/2018

Assistant Surgeon Policy

Assistant surgeon services are payable only when the

code allows an assistant in accordance with CMS.

1/01/2018

Assistant Surgeon Policy

Clinical documentation is required for Assistant surgeon

services in accordance with CMS.

1/01/2018

Assistant Surgeon Policy

Procedure codes billed as assistant surgeon are not

payable when the codes are designated as codes to

which the concept of Assistant Surgeon Does Not Apply.

(CMS)

1/01/2018

Assistant Surgeon Policy

Primary surgeons that also bill for assistant surgeon

under the same provider ID are not payable.

1/01/2018

Assistant Surgeon Policy

Services billed for assistant surgeon when the codes are

designated as Assistant Surgeons Payment Restriction

May Apply (CMS assistant surgeon indicator "2") and the

bill type is 0850-085Z (Critical access hospital) and the

revenue code is 0960-0989 (Professional fee).

1/01/2018

Updated to include

CNY, PPOC &

PPOMR effective

8/01/2022

Assistant Surgeon Policy

Services billed for an assistant surgeon are not payable

when the codes are designated as Assistant Surgeon Not

Allowed (CMS assistant surgeon indicator "1") and the

bill type is 0850-085Z (Critical Access Hospital) and the

revenue code is 0960-0989.

1/01/2018

Assistant Surgeon Policy

Services billed for an assistant surgeon are not payable

when the codes are designated as Assistant Surgeon Not

Allowed (CMS assistant surgeon indicator "9") and the

bill type is 0850-085Z (Critical Access Hospital) and the

revenue code is 0960-0989.

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Assistant Surgeon Policy

Global obstetrical care, Cesarean delivery procedures

are not payable when billed with an assistant surgeon

modifier.

1/01/2018

Assistant Surgeon Policy

Global obstetrical care, Cesarean delivery, following

failed VBAC is not payable when billed with an assistant

surgeon modifier.

1/01/2018

Assistant Surgeon Policy

Cesarean delivery only, following failed VBAC, including

postpartum care (CPT code 59622) is not payable when

billed with an assistant surgeon modifier.

1/01/2018

Assistant Surgeon Policy

Cesarean delivery only, including postpartum care (CPT

code 59515) is not payable when billed with an assistant

surgeon modifier.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Assistant Surgeon Policy

Any claim with multiple assistant surgeon claims for the

same surgical procedure is not payable.

1/01/2018

Assistant Surgeon Policy

Reimbursement for an assistant surgeon is not payable

when billed by the primary surgeon.

1/01/2018

Assistant Surgeon Policy

Procedures are not payable when billed as assistant

surgeon and the codes are designated as assistant

surgeon not allowed.

1/01/2018

Assistant Surgeon Policy

Procedures are not payable when billed as assistant

surgeon when the codes are designated as assistant

surgeon payment restriction may apply.

1/01/2018

Assistant Surgeon Policy

In accordance with AMA, a procedure code is not

payable when billed with modifier 80, 81, 82, or AS

(Assistant Surgeon) when the same procedure code has

not been billed without modifier 80, 81, 82, or AS

(Primary Surgeon) by a different Provider ID.

4/15/2024

F, P

Asthma and Allergy Policy

Care management services (CPT codes 99487, 99489-

99490, G2058) is not payable when billed within the

same calendar month when certain services have

already been paid.

1/01/2018

Bariatric Surgery Policy

Hiatal hernia repair CPT codes 43280, 43281, 43282,

43289, 43499 or 43659, when reported with bariatric

surgery code ranges 43770–43775 and 43842–43848,

43644, 43645, 43886, 43887

or 43888, will deny as incidental/inclusive procedures.

Modifier 59 will not override these codes as hiatal hernia

repair is considered an integral part of bariatric surgery,

in accordance with CMS guidelines.

4/15/2024

Bilateral Procedures Policy

Services reported with lateral anatomic modifier LT (Left

side) or RT (Right side) are not payable when billed on

the same line with modifier 50 (Bilateral procedure).

1/01/2018

Bilateral Procedures Policy

Procedure codes to which the bilateral concept does not

apply are not payable when billed with modifier 50, LT

or RT.

1/01/2018

Bilateral Procedures Policy

Procedures that are bilateral in nature are not payable

when billed with RT or LT to its counterpart unilateral

code.

1/01/2018

Bilateral Procedures Policy

Bilateral procedures are payable when billed in

accordance with the CMS Physician RVU file Bilateral

designation.

1/01/2018

Bilateral Procedures Policy

According to our policy, when bilateral indicator "1"

codes are rendered bilaterally, only one claim line with

modifier 50 appended is payable.

1/01/2018

F, P

Bilateral Procedures Policy

Ophthalmic biometry by ultrasound echography, A-scan;

with intraocular lens power calculation (CPT code

76519), or ophthalmic biometry by partial coherence

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

interferometry with intraocular lens power calculation

(CPT code 92136) is not payable when billed twice on

the same date of service, as either the global service or

the technical service (with modifier TC).

F, P

Bilateral Procedures Policy

Ophthalmic biometry by ultrasound echography, A-scan;

with intraocular lens power calculation (CPT code

76519), or ophthalmic biometry by partial coherence

interferometry with intraocular lens power calculation

(CPT code 92136) is not payable when billed globally and

the same procedure is also billed with modifiers 26-LT

and 26-RT.

1/01/2018

Bilateral Procedures Policy

Ultrasound, breast, unilateral, real time with image

documentation, including axilla when performed; limited

(CPT code 76642) is not payable when billed by any

provider on the same date of service for the same side

an ultrasound, breast, unilateral, real time with image

documentation, including axilla when performed;

complete (CPT code 76641) is performed.

1/01/2018

Bilateral Procedures Policy

If 76642 (Ultrasound, breast, unilateral, real time with

image documentation, including axilla when performed;

limited) is billed with modifier LT (Left side) on the same

date of service as 76641 (Ultrasound, breast, unilateral,

real time with image documentation, including axilla

when performed; complete) billed with modifier LT (Left

side) or 50 (Bilateral procedure) by any provider, then

deny 76642 with reason Included In Primary Procedure.

1/01/2018

F, P

Bilateral Procedures-

Modifiers 50, RT, LT

Identifies claim lines where the procedure code is

submitted with modifier 50 and the line quantity is

greater than 1. Procedures billed with modifier 50

indicate a bilateral procedure and a line quantity greater

than one is not allowed.

This rule identifies specific bilateral procedures

(conditionally bilateral and independently bilateral) that

should not be billed with a quantity greater than 1 and

modifies the line quantity to equal 1.

This rule identifies only specific bilateral procedures

from the CMS Conditional or Independent bilateral

procedure code lists that are submitted with modifier 50

with a line quantity (units of service) greater than 1.

CMS Bilateral Indicators:

• Codes with Bilateral Indicator 0: Bilateral

surgery rules do not apply to codes with a

2015

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

status indicator 0. These codes should not be

billed with modifiers 50, LT or RT.

• Codes with Bilateral Indicator 1: If the same

code is reported once with modifier RT and

once with modifier LT this is not allowed.

Instead, the code should be reported with

modifier 50 for 1 unit. The 150% payment

adjustment will apply.

• Codes with Bilateral indicator 2: These codes

should not be billed with modifier 50 as these

codes are already established as being

performed bilaterally. These codes should be

billed with no more than 1 unit of service.

• Codes with Bilateral Indicator 3: These codes

should be reported with the appropriate

anatomical LT or RT modifier, with one unit of

service for each.

• Codes with Bilateral Indicator 9: Bilateral

surgery concept does not apply. These

procedure codes should not be billed with

modifiers 50, LT or RT (e.g., xxxxx, billed with 1

unit).

The rule modifies the line quantity to equal 1. Modifying

the line quantity to the correct quantity of 1 provides a

timely and accurate claim resolution.

The CMS edit returns the claim to the provider without

modifying the line quantity. The source for this edit is

the CMS Integrated Outpatient Code Editor(I/OCE).

The default is set to override this edit if modifier -59

(distinct procedural service) is reported on the same

claim line with modifier -50.

Breast Milk Bag Frequency

Policy

Disposable collection and storage bags for breast milk

(K1005, A4287) are not payable when limit of 200 milk

bags is exceeded within a calendar month

1/1/2023

F, P

Bundled Ambulance Services

This rule recommends the denial of any claim lines with

a procedure code other than a valid ambulance HCPCS

service or mileage code reported along with a valid

ambulance HCPCS procedure code for the same

beneficiary, same date of service, by the same provider

and on Same Claim Only.

2018

Bundled Services Policy

Packaged HCPCS codes are not payable when billed by

an ambulatory surgical center.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Bundled Services Policy

Packaged HCPCS codes are not payable when billed by

an ambulatory surgical center

1/01/2018

Bundled Services Policy

Codes with a status indicator T are not payable when

other payable services (CMS) are billed on the same day.

1/01/2018

Bundled Services Policy

Bundled services (Status indicator P) are not payable

when billed with other payable services on the same

day.

1/01/2018

Bundled Services Policy

Bundled services for which payment is always routinely

bundled into other services and supplies are not

payable.

1/01/2018

Bundled Services Policy

As per the April 2021 AMA CPT Assistant for breast

reconstruction revision, if CPT code 19380 is reported,

no other codes should be reported for work related to

the breast envelope (ie, scar revision, mastopexy,

liposuction, capsule modification, etc.). Exchanging an

implant (CPT code 19342) or autologous fat-grafting for

increased volume or contouring (CPT codes 15571,

15772) may be reported separately.

4/01/2021

Bundled Services Policy

CMS has implemented a conditional package status

indicator Q4 (Laboratory services subject to conditional

packaging) that will identify laboratory codes when they

are the only service rendered in the outpatient hospital

(Bill Type 0130-013Z) in order to pay them separately

under the Clinical Laboratory Fee Schedule (CLFS).

The conditional packaging indicator designates services

will be packaged if billed on the same claim as a HCPCS

code that has an assigned OPPS payable status indicator.

Conditionally packaged laboratory service codes (Status

indicator Q4) will deny when billed with any non-

laboratory service and the bill type is 0130-013Z

(Hospital outpatient).

9/13/2023

Bundled Services Policy

According to CMS policy, certain ancillary HCPCS codes

are considered integral to the delivery of other

procedures and services and their payment is packaged

into the payment for the other services. These packaged

services are not separately reimbursable.

These services have a status indicator of N (Items and

services packaged into APC rates) and there is no

separate APC payment.

HCPCS Codes with Status Indicator N will deny when

billed by an outpatient hospital.

9/13/2023

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Bundled Services Policy

CMS has established a list of services that are considered

packaged into the APC payment when billed with certain

services; otherwise these services are separately

payable. These specific service codes are considered

packaged in the presence of any code with status

indicator S, T or V (STV-Packaged).

When one of these STV-Packaged services is reported on

the same claim as a code with an APC status indicator of

S, T or V, then the STV-Packaged service will be denied.

9/13/2023

Bundled Services Policy

According to CMS, certain service codes are considered

packaged in the presence of any code with a status

indicator T (T-Packaged).

When one of these T-Packaged services is reported on

the same day as a code with an APC status indicator of T,

then the T-Packaged service will be denied.

9/13/2023

CPAP and BIPAP Services

Identifies supply codes associated with the

Continuous Positive Airway Pressure or Bi- level Positive

Airway Pressure CPAP/BIPAP) therapy that are being

submitted at a rate that exceeds the usual or customary

rate.

This rule will also identify those supply codes submitted

without modifier –KX (Requirements specified in the

medical policy have been met).

1/01/2018

Cardiology Policy

CPT 93970-93971 (Venous studies) are not payable

when billed with 93922-93931 (Arterial studies) and a

supporting diagnosis for the venous study is not present.

9/20/2019

Cardiology Policy

Evaluation and management services (CPT codes 99211-

99480 or 99499) are not payable when billed without

modifier 25 on the same date of service as implantable

cardiac device monitoring services (CPT codes 93260-

93261), cardiac device evaluation services (CPT codes

93279-93298, 0417T-0418T, 0521T, 0522T, 0528T,

0529T, 0575T-0576T, 0578T-0579T, G2066), or

noninvasive physiologic studies (CPT codes 93724,

93740, 93750).

1/01/2018

Cardiology Policy

When more than one myocardial perfusion or cardiac

blood pool imaging study (CPT codes 78451-78454,

78466-78469 or 78472, 78473, 78483, 78494) are billed

the procedure with the lowest allowed amount for the

same date of service will not be payable.

1/01/2018

F, P

Cardiology Policy

A complete transthoracic echocardiography is not

payable when the same complete echocardiography has

been billed within six months with the same diagnosis.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 12 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Cardiology Policy

CPT 93260-93261, 93282-93284, 93289 or 93292

(Programming/interrogation device evaluation [in

person] defibrillator system) are not payable when billed

greater than once in a three-month period for a

diagnosis indicating the presence of an automatic

(implantable) cardiac defibrillator.

1/01/2018

Cardiology Policy

CPT 93922-93931 (Arterial studies) are not payable

when billed with 93970-93971 (Venous studies) and a

supporting diagnosis for the arterial study is not present.

1/01/2018

F, P

Cardiology Policy

Myocardial perfusion imaging; single study (CPT code

78451) is not payable when billed more than once on

the same claim for the same or the previous date of

service.

1/01/2018

F, P

Cardiology Policy

External mobile cardiovascular telemetry [MCT](CPT

codes 93228-93229) or external patient activated ECG

event recording (CPT codes 93268-93272) are not

payable when billed more than once in a six month

period by any provider.

1/01/2018

Terminated

effective

3/26/2023

Cardiology Policy

Complete fetal echocardiography is not payable when

the same complete echocardiography has been billed

within six months with the same diagnosis.

1/01/2018

Cardiology Policy

Electrocardiogram, routine ECG with at least 12 leads;

with interpretation and report (CPT code 93000) is not

payable when billed in the office setting for a patient 18

years of age or older and the only diagnosis is a

screening diagnosis code.

1/01/2018

F, P

Cardiology Policy

Evaluation of cardiovascular function with tilt table

evaluation (CPT code 93660) is not payable when billed

without a diagnosis of syncope and collapse.

1/01/2018

Cardiology Policy

Arterial studies (CPT codes 93922-93931) are not

payable when billed with venous studies (CPT codes

93970-93971) and a supporting diagnosis for the arterial

study is not present.

1/01/2018

Cardiology Policy

Venous studies (CPT codes 93970-93971) are not

payable when billed with arterial studies (CPT codes

93922-93931) and a supporting diagnosis for the venous

study is not present.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 13 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Cardiology Policy

Duplex scan of extracranial arteries; complete bilateral

study (CPT code 93880) or duplex scan of extracranial

arteries; unilateral or limited study CPT code 93882) is

not payable when billed with Place of Service 11 (Office),

12 (Home), 15 (Mobile Unit), 19 (Off campus-Outpatient

Hospital, 20 (Urgent Care), 22 (On Campus-Outpatient

Hospital), 24 (ASC), 32 (Nursing Facility), or 49

(Independent Clinic), the patient's age is 18 years or

greater, and a carotid artery stenosis symptom diagnosis

is not present on the claim.

1/01/2018

Chemistry Lab Unbundled

Policy

Unbundled individual components of a disease-oriented

or chemistry panel are not payable when submitted for

the same date of service by the same provider. Provider

must bill the appropriate comprehensive panel or

automated multichannel test code that includes the

multiple test components.

All PPO 1/01/2022

HMOMR and

HMOC 03/17/2021

HMOMD

10/01/2021

Claims Processing

Parameters Policy

Any service when there exists an inpatient or outpatient

claim with a discharge status of 20, 40, 41, or 42 (Patient

deceased or expired) prior to the date of service will be

denied.

1/01/2018

Updated to include

CNY, PPOC &

PPOMR effective

8/01/2022

Claims Processing

Parameters Policy

A claim submitted with a no-pay bill type is not payable.

1/01/2018

Updated to include

CNY, PPOC

&PPOMR effective

8/01/2022

Claims Processing

Parameters Policy

Any service when there exists an inpatient or outpatient

claim with a discharge status of 20, 40, 41, or 42 (Patient

deceased or expired) prior to the date of service is not

payable.

1/01/2018

F, P

CMS Coverage Policies

Any combination of outpatient cardiac rehabilitation

(CPT codes 93797-93798) that is beyond 36 units in 36

weeks by any provider is not payable unless reported

with modifier KX (Requirements specified in the medical

policy have been met).

1/01/2018

CMS Coverage Policies

CMS defined non-covered services are not payable.

(CMS-1450)

1/01/2018

Updated to include

PPOMR effective

8/01/2022

CMS Coverage Policies

Processing, preserving and transporting corneal tissue

(HCPCS code V2785) is not payable when billed without

a corneal transplant procedure (CPT codes 65710,

65730, 65750, 65755, 65756, 65765, 65767).

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 14 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

F, P

CMS Coverage Policies

FQHC visit, established patient (HCPCS code G0467) is

not payable when reported for PPS payment and a

qualifying visit code is not also present on the claim.

1/01/2018

F, P

CMS Coverage Policies

Services are not payable if billed with Bill Types 0771-

077Z (FQHC) and Condition Code 65 is not present on

the claim (i.e. reported for PPS payment) and a FQHC

visit code (HCPCS codes G0466-G0470) are not also

present on the claim.

1/01/2018

CMS Coverage Policies

Anesthesia for lower intestinal endoscopic procedures

[screening colonoscopy] (CPT code00812) is not payable

when billed with modifier 33 and colorectal cancer

screening (HCPCS codes G0105, G0121) have not been

billed for the same date of service by any provider.

1/01/2018

CMS Coverage Policies

Pneumococcal vaccine (CPT code 90670 or 90732) is not

payable when billed by any provider and the same code

has been billed in the patient's lifetime.

1/01/2018

CMS Coverage Policies

Pneumococcal vaccine (CPT 90670 or 90732) is not

payable when billed and 90670 or 90732 has been billed

in the previous 12 months.

1/01/2018

F, P

CMS Coverage Policies

Annual wellness visit (HCPCS code G0439) is not payable

when billed and another annual wellness visit (HCPCS

code G0438 or G0439) has been billed and paid in the

previous 11 months by any provider.

1/01/2018

F, P

CMS Coverage Policies

Annual wellness visit (HCPCS code G0438 or G0439) is

not payable when billed and initial preventive physical

examination (HCPCS code G0402) has been billed and

paid in the previous 11 months by any provider.

1/01/2018

CMS Coverage Policies

CMS defined non-covered services are not payable.

12/01/2019

F, P

CMS Coverage Policies

Any combination of CPT codes 93797-93798 (Outpatient

cardiac rehabilitation) are limited to 36 units within a

36-week period by any provider unless reported with

modifier KX (Requirements specified in the medical

policy have been met).

1/01/2018

CMS Coverage Policies

Claims with revenue codes not recognized by CMS are

not payable.

1/01/2018

Updated to include

PPOMR effective

8/01/2022

CMS Coverage Policies

CMS-defined services not recognized by Medicare are

not payable when billed with Bill Type 0120-012Z, 0130-

013Z or 0140-014Z.

1/01/2018

Updated to include

PPOMR effective

8/01/2022

CMS Coverage Policies

Deny items, services and procedures designated as Non-

Covered Services (CMS).

4/30/2019

CMS Coverage Policies

Physician voluntary reporting program codes are not

reimbursable with greater than $0.00.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 15 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

CMS Coverage Policies

HCPCS V2787 or V2788 are not payable.

1/01/2018

CMS Coverage Policies

HCPCS R0070 or R0075 (Transportation of portable x-ray

equipment) is not payable when the accompanying

radiological service has not been billed or paid for the

same date of service by the same or different provider.

1/01/2018

CMS Coverage Policies

Performance measurement code with status indicator M

are not payable >0.00 based on CMS designation.

1/01/2018

F, P

CMS Coverage Policies

Chiropractic manipulation (98940-98942) is not payable

when billed without a primary diagnosis of subluxation

and a secondary diagnosis for the symptoms associated

with the diagnosis of subluxation is not present.

1/01/2018

F, P

CMS Coverage Policies

Chiropractic manipulation (98940-98942) is not payable

when billed without modifier AT.

1/01/2018

CMS Coverage Policies

HCPCS G0372 (Physician service required to establish

and document the need for a power mobility device) is

not payable when billed and a face-to-face Evaluation

and Management service has not been billed and paid

on the same claim for the same date of service.

1/01/2018

F, P

CMS Coverage Policies

G0438 (Annual wellness visit; initial visit) is not payable

when billed more than once in a patient's lifetime.

1/01/2018

CMS Coverage Policies

Major surgical procedures are not payable when billed

by a non-physician practitioner (NPP) and modifier 80,

81, 82 or AS is not appended to the claim line.

1/01/2018

F, P

CMS Coverage Policies

Transportation of portable x-ray equipment, one patient

seen (HCPCS code R0070) is not payable when billed

with modifiers UN (Two patients served), UP (Three

patients served), UQ (Four patients served), UR (Five

patients served), or US (Six patients served).

1/01/2018

CMS Coverage Policies

CMS defined Services Not Recognized by OPPS are not

payable when billed with Bill Types 0120-012Z, 0130-

013Z or 0140-014Z.

1/01/2018

Updated to include

PPOMR effective

8/01/2022

F, P

CMS Coverage Policies

Outpatient cardiac rehabilitation (CPT codes 93797-

93798) or intensive cardiac rehabilitation (HCPCS codes

G0422-G0423) are not payable when billed without a

covered diagnosis on the claim.

1/01/2018

CMS Coverage Policies

Revenue code 0637 (Pharmacy-self-administered drugs)

is not payable when billed without a HCPCS Code.

1/01/2018

CMS Coverage Policies

Items, services and procedures designated as Not Valid

for Medicare are not payable.

1/01/2018

F, P

CMS Coverage Policies

Face-to-face educational services related to the care of

chronic kidney disease (HCPCS code G0420-G0421) is

not payable if not accompanied by a diagnosis of chronic

kidney disease, stage IV, [severe].

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 16 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

CMS Coverage Policies

Pulmonary rehabilitation (HCPCS code G0424) is not

payable when billed with Bill Type 0130-013Z

(Outpatient hospital) and the revenue code is not 0948

(Pulmonary rehabilitation).

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

F, P

CMS Coverage Policies

Injection, heparin sodium, [heparin lock flush], per 10

units (HCPCS code J1642) is not payable.

1/01/2018

F, P

CMS Coverage Policies

Pulmonary rehabilitation (HCPCS code G0424) is not

payable when billed for more than 36 units in a patient's

lifetime by any provider (excluding a repeat course of

therapy appended with modifier KX).

1/01/2018

CMS Coverage Policies

Tissue marker, implantable, any type, each (HCPCS code

A4648) or implantable radiation dosimeter, each (HCPCS

code A4650) are not payable when billed and placement

of soft tissue localization device, percutaneous, including

imaging guidance (CPT codes 10035-10036), biopsy,

breast, with placement of breast localization device and

imaging of the biopsy specimen, percutaneous, including

imaging (CPT codes 19081-19086), placement of breast

localization device, including imaging (CPT codes 19281-

19288), unlisted procedure, breast (CPT code 19499),

placement of interstitial device for radiation therapy

guidance, percutaneous, intra-thoracic (CPT code

32553), placement of interstitial device for radiation

therapy guidance, percutaneous, intra-abdominal, intra-

pelvic [except prostate], and/or retroperitoneum (CPT

code 49411), or placement of interstitial device for

radiation therapy guidance, prostate [via needle, any

approach] (CPT code 55876) has not been billed or paid

for the same date of service.

1/01/2018

F, P

CMS Coverage Policies

Pulmonary rehabilitation (HCPCS code G0424) is not

payable beyond two units per date of service.

1/01/2018

Updated to include

PPOC, PPOMR

effective

8/01/2022

F, P

CMS Coverage Policies

Annual wellness visit; initial visit or subsequent visit

(HCPCS codes G0438 or G0439) are not payable when

billed by any provider greater than one unit per date of

service.

1/01/2018

F, P

CMS Coverage Policies

Subsequent service, supply or device procedure codes

are not payable when modifiers PM, P6 or QL have been

reported in the past for the same patient by any

provider.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 17 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

CMS Coverage Policies

High-cost skin substitute application procedures (CPT

codes 15271-15278) are not payable when billed with

bill types 0120-012Z (Inpatient Hospital-Part B), 0130-

013Z (Outpatient Hospital-Part B), or 0140-014Z

(Outpatient Hospital-other) and a qualifying high-cost

skin substitute product code has not been either paid or

denied for the same date of service.

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

F, P

CMS Coverage Policies

Set-up portable X-ray equipment (HCPCS code Q0092) is

not payable when billed and transportation of portable

x-ray equipment (HCPCS codes R0070 or R0075) has not

been billed or paid for the same date of service by same

or different provider.

1/01/2018

F, P

CMS Coverage Policies

Services submitted with a principal diagnosis found on

the Outpatient Prospective Payment System (OPPS)

Unacceptable Principal Diagnosis list are not payable.

10/15/2024

F, P

CMS Coverage Policies

Procedures or treatments are not payable when the only

diagnosis on the claim line is for a procedure or

treatment not carried out due to contraindication or

other unspecified reason.

10/15/2024

F, P

CMS Coverage Policies

Procedures or treatments are not payable when the only

diagnosis on the claim line is for a procedure or

treatment not carried out due patient decision.

10/15/2024

F, P

CMS Coverage Policies

In accordance with CMS, when either the Mohs

micrographic surgery procedure (CPT codes 17311 or

11713) or surgical pathology examination (codes 88300-

88309, 88312, 88313, 88331, 88342, 88344) are

reported separately for the same date of service by

different providers, they will be denied.

10/15/2024

F, P

CMS National Coverage

Determinations (NCD) Policy

Aluminum (CPT code 82108) is not payable when billed

more than once in a three-month period by any provider

with a diagnosis of end-stage renal disease on the claim.

1/01/2018

Updated to include

Facility (HMOC,

HMOMD,

HMOMR) effective

11/16/2021

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

F, P

CMS National Coverage

Determinations (NCD) Policy

Ambulatory blood pressure monitoring (CPT code

93784) is not payable when a diagnosis of elevated

blood pressure reading without diagnosis of

hypertension is not present on the claim.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 18 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

CMS National Coverage

Determinations (NCD) Policy

Peripheral arterial disease (PAD) rehabilitation, per

session (CPT code 93668) is not payable when billed and

a diagnosis of atherosclerosis with intermittent

claudication is not present.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

Cytogenetic studies (CPT codes 88230-88291) are not

payable when billed without a CMS approved diagnosis

on the claim.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

HIV screening tests (HCPCS codes G0432, G0433,

G0435, or G0475 ) are not payable when billed with a

diagnosis of encounter for screening for HIV and the

patient's age is greater than 65 years of age, and a

diagnosis of high risk is not also present.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

HIV screening tests (HCPCS codes G0432, G0433, G0435,

or G0475) are not payable when billed with a diagnosis

of encounter for screening for HIV and the patient's age

is less than 15 years of age, and a diagnosis of high risk is

not also present.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

HIV screening tests (HCPCS codes G0432, G0433, G0435,

or G0475) are not payable when billed and the place of

service is not 11 (Office), or 81 (Independent

laboratory).

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Bioimpedance-derived physiologic cardiovascular

analysis (CPT code 93701) is not payable when billed

without an acceptable diagnosis on the claim.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Electrical osteogenesis stimulator (HCPCS code E0748) is

not payable when billed and a diagnosis of post-surgical

arthrodesis status is not present.

1/01/2018

Updated to include

CNY effective

8/01/2022

CMS National Coverage

Determinations (NCD) Policy

Vitrectomy (CPT codes 67005, 67010, 67036, 67039-

67043) are not payable when billed and the revenue

code is not 0360-0369 (Operating room services general

classification) or 0490-0499 (Ambulatory surgical care

general classification).

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

F, P

CMS National Coverage

Determinations (NCD) Policy

Medical nutrition therapy (MNT) services for

reassessment and subsequent intervention following

second referral in same year (HCPCS code G0270 or

G0271) is not payable when billed and MNT service

codes (CPT codes 97802-97804) have not been billed

within the same calendar year.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Subsequent billings of an initial medical nutritional

service (CPT code 97802) is not payable when billed

more than once within a calendar year.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Additional units of group medical nutrition therapy (CPT

code 97804) is not payable when greater than 6 units

have been billed within a calendar year.

1/01/2018

Terminated

1/01/2020

Reimbursement Policy:

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(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

CMS National Coverage

Determinations (NCD) Policy

Additional units of medical nutrition therapy (CPT codes

97802, 97803 or 97804) are not payable when greater

than 12 combined units have been billed within a

calendar year.

1/01/2018

Terminated

1/01/2020

F, P

CMS National Coverage

Determinations (NCD) Policy

Additional units of medical nutrition therapy individual

reassessment and intervention (CPT code 97803) is not

payable when greater than 11 units have been billed

within the same calendar year.

1/01/2018

Terminated

1/01/2020

CMS National Coverage

Determinations (NCD) Policy

Obstetric panel [includes HIV testing] (CPT code 80081),

G0432, G0433, G0435, or G0475 (HIV screening tests)

are not payable when billed more frequently than three

times by any provider per term of pregnancy.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Aprepitant, oral, 5 mg (HCPCS code J8501), unspecified

oral dosage form, FDA approved prescription anti-

emetic (HCPCS code J8501), netupitant 300 mg and

palonosetron 0.5 mg, oral (HCPCS code J8655), or

rolapitant, oral, 1 mg (HCPCS code J8670) are not

payable when billed and a diagnosis indicating

encounter is for antineoplastic chemotherapy (ICD-10

Z51.11) is not present.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

CPT 88230-88291 (Cytogenetic studies) are not payable

when billed without an approved diagnosis on the claim.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

CPT 93668 (Peripheral arterial disease (PAD)

rehabilitation, per session) is not payable when billed

and a diagnosis of atherosclerosis with intermittent

claudication is not present.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

CPT 93784 (Ambulatory blood pressure monitoring)

when billed with a diagnosis of elevated blood pressure

reading, without diagnosis of hypertension is not

payable.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

CPT 82270 or G0328 (Colorectal cancer screening by

fecal occult blood test) are not payable when billed by

any provider more than once per year.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

Electrical osteogenesis stimulator (HCPCS code E0747) is

not payable when billed without a required diagnosis on

the claim.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

Ultrasonic osteogenesis stimulator (HCPCS code E0760)

is not payable when billed without a required diagnosis

on the claim.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Hemoglobin; glycosylated (A1C), CPT code 83036, is not

payable when billed by any provider more than once per

month and the diagnosis is diabetes mellitus in pregnant

women.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Bilateral screening mammography, CPT codes 77063 or

77067, are not payable when billed and the patient is

less than 35 years of age.

1/01/2018

Reimbursement Policy:

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(Commercial, Medicare & Medicaid)

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Page 20 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

CMS National Coverage

Determinations (NCD) Policy

Ultrasonic osteogenesis stimulator, HCPCS code E0760,

is not payable when billed by any provider and electrical

osteogenesis stimulator, HCPCS codes E0747 or E0748

has been billed within the past month.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Smoking and tobacco cessation counseling visits, CPT

codes 99406 or 99407, are not payable when billed in

any combination more than eight units per year by any

provider.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

CPT 82728 (Ferritin) is not payable when the diagnosis is

end-stage renal disease and 82728 has been billed more

than once in a 90-day period by any provider for the

same diagnosis.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

Destruction of localized lesion of choroids, HCPCS codes

67221-67225 or Verteporfin, HCPCS code J3396, is not

payable when billed and diagnostic imaging study (CPT

codes 92133- 92134) and fluorescein angiography (CPT

code 92235) has not been billed by any provider on the

same day or within the past month.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

As per CMS, CPT 99183 (Hyperbaric oxygen therapy) or

G0277 (Hyperbaric oxygen under pressure, full body

chamber, per 30-minute interval) are not payable when

submitted without a requisite diagnosis.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

HCPCS G0166 is not payable when greater than 35 units

have been billed within a two-month period.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

HCPCS G0102 or G0103 are not payable when billed

more than once every 11 months.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

HCPCS E0650-E0651, or E0655-E0673 (Pneumatic

compressor/appliance device) are not payable when

billed without a required diagnosis.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

Knee arthroscopy (surgical) is not payable when billed

with a primary diagnosis of osteoarthritis of the knee.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

HCPCS J0881, J0885 or Q5106 are not payable when

billed with modifier EB.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

J0881, J0885 or J0888 are not payable when billed with

modifier EC and the diagnosis associated to the claim

line is not approved for ESA treatment.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

J0881, J0885 or J0888 are required to be billed with

modifier EA, EB or EC as applicable.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

CPT 93025 (Microvolt T-wave alternans for assessment

of ventricular arrhythmias) is not payable when billed

without a covered diagnosis.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

Medical nutrition therapy services (CPT codes 97802-

97804 or G0270-G0271) are not payable when billed by

a provider other than a registered dietician, nutritional

professional, or hospital.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

CMS National Coverage

Determinations (NCD) Policy

Medical nutrition therapy services (CPT codes 97802-

97804 or HCPCS codes G0270-G0271) are not payable

when there are paid dialysis services within the same

calendar month.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Screening pelvic examinations (HCPCS code G0101) are

not payable when billed by any provider more than once

in a two-year period, except when a high-risk diagnosis

is present.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Acupuncture (CPT codes 97810-97814) are not payable

when the diagnosis is fibromyalgia.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Total disc arthroplasty (artificial disc), anterior approach,

including discectomy to prepare interspace (other than

for decompression), lumbar, single interspace) (CPT

code 22857) is not payable when billed and the patient's

age is greater than 60 years.

1/01/2018

Updated to include

CNY effective

8/01/2022

F, P

CMS National Coverage

Determinations (NCD) Policy

Continuous passive motion exercise device (HCPCS code

E0935) is limited to one unit per day when billed by any

provider within three weeks of the original arthroplasty.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Bacterial urine cultures (CPT codes 87086 and 87088)

are not payable when billed without a covered

diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Human immunodeficiency virus testing (CPT codes

86689, 86701-86703, 87390-87391, 87534-87535,

87537, or 87538) are not payable when billed without a

covered diagnosis on the claim.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Blood count (CPT codes 85004-85008, 85013-85027,

85032, 85048-85049, G0306-G0307) are not payable

when billed with a non-covered diagnosis and the non-

covered diagnosis is the only diagnosis on the claim.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Thromboplastin time, partial [PTT]; plasma or whole

blood (CPT code 85730) is not payable when billed

without a covered diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Prothrombin time (CPT code 85610) is not payable when

billed without a covered diagnosis on the claim.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Ferritin (CPT code 82728), iron (CPT code 83540), iron

binding capacity (CPT code 83550) or transferrin (CPT

code 84466) are not payable when billed without a

covered diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Collagen crosslinks, any method (CPT code 82523) is not

payable when billed without a covered diagnosis on the

claim.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Glucose; quantitative, blood (CPT code 82947), glucose;

blood, reagent strip (CPT code 82948) or glucose, blood

by glucose monitoring device cleared by the FDA

specifically for home use (CPT code 82962) are not

payable when billed without a covered diagnosis.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

CMS National Coverage

Determinations (NCD) Policy

Glycated protein (CPT code 82985) or hemoglobin;

glycosylated (CPT code 83036) are not payable when

billed without a covered diagnosis on the claim.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Thyroxine; total (CPT code 84436), thyroxine; free (CPT

code 84439), thyroid stimulating hormone (CPT code

84443) or thyroid hormone uptake or thyroid hormone

binding ratio (CPT code 84479) are not payable when

billed without a covered diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Lipid panel/testing CPT code 80061, 82465, 83700,

83701, 83704, 83718, 83721 or 84478) are not payable

when billed without a covered diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Alpha-fetoprotein; serum (CPT code 82105) is not

payable when billed without a covered diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Carcinoembryonic antigen (CPT code 82378) is not

payable when billed without a covered diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Gonadotropin, chorionic; quantitative (CPT code 84702)

is not payable when billed without a covered diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Immunoassay for tumor antigen, quantitative; CA 125

(CPT code 86304) is not payable when billed without a

covered diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Immunoassay for tumor antigen, quantitative; CA 15-3

[27.29] (CPT code 86300) is not payable when billed

without a covered diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Immunoassay for tumor antigen, quantitative; CA 19-9

(CPT code 86301) is not payable when billed without a

covered diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Prostate specific antigen [PSA], total (CPT code 84153) is

not payable when billed without a required diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Glutamyltransferase, gamma (CPT code 82977) when

billed without a covered diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Acute Hepatitis Panel (CPT code 80074) when billed

without a covered diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Blood, occult, by peroxidase activity, qualitative; feces,

single specimen (CPT code 82272) when billed without a

covered diagnosis on the claim.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Prostate cancer screening services (HCPCS codes G0102

and G0103) are not payable when billed and the

diagnosis is not screening for malignant neoplasm of

prostate.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Prostate cancer screening services (HCPCS codes G0102

or G0103) are not payable when billed and the patient is

under 50 years of age.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

CMS National Coverage

Determinations (NCD) Policy

Deny 84153 (Prostate specific antigen [PSA], total) when

billed by any provider more than once per year and the

diagnosis is indicative of lower urinary tract signs and

symptoms.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Carcicoembryonic antigen testing (CPT code 82378) is

not payable when billed more than twice in a patient's

lifetime by any provider with a diagnosis of carcinoma in

situ of the digestive organs.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

Hyperbaric oxygen therapy (CPT code 99183) is not

payable when billed and the place of service is not 11

(Office), 19 (Outpatient hospital-off campus), 21

(Inpatient hospital), 22 (Outpatient hospital-on campus),

or 49 (Independent clinic).

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Laboratory tests are not payable when the only

diagnosis code billed is one that is never covered by

CMS.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

Screening pap smear, examination (HCPCS code Q0091)

for low risk diagnosis is not payable when billed by any

provider more than once in a two-year period.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Injection, DMSO, dimethlsulfoxide, 50%, 50 ml (HCPCS

code J1212) is not payable when billed and the diagnosis

is not interstitial cystitis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Ingestion challenge test (CPT code 95076) is not payable

when billed and the only diagnoses on the claim is

rheumatoid arthritis, depression, or respiratory

disorders.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Vitrectomy (CPT codes 67005, 67010, 67036 or 67039-

67043) is not payable when billed without a required

diagnosis on the claim

1/01/2018

Updated to include

Facility (HMOMR)

effective

11/16/2021

Updated to include

PPOMR effective

8/01/2022

F, P

CMS National Coverage

Determinations (NCD) Policy

Vitrectomy (CPT codes 67005, 67010, 67036, 67039-

67043) is only payable when rendered to treat vitreous

loss incident to cataract surgery, vitreous opacities due

to vitreous hemorrhage or other causes, retinal

detachments secondary to vitreous strands, proliferative

retinopathy, and vitreous retraction.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 24 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

F, P

CMS National Coverage

Determinations (NCD) Policy

E/M services for patient with diabetic LOPS (HCPCS

codes G0245-G0246) or routine foot care service for

patient with diabetic LOPS (HCPCS code G0247) are not

payable when billed and the diagnosis is not diabetes

mellitus with neurological complications.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Routine foot care service for patient with diabetic LOPS

(HCPCS code G0247) are not payable when billed

without E/M for patient with diabetic LOPS (HCPCS

codes G0245-G0246) on the same date of service.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

E/M services for patients with diabetic LOPS, or routine

foot care (HCPCS codes G0245-G0246, or G0247) are not

payable when billed by any provider within six months

of routine footcare services (CPT codes 11055-11057 or

11719-11721).

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Bioimpedance-derived physiologic cardiovascular

analysis (CPT code 93701) is not payable when billed

with the same date of service as cardiac bypass surgery

(CPT codes 33510-33536).

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Bladder instillation of anticarcinogenic agent (CPT code

51720) is not payable when billed with injection, DMSO,

dimethlsulfoxide, 50%, 50 ml (HCPCS code J1212) and

the diagnosis is not interstitial cystitis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Verteporfin (HCPCS codes J3396) is not payable when

billed with destruction of localized lesion of choroids

(CPT codes 67221-67225) and without a covered

diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Verteporfin (HCPCS code J3396) is not payable when

billed and destruction of localized lesion of choroid (CPT

codes 67221-67225) has not been billed or paid for the

same date of service by any provider.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Screening pelvic examination (HCPCS codes G0101) are

not payable when billed without a low-risk or high-risk

requisite diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Cryosurgical ablation of the prostate (CPT code 55873) is

not payable when billed and the diagnosis on the claim

is not prostate cancer.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Acupuncture (CPT codes 97810-97814) is not payable

when the diagnosis is osteoarthrosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Diabetes self-management training (HCPCS codes

G0108-G0109) is not payable when billed and the

diagnosis is not diabetes mellitus.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Diabetes self-management training, per 30 minutes

(HCPCS codes G0108-G0109) is not payable when billed

by any provider with greater than 24 combined units of

service within a year. Under Medicaid, the maximum is

40 units per year.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

CMS National Coverage

Determinations (NCD) Policy

Screening mammography, bilateral (CPT codes 77063 or

77067) is not payable when billed without a screening

mammography diagnosis.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Cellular Therapy (HCPCS code M0075) is a noncovered

service.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Edetate disodium, 150 mg (HCPCS code J3520) and

chelation-related administration services (CPT codes

96365, 96366, 96367, 96368, M0300, S9355) are not

payable when billed with a diagnosis of atherosclerosis,

arteriosclerosis, or calcinosis, and no other

nonchemotherapy drug administered by intravenous

infusion greater than an hour has been billed for the

same date of service.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Liver transplantation (CPT code 47135) is not payable

when billed without a CMS covered diagnosis and the

patient's age is 18 or over.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

External counterpulsation therapy (HCPCS code G0166)

is not payable when billed without a diagnosis on the

claim of stable, disabling angina.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Injection, epidural, of blood or clot patch (CPT code

62273) is not payable when billed and the diagnosis on

the claim is not due to severe headaches following

performance of spinal anesthesia or spinal tap.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

HCPCS codes J0882, J0887 or J0890 are not payable

when billed with modifiers EA, EB or EC and the

diagnosis is end stage renal disease.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Colorectal cancer screening (CPT/HCPCS codes 82270,

G0104, G0106, or G0328) is not payable when billed and

the patient is less than 50 years of age.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

Hospital bed, institutional type includes: oscillating,

circulating and Stryker frame, with mattress (HCPCS

code E0270) is not payable when billed and the place of

service is 04 (Homeless shelter), 12 (Home), 13 (Assisted

living facility), 14 (Group home), 16 (Temporary lodging)

or 33 (Custodial care).

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Application of electrical stimulation (CPT/HCPCS codes

97014, 97032, E0745, G0283), or electrical stimulator

supplies (HCPCS code A4595) is not payable when billed

and the only diagnosis on the claim is Bell's palsy.

1/01/2018

Updated to include

CNY effective

8/01/2022

F, P

CMS National Coverage

Determinations (NCD) Policy

Air fluidized bed (HCPCS code E0194) is not payable

when billed and a diagnosis of a Stage III or Stage IV

pressure ulcer is not present.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 26 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

F, P

CMS National Coverage

Determinations (NCD) Policy

Photopheresis, extracorporeal (CPT code 36522) is not

payable when billed and the diagnosis is not cutaneous

T-cell lymphoma, acute cardiac allograft rejection,

chronic graft-versus-host disease, or bronchiolitis

obliterans syndrome following lung allograft

transplantation.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Lipid testing (CPT codes 80061, 82465, 83718, 83721 or

84478) is not payable when billed more than six times

per year in any combination by any provider.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

HCPCS code J0881 or J0885 is not payable when billed

without modifier EA, EB or EC.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Screening colonoscopy for high risk (HCPCS code G0105

is not payable when billed without a high-risk diagnosis

on the claim.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Comprehensive electrophysiologic evaluation (CPT codes

93619, 93620, 93653, 93654, or 93656) is not payable

when billed without a CMS requisite diagnosis on the

claim.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Elastic garment/covering, each (HCPCS code A4466),

surgical leggings (HCPCS codes A4490-A4510),

incontinence garment (HCPCS code A4520), disposable

underpads (HCPCS codes A4553 and A4554), surgical

face mask (HCPCS code A4928), exercise equipment

(HCPCS code A9300), bath and toilet aids (HCPCS codes

E0240-E0245), bed boards (HCPCS code E0273), over

bed tables (HCPCS code E0274), bed accessory: board,

table, or support device, any type (HCPCS code E0315),

patient lift, bathroom (HCPCS code E0625), whirlpool,

portable (HCPCS code E1300), whirlpool tub, walk-in,

portable (HCPCS code K1003), and diapers (HCPCS codes

T4521-T4545) are non-covered services.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

PET services reported for an oncologic diagnosis are not

payable when modifier PI or PS is not appended.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Medical nutritional therapy services (CPT codes 97802-

97804 and HCPCS codes G0270-G0271) are not payable

when billed without a requisite diagnosis on the claim.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

HIV screening tests (HCPCS codes G0432, G0433, G0435

or G0475) are not payable when billed and the diagnosis

is not screening for human immunodeficiency virus

(HIV).

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Evaluation and management service (CPT code 99202-

99397 or 99417-99499) is not payable when billed with

smoking and tobacco cessation counseling visit (CPT

codes 99406 or 99407) on the same date of service.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 27 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

F, P

CMS National Coverage

Determinations (NCD) Policy

Electrical stimulation, unattended, for chronic ulcers

(HCPCS code G0281) or electromagnetic therapy, for

chronic ulcers (HCPCS code G0329) are not payable

when billed without an approved ulcer diagnosis on the

claim.

1/01/2018

Updated to include

PPOC, PPOMR

effective

8/01/2022

F, P

CMS National Coverage

Determinations (NCD) Policy

Photopheresis, extracorporeal (CPT code 36522) is not

payable when billed with a diagnosis of chronic graft-

versus-host disease and a diagnosis of complications of

transplanted organ is not also present.

1/01/2018

Updated to include

PPOC, PPOMR

effective

8/01/2022

CMS National Coverage

Determinations (NCD) Policy

Face-to-face behavioral counseling for obesity (HCPCS

code G0447 or G0473) is not payable billed more than

22 times per year.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Face-to-face behavioral counseling for obesity (HCPCS

code G0447 or G0473) is not payable when billed

without a diagnosis of Body Mass Index 30 or greater.

1/01/2018

Updated to include

PPOC, PPOMR

effective

8/01/2022

F, P

CMS National Coverage

Determinations (NCD) Policy

Photopheresis, extracorporeal (CPT code 36522) is not

payable when billed with a diagnosis of bronchiolitis

obliterans syndrome following lung allograft

transplantation and a diagnosis of examination of

participant in clinical trial is not also present.

1/01/2018

Updated to include

PPOC, PPOMR

effective

8/01/2022

F, P

CMS National Coverage

Determinations (NCD) Policy

Photopheresis, extracorporeal (CPT code 36522) is not

payable when billed with a diagnosis of bronchiolitis

obliterans syndrome following lung allograft

transplantation and clinical service modifier Q0 or Q1 is

not also present.

1/01/2018

Updated to include

PPOC, PPOMR

effective

8/01/2022

F, P

CMS National Coverage

Determinations (NCD) Policy

TENS device (HCPCS codes E0720 or E0730) are not

payable when billed with a diagnosis of chronic low back

pain and modifier KX (Requirements specified in the

medical policy have been met) is not present.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Components of oral anti-emetic 3-drug combinations are

not payable when all three drugs have not been billed

for the same date of service on the same claim.

1/01/2018

F, P

CMS National Coverage

Determinations (NCD) Policy

Dermal filler injections (HCPCS codes G0429, Q2026, or

Q2028) are not payable when billed without a diagnosis

of HIV and lipodystrophy on the claim.

1/01/2018

CMS National Coverage

Determinations (NCD) Policy

Smoking and tobacco cessation counseling visit (CPT

codes 99406 or 99407) is not payable when billed with

bill types 0120-012Z (Hospital inpatient Part B), 0130-

013Z (Hospital outpatient), 0220-022Z (SNF inpatient

part B), 0230-023Z (SNF outpatient part B), 0340-034Z

(Home health services not under a plan of treatment)

and the revenue code is not 0942 (Education/training).

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 28 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

CMS Status Indicators

Identifies claim lines containing procedure codes with a

status indicator of C, I, M, N, P, R as defined by CMS on

the Medicare Physician Fee Schedule. According to the

Medicare Physician Fee Schedule, status codes indicate

whether the code is in the fee schedule and if it is

separately payable when the service is covered. This rule

identifies codes subject to a payment review or denial

according to their assigned status code defined by CMS.

2018

CMS Status Indicators

According to the Medicare Physician Fee Schedule,

codes with a status indicator of I are defined as “not

valid for Medicare purposes. Medicare uses another

code for reporting of, and payment for, these services.”

These codes are not covered and are non-reimbursable.

2018

Co-Surgeon Policy

Procedures designated as co-surgeons allowed are not

payable when billed without modifier 62 and the same

procedure on the same claim has been billed with

modifier 62 and the bill type is 0850-085Z (CAH) and the

revenue code is 0960-0989 (Professional fees).

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Co-Surgeon Policy

Procedures designated as co-surgeons concept does not

apply will deny when billed with modifier 62

1/01/2018

Co-Surgeon Policy

Procedures billed with modifier 62 are not payable when

designated as co-surgeons not allowed. (CMS)

1/01/2018

Co-Surgeon Policy

Procedures billed with modifier 62 are not payable

without clinical documentation supporting the need for

co-surgeons, when designated as co-surgeons payment

restriction may apply. (CMS)

1/01/2018

Co-Surgeon Policy

Procedures designated as co-surgeons not allowed are

not payable when billed without modifier 62 and there

exists a previously processed claim for the same

procedure code with modifier 62 by a different provider

(CMS).

1/01/2018

Co-Surgeon Policy

Procedures designated as co-surgeons allowed and

billed with modifier 62 will not be allowed when there

exists a previously processed claim for the same

procedure code by a different provider without modifier

62 (CMS).

1/01/2018

Co-Surgeon Policy

Co-surgeon procedures are not payable when both

surgeons have the same subspecialty for procedures

designated as co-surgeons are allowed. (CMS)

1/01/2018

Co-Surgeon Policy

Procedures billed with modifier 62 are not payable when

designated as co-surgeons payment restriction may

apply.

5/29/2019

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 29 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Co-Surgeon Policy

Procedures billed with modifier 62 are not payable when

designated as co-surgeons not allowed.

1/01/2018

Co-Surgeon Policy

Procedures designated as co-surgeons allowed when

billed without modifier 62 and there exists a previously

processed claim for the same procedure code with

modifier 62 by a different provider are not payable.

1/01/2018

Co-Surgeon Policy

Procedures billed with modifier 62 are not payable when

designated as co-surgeons not allowed and the bill type

is 0850-085Z (CAH) and the revenue code is 0960-0989

(Professional fees)

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Co-Surgeon Policy

Procedures billed with modifier 62 are not payable when

designated as co-surgeons payment restriction may

apply and the bill type is 0850-085Z (CAH) and the

revenue code is 0960-0989 (Professional fees)

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Co-Surgeon Policy

Procedures designated as co-surgeons concept does not

apply when the bill type is 0850-085Z (CAH) and the

revenue code is 0960-0989 (Professional fees). (CMS)

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Co-Surgeon Policy

Procedures designated as co-surgeons allowed billed

with modifier 62 are not payable when the same

procedure has been billed without modifier 62 on the

same claim and the bill type is 0850-085Z (CAH) and the

revenue code is 0960-0989 (Professional fees) (CMS)

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Continuous Intraoperative

Neurophysiology Monitoring

(IONM)

Continuous intraoperative neurophysiology monitoring

in the operating room (CPT code 95940) is not payable

when continuous intraoperative neurophysiology

monitoring from outside the operating room (HCPCS

code G0453 or CPT code 95940) is reported on the same

day by the same provider.

3/01/2022

Deleted HCPCS Codes Policy

Deleted HCPCS codes will be denied as obsolete.

1/01/2018

Device and Supply Policy

Imaging agents are not payable when billed without the

requisite imaging procedures as defined by Regional

CMS guidelines.

1/01/2018

Device and Supply Policy

Imaging agents are not payable when billed without the

requisite imaging procedures as defined by National

CMS guidelines.

1/01/2018

Device and Supply Policy

Imaging agents are not payable when billed without the

requisite imaging procedures.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 30 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Diagnosis Code Guideline

Policy

Procedures or services received with a principal or

primary diagnosis of external causes are not correct

coding and not payable.

1/01/2018

Diagnosis Code Guideline

Policy

ICD-10 Diagnosis codes are required to be reported in

accordance with ICD-10 coding guidelines in the ICD-10

manual and CMS and NGS Medicare.

• Code must be valid for the date of service

• Code to the highest specificity

• Manifestation or secondary diagnoses codes cannot be

the only code on the claim.

• Encounter diagnoses codes for chemo or

immunotherapy administration procedures must be

reported with a primary diagnosis for which the

treatment is needed.

1/01/2018

Diagnosis Code Guideline

Policy

When a diagnosis code is billed, and it indicates laterality

(Right/Left), and the procedure/modifier code is

conflicting, the service is not payable.

1/01/2018

Diagnosis Code Guideline

Policy

When a diagnosis code is billed, and it indicates laterality

(Right/Left), and the procedure/modifier code is

conflicting, the service is not payable.

1/01/2018

Diagnosis Code Guideline

Policy

Claim lines reported with mutually exclusive code

combinations according to the ICD-10-CM Excludes 1

Notes guideline policy are not payable.

1/01/2018

Will apply to

preventative

services effective

9/15/2023

Diagnosis Code Guideline

Policy

Any procedure or service received with a ICD-10-CM

sequela (7th character "S") code billed as the only

diagnosis on the claim is not payable.

1/01/2018

Diagnosis Code Guideline

Policy

Any procedure or service received with a ICD-10-CM

sequela (7th character "S") code billed in the primary,

first listed or principal diagnosis position is not payable.

1/01/2018

F, P

Diagnosis Code Guideline

Policy

Procedures or services received with a secondary

diagnosis code as the only diagnosis on the claim are not

payable.

1/01/2018

F, P

Diagnosis Code Guideline

Policy

Procedures or services received with a primary diagnosis

of external causes as the only diagnosis on the claim are

not payable.

1/01/2018

Diagnosis Code Guideline

Policy

When a diagnosis code is available to specify whether

the condition occurs on the Right, Left or Bilateral, it is

not appropriate to report an unspecified code for the

same condition

1/01/2018

F, P

Diagnosis Code Guideline

Policy

When a diagnosis code indicates laterality, specifying

that the condition occurs on both the left and right and

the more specific bilateral code is available, it is not

appropriate to report both the left and right code.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 31 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Diagnosis Code Guideline

Policy

Non-preventive evaluation and management services

(excluding normal newborn care) billed with CPT codes

99381-99412, 99420, 99429 (Preventive medicine

services) are not payable when reported with an ICD-10

"Z" diagnosis code as the only diagnosis on the claim.

1/01/2018

Diagnosis Code Guideline

Policy

Claims received with a diagnosis of acute stroke (I63.-)

or sepsis (A41.-) on will be denied when billed with the

following Place of Service (POS) codes:

• Office (POS 11)

• Telehealth (Use POS 2 when patient and

provider are in a facility; POS 10 for patients at

home)

• Off Campus outpatient hospital (POS 19)

• On Campus outpatient hospital (POS 22)

• Skilled nursing facility (POS 31)

• Federally Qualified Health Center (POS 50)

12/06/2024

F, P

Diagnosis Procedure Policy

Debridement (CPT codes 11042-11047) are not payable

when billed with a pressure ulcer stage 1 or stage 2

diagnosis and another pressure ulcer stage (3 or 4) or a

non-pressure chronic ulcer diagnosis is not reported on

the claim.

1/01/2018

F, P

Diagnosis Procedure Policy

Other peripheral nerve injection (CPT code 64450) is not

payable when used for the treatment of multiple

neuropathies or peripheral neuropathies caused by

underlying systemic diseases.

1/01/2018

Terminated

effective

9/24/2023

F, P

Diagnosis Procedure Policy

Pulmonary diagnostic testing procedures (CPT codes

94010, 94060, 94070, 94200-94450, and 94680-94729)

are payable when the evaluation of lung function is

indicated to determine; 1. the presence of lung disease

or abnormality of lung function, 2. the extent of

abnormalities and the potential causative disease

process, 3. the extent of pulmonary impairment due to

abnormal lung function, 4. the progression or

improvement of the disease, 5. the type of disease or

pulmonary abnormality, 6. the response to a course of

therapy in the treatment of the particular condition, or

6. the presence of lung disease or abnormality of lung

function secondary to toxicity of medication.

1/01/2018

F, P

Diagnosis Procedure Policy

Debridement of muscle, fascia or bone (CPT codes

11043, 11044 or 11046, 11047) are not payable when

billed with a pressure ulcer stage 3 diagnosis and a stage

4 pressure ulcer or a non-pressure chronic ulcer

diagnosis is not reported on the claim.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 32 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Diagnosis Procedure Policy

Procedures billed with a diagnosis which does not

remedy a health state are not payable.

1/01/2018

Diagnosis Procedure Policy

All clinical trial procedures billed with modifier Q0

(Investigational clinical service provided in a clinical

research study that is in an approved clinical research

study), or Q1 (Routine clinical service provided in a

clinical research study that is in an approved clinical

research study) and the required diagnosis to indicate

participation in a clinical trial or research study is not

present will deny. The correct encounter code must be

used.

1/01/2018

Diagnosis Procedure Policy

CPT 20610 or 20611 (Arthrocentesis, aspiration and/or

injection; major joint or bursa [e.g., shoulder, hip, knee

joint, subacromial bursa]) are not payable when

submitted without an appropriate diagnosis code.

1/01/2018

Diagnosis-Age Policy

Services reported with a maternity diagnosis are not

payable when the member is less than nine years of age

or 65 years of age or older.

1/01/2018

F, P

Diagnosis Specificity Policy

Claims submitted with diagnosis codes that are not in

the full ICD-10 code format are not payable.

All PPO 1/01/2022

HMOMR and

HMOC 03/17/2021

HMOMD

10/01/2021

F, P

Diagnosis Validity Policy

Claim lines are not payable if submitted without at least

one diagnosis code is invalid and all diagnosis codes are

not coded to the highest level of specificity or are

invalid.

1/01/2018

F, P

Diagnosis Validity Policy

Claim lines submitted with diagnosis codes are not

coded to the highest level of specificity are not payable.

1/01/2018

DME Rentals

Capped rentals are not payable when billed without

modifier KH, KI, or KJ.

1/01/2022

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 33 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Drug and Biological Policy

Consistent with Centers for Medicare & Medicaid

Services’ (CMS) Internet Only Manual 100-04, Chapter

17, Section 40 –Drug Label Guidelines; drug and

biological codes dispensed in single use vials/packaging

when billed with modifier JW (Drug amount

discarded/not administered to any patient) and the

billed units equal or exceed the package

insert/prescribing information units will be denied.

Example: (Based on CMS Policy and the FDA-approved

package insert/prescribing information)

• Adenosine (J0153) is supplied in 60 mg and 90

mg single-dose vials. It is expected that a

provider will use a combination of vial sizes

that eliminates or minimizes drug wastage.

The billed drug code will be denied when submitted with

a modifier indicating the drug was discarded (JW) and

the units equaled or exceeded 60.

1/01/2023

F, P

Drug and Biological Policy

Fluocinolone injection (HCPCS code J7313) is not payable

when billed without intravitreal injection of a

pharmacologic agent (CPT code 67028).

1/01/2018

F, P

Drug and Biological Policy

Leuprolide acetate injection (HCPCS code J1950) is not

payable when billed and the diagnosis is prostate

cancer.

1/01/2018

Updated to include

CNY effective

8/01/2022

F, P

Drug and Biological Policy

Valrubicin injection (HCPCS code J9357) is not payable

when billed and bladder instillation therapy (CPT code

51720) has not been billed by any provider for the same

date of service.

1/01/2018

F, P

Drug and Biological Policy

Ocriplasminn injection (HCPCS code J7316) is not

payable when billed and intravenous administration of

pharmacologic agent (CPT code 67028) has not been

billed for the same date of service by any provider.

1/01/2018

Updated to include

CNY effective

8/01/2022

F, P

Drug and Biological Policy

Dexamethasone injection (HCPCS code J7312) is not

payable when billed without intravitreal injection of a

pharmacologic agent (CPT code 67028).

1/01/2018

F, P

Drug and Biological Policy

Ranibizumab injection (HCPCS code J2778) is not

payable when billed without intravitreal injection of a

pharmacologic agent (CPT code 67028).

1/01/2018

F, P

Drug and Biological Policy

Intravitreal injection of a pharmacologic agent (HCPCS

code 67028) is not payable when billed with

ranibizumab injection (HCPCS code J2778) and modifier

LT (Left side), RT (Right side), or 50 (Bilateral procedure)

is not appended to code 67028.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 34 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Drug and Biological Policy

Intramuscular immune globulin injections (Procedures

codes 90281, J1460, or J1560) are not payable when

billed and an FDA approved indication or an approved

off-labeled indication is not present on the claim.

1/01/2018

Updated to include

PPOC, PPOMR

effective

8/01/2022

F, P

Drug and Biological Policy

Aflibercept injections (HCPCS code J0178) is not payable

when billed without intravitreal injection of a

pharmacologic agent (CPT code 67028).

1/01/2018

F, P

Drug and Biological Policy

Intravitreal injection of a pharmacologic agent (CPT code

67028) is not payable when billed with HCPCS code

J0178 and modifier LT (Left side), RT (Right side), or 50

(Bilateral procedure) is not appended to code CPT code

67028.

1/01/2018

F, P

Drug and Biological Policy

Modifier JW is not payable with any code that is not a

drug code. Modifier JW = Drug amount discarded/not

administered to any patient.

9/01/2021

Updated to include

PPOMR effective

8/01/2022

F, P

Drug and Biological Policy

A drug billed with modifier JW (Drug amount

discarded/not administered to any patient) Is not

payable when another claim line does not exist for the

same drug on the same date of service.

9/01/2021

Updated to include

PPOMR effective

8/01/2022

F, P

Drug and Biological Policy

HCPCS J9035, Q5107, or Q5118 are not payable when

billed with modifier JW (Drug amount discarded/not

administered to any patient) and the units equal or

exceed 10.

9/01/2021

Updated to include

PPOMR effective

8/01/2022

F, P

Drug and Biological Policy

HCPCS J9041 or J9044 are not payable when billed with

modifier JW (Drug amount discarded/not administered

to any patient) and the units equal or exceed 35.

9/01/2021

Updated to include

PPOMR effective

8/01/2022

F, P

Drug and Biological Policy

HCPCS J9055 is not payable when billed with modifier

JW (Drug amount discarded/not administered to any

patient) and the units equal or exceed 10.

9/01/2021

Updated to include

PPOMR effective

8/01/2022

F, P

Drug and Biological Policy

HCPCS J0585 is not payable when billed with modifier

JW (Drug amount discarded/not administered to any

patient) and the units equal or exceed 100.

9/01/2021

Updated to include

PPOMR effective

8/01/2022

F, P

Drug and Biological Policy

HCPCS J1745, Q5103, Q5104, Q5109, or Q5121 are not

payable when billed with modifier JW (Drug amount

discarded/not administered to any patient) and the units

equal or exceed 10.

9/01/2021

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

F, P

Drug and Biological Policy

HCPCS J0587 is not payable when billed with modifier

JW (Drug amount discarded/not administered to any

patient) and the units equal or exceed 25.

9/01/2021

Updated to include

PPOMR effective

8/01/2022

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 35 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Drug and Biological Policy

HCPCS J0588 is not payable when billed with modifier

JW (Drug amount discarded/not administered to any

patient) and the units equal or exceed 50.

9/01/2021

Updated to include

PPOMR effective

8/01/2022

F, P

Drug and Biological Policy

Drugs that are only packaged for multiple doses are not

payable when billed with modifier JW (Drug amount

discarded/not administered to any patient).

9/01/2021

Updated to include

PPOMR effective

8/01/2022

F, P

Drug and Biological Policy

HCPCS J9171 is not payable when billed with modifier

JW (Drug amount discarded/not administered to any

patient) and the units equal or exceed 20

9/01/2021

Updated to include

PPOMR effective

8/01/2022

Duplicate Claim Logic for

Drugs

Duplicate drug codes are not payable when the same

code with the same units has been billed on a different

claim by any provider for the same date of service.

9/15/2021

F, P

Drug and Biological Policy

HCPCS code J0205 is not payable when billed and an FDA

approved indication or an approved off-labeled

indication is not present on the claim.

1/01/2018

F, P

Drug and Biological Policy

HCPCS code J0289 is not payable when billed and an FDA

approved indication or an approved off-labeled

indication is not present on the claim.

1/01/2018

Updated to include

Facility (HMOC,

HMOMR,

HMOMD) effective

11/16/2021

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

F, P

Duplicate Services Policy

Only one professional component for the same service is

payable when billed by different providers.

1/01/2018

Duplicate Services Policy

Identical codes billed for the same date of service by a

non-physician practitioner (NPP) with the same Tax ID

and the primary diagnosis on the submitted claim

matches any diagnosis (first three characters) on the

different claim regardless of Provider ID and Specialty

are not payable.

1/01/2018

Duplicate Services Policy

Duplicate services are not payable when the duplicate

criteria have been met.

1/01/2018

Duplicate Services Policy

Duplicate professional component services are not

payable when billed by different providers for the same

service.

1/01/2018

Duplicate Services Policy

Duplicate technical component services are not payable

when billed by different providers for the same service.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 36 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Duplicate Services Policy

Duplicate services are not payable when the duplicate

criteria have been met.

1/01/2018

Duplicate Services Policy

Duplicate services are not payable when the duplicate

criteria have been met.

1/01/2018

Duplicate Services Policy

Doxorubicin liposomal injections (HCPCS codes Q2049 or

Q2050) are not payable when billed more than once

every three weeks by any provider and the diagnosis is

of adult T-cell leukemia/lymphoma, AIDS-related

Kaposi's sarcoma, Castleman's disease, diffuse large B-

cell lymphoma, follicular lymphoma (grade 1-2), multiple

myeloma, ovarian cancer/fallopian tube cancer/primary

peritoneal cancer, peripheral T-cell lymphoma, or

primary cutaneous CD30+ T-cell lymphoproliferative

disorder.

1/01/2018

Duplicate Services Policy

Duplicate professional component services are not

payable when billed by different providers for the same

service.

1/01/2018

Duplicate Services Policy

Duplicate technical component services are not payable

when billed by different providers for the same service.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

30-day pharmacy dispensing fee (HCPCS code G0333 or

Q0513) is not payable when billed by any provider on

the same date of service of a 90-day dispensing fee

(HCPCS code Q0514).

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Ultra-light material endoskeletal system additions

(HCPCS codes L5940-L5960) are not payable when billed

without a qualifying endoskeletal system or socket

HCPCS code.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Addition to lower extremity orthosis, for custom

fabricated orthosis only (HCPCS code L2755) is not

payable when billed and an appropriate base device has

not been billed within the previous three years.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Replacement lead wires (HCPCS code A4557) is not

payable when billed by any provider within a year of

billing a TENS device (HCPCS codes E0720, E0730).

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Toe extension/flexion device (HCPCS code E1830 or

E1831) is not payable when billed without a toe

anatomical modifier (TA-T9).

1/01/2018

Durable Medical Equipment

and Supplies Policy

DME repair codes are not payable when billed the same

day as a rental or purchase of a new or used piece of

equipment.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Finger extension/flexion device (HCPCS code E1825) is

not payable when billed without a finger anatomical

modifier (FA-F9).

1/01/2018

Durable Medical Equipment

and Supplies Policy

Home glucose monitoring supplies are not payable when

billed without the requisite modifier.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 37 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Durable Medical Equipment

and Supplies Policy

Stationary oxygen delivery system rentals (HCPCS codes

E0424, E0439, E1390, and E1391) are not payable when

billed more than once a month in any combination.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Oxygen accessories and supplies are not payable when

billed the same day or during the same month as a

monthly oxygen rental billing.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Oximeters and oximeter replacement probes as

convenience items that do not meet definition of DME

are not payable.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Silicone breast prosthesis items, HCPCS code L8030, are

not payable if billed more than one unit per side within a

two-year period.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Mutually exclusive respiratory assist devices are not

payable when billed within the same date of service or

within a month.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Replacement lens shield cartridges for use with laser

skin piercing device, HCPCS code A4257, or skin piercing

devices for collection of capillary blood, laser, each

HCPCS code E0620 are not payable.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Home blood glucose monitors (HCPCS codes E0607,

E2100, and E2101) are not payable when billed in any

combination more than once on the same date of

service by any provider.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Diabetic shoes are not payable when billed more than

two units within a calendar year.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Therapeutic shoe inserts/modifications for diabetics only

are not payable when billed more than six units within a

calendar year.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Custom molded shoes (HCPCS code L3250) are not

payable when billed with leg prostheses (HCPCS codes

L5010-L5600).

1/01/2018

Updated to include

PPOMR effective

8/01/2022

F, P

Durable Medical Equipment

and Supplies Policy

Walker with enclosed frame (HCPCS code E0144) are not

payable.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Walker wheel attachment (HCPCS code E0155) is not

payable when billed on the same day, or within one

month of a new or used nonwheeled walker (E0130,

E0135, E0148).

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Durable Medical Equipment

and Supplies Policy

Oxygen accessories and supplies are not payable.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Underarm, articulating, spring assisted crutch (HCPCS

code E0117) is not payable.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 38 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Durable Medical Equipment

and Supplies Policy

90-day pharmacy dispensing fee (HCPCS code Q0514) is

not payable when billed by any provider within 83 days

of a previous 90-day dispensing fee.

1/01/2018

Durable Medical Equipment

and Supplies Policy

30-day pharmacy dispensing fee (HCPCS code G0333 or

Q0513) are not payable when billed by any provider

within 83 days of a previous 90-day dispensing fee

(HCPCS code Q0514).

1/01/2018

Durable Medical Equipment

and Supplies Policy

30-da, or 90-day pharmacy dispensing fees (HCPCS

codes G0333, Q0513, or Q0514) are not payable when

the inhalation drug is not billed on the same claim.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Limit frequency of inhalation drugs based on CMS

guidelines.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Walker, heavy duty, multiple braking system, variable

wheel resistance (HCPCS code E0147) is not payable

when billed without modifier KX.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Prosthesis and orthosis codes are not payable when

billed without modifiers LT (Left) or RT (Right).

1/01/2018

Durable Medical Equipment

and Supplies Policy

Adhesive tape supply codes (HCPCS codes A4450 or

A4452) are not payable when billed without modifiers

AU, AV, AW, or AX and other TENS supply codes (HCPCS

codes A4364, A4455, A4456, A4555, A4556, A4558,

A4630, L7362, L7366) are not payable when billed on

the same date or during the same month as TENS supply

code, HCPCS code A4595, by any provider.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Any combination of HCPCS codes B4081-B4083

(Nasogastric tubes) is not payable when billed by any

provider more frequently than three tubes every three

months.

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Durable Medical Equipment

and Supplies Policy

Oxygen systems (HCPCS codes E0425, E0430, E0435,

E0440) are not payable when presented for purchase.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Oxygen contents (HCPCS codes E0441-E0444, E0447,

S8120, S8121) are not payable when billed the same day

or within the same month of an oxygen system rental

(HCPCS codes E0424, E0439, E1390, E1391) by any

provider.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Portable oxygen delivery systems (HCPCS codes E0431,

E0433, E0434, E1392, K0738) are not payable when

billed more than once a month in any combination.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Subsequent hospital beds are not payable if billed more

than once within a month.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Subsequent parenteral pumps (HCPCS codes B9004-

B9006) are not payable if billed more than once within a

month.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Durable Medical Equipment

and Supplies Policy

Nutritional additives (HCPCS codes B4164, B4180,

B4168-B4178, B4216) are not payable when billed with

premix formula (HCPCS codes B4189-B4199, B5000-

B5200).

1/01/2018

Durable Medical Equipment

and Supplies Policy

IV pole (HCPCS code E0776) and parenteral pumps

(HCPCS codes B9004-B9006) are only payable when

billed in the patient's home (POS 04, 12, 13, 14 and 55),

temporary lodging (POS 16), or in a custodial care facility

(POS 33).

1/01/2018

Durable Medical Equipment

and Supplies Policy

Enteral feeding kits (HCPCS codes B4034-B4036) are not

payable when billed by any provider for more than 31

feeding kits within a month's time.

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

F, P

Durable Medical Equipment

and Supplies Policy

Syringe enteral feeding kit (HCPCS code B4034) or

Gravity fed enteral feeding kit (HCPCS code B4036) are

not payable when billed by any provider on the same

day or within one month of an enteral nutrition infusion

pump (HCPCS code B9002).

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Updated to include

Facility claims

effect. 12/01/2021

Durable Medical Equipment

and Supplies Policy

Disposable nebulizers (HCPCS code A7008) are not

payable.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Only one crutch code (HCPCS codes E0110-E0116) are

allowed per date of service.

1/01/2018

Durable Medical Equipment

and Supplies Policy

DME rentals for the same code are not payable when

billed more than once within a month's time by any

provider.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Capped rentals are not payable when billed by any DME

provider in excess of 13 months within a 60-month time

period.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Commode chair mobile or stationary (HCPCS codes

E0163-E0171) are not payable when billed without

modifier KX.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Speech generating software (HCPCS code E2511) is not

payable when billed with other speech generating

devices (HCPCS codes E2500-E2510).

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Large volume ultrasonic nebulizer (HCPCS code E0575)

or reservoir bottle, non-disposable, used with large

volume ultrasonic nebulizer (HCPCS code A7009) are not

payable.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 40 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Durable Medical Equipment

and Supplies Policy

Deluxe feature, depth in-lay shoe or custom-molded

shoe (HCPCS code A5508) or direct formed, compression

molded inserts (HCPCS code A5510) are not payable.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Therapeutic shoe inserts/modifications for diabetics only

(HCPCS codes A5503-A5507 or A5512-A5514) are not

payable when billed with orthopedic footwear (HCPCS

codes L3215-L3253).

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Durable Medical Equipment

and Supplies Policy

Therapeutic shoe inserts/modifications for diabetics only

(HCPCS codes A5503-A5507 or A5512-A5514) are not

payable when billed more than six units per calendar

year

1/01/2018

Updated to include

Facility (HMOC,

HMOMR,

HMOMD) effective

11/16/2021

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

F, P

Durable Medical Equipment

and Supplies Policy

Orthopedic shoe inserts (HCPCS codes L3000-L3090),

heel stabilizers (HCPCS code L3170), orthopedic shoe lift

elevation per inch (HCPCS codes L3300-L3334),

orthopedic shoe wedges (HCPCS codes L3340-L3420),

orthopedic shoe additions (HCPCS codes L3430-L3595),

and misc. orthopedic shoe, addition modification or

transfer (HCPCS code L3649) are not payable when billed

with diabetic footwear (HCPCS codes A5500 or A5501).

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Durable Medical Equipment

and Supplies Policy

Prosthesis code are not payable when billed with

modifier K0 or KO.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Advanced knees, ankles and feet durable medical

equipment codes without the required K0-K4 functional

modifiers are not payable.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Durable Medical Equipment

and Supplies Policy

Advanced knees, ankles and feet durable equipment

codes reported with the inappropriate K0-K4 functional

modifiers are not payable.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Test sockets are not payable when billed with immediate

prostheses.

6/30/2020

Updated to include

Facility claims

effect. 12/01/2021

F, P

Durable Medical Equipment

and Supplies Policy

Additions to the preparatory prosthesis are not payable.

6/30/2020

Updated to include

Facility claims

effect. 12/01/2021

Durable Medical Equipment

and Supplies Policy

Orthopedic shoes, additions, or modifications are not

payable when billed without modifier KX.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 41 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Durable Medical Equipment

and Supplies Policy

Pneumatic appliances (sleeves) are not payable when

rented from the corresponding compressor that was

paid for within the same month or the purchased (new

or used) corresponding compressor that was also paid

for within the same year by any provider.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

IV pole (HCPCS code E0776) is not payable when billed

with ambulatory infusion pump codes (HCPCS codes

E0779-E0781, E0784, K0455) and billed without

parenteral infusion pump, stationary, single or multi-

channel (HCPCS code E0791) by any provider.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Durable Medical Equipment

and Supplies Policy

Prosthetic device repair labor service, HCPCS code

L7520, is not payable when billed with replacement

sockets/prostheses or with prosthetics billed with RA/RB

modifiers.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Any DMEPOS billed with Modifier EY (No physician or

other licensed health care provider order for this item or

service) will not be paid.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Deny frequently serviced items and oxygen systems

when presented for purchase, repair or replacement.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Skin protection and positioning wheelchair seat

cushions, HCPCS codes E2607, E2608, E2624, or E2625

are not payable when billed without the requisite

diagnosis criteria.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Replacement sockets are not payable when billed with

lower limb prosthesis or a preparatory lower limb

prosthesis.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Durable Medical Equipment

and Supplies Policy

Prosthetic repair labor services, HCPCS code L7520, is

not payable when billed within 3 months of lower limb

prostheses, HCPCS codes L5000-L5420, or preparatory

lower limb prostheses, HCPCS codes L5500-L5600, upper

limb prostheses, HCPCS codes L6000-L6370, L6388-

L6550, L6900-L6915, L6920-L6975, or preparatory upper

limb prostheses, HCPCS codes L6570-L6590.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Surgical dressings billed without modifiers A1-A9, or GY

are not payable.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Surgical dressings are not payable when submitted

multiple times with different wound modifiers (A1-A9)

by any provider for the same dressing.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Durable Medical Equipment

and Supplies Policy

Non-surgical dressing codes are not payable when

appended with surgical dressing modifiers A1-A9.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Gauze, impregnated, water or normal saline, HCPCS

codes A6228-A6230 are not payable.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Ocular prosthesis enlargement, HCPCS code V2625, is

payable once every five years.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 42 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Durable Medical Equipment

and Supplies Policy

Limit ocular prosthesis reduction (V2626) to once every

five years.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Sterile saline, HCPCS codes A4216/A4217, is not payable

when billed with oropharyngeal suction catheter, HCPCS

code A4628, or when a tracheal suction catheter, HCPCS

codes A4605/A4624, has not been billed within the

same month.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Diagnostic sockets, HCPCS codes L5618-L5628, are not

payable when more than two are reported for the same

date of service and same anatomical site.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Intermittent urinary catheters, HCPCS codes A4351-

A4353 are not payable for more than 600 combined

units per three months.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Indwelling catheters, HCPCS codes A4311-A4313, A4314-

A4316, A4338-A4346 are not payable when reported for

more than three units when billed in any combination

within three months.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

External urinary catheters, HCPCS code A4326, A4327-

A4328, A4349 are not payable when billed within the

same month as an indwelling urinary catheter, HCPCS

codes A4311-A4316, A4338-A4346.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Intermittent catheter, HCPCS code A4351/A4352, is not

payable when billed with catheter insertion tray, HCPCS

code A4310, and lubricant, HCPCS code A4332, by the

same provider on the same date of service.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Durable Medical Equipment

and Supplies Policy

Supplies are not payable when billed with a new

tracheostomy care kit, HCPCS codes A4625.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Amino acid and carbohydrate parenteral nutrition

compounds, HCPCS codes B4189-B4199, are not payable

beyond a maximum of 31 units within a month's time.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Parenteral supply kits, HCPCS codes B4220 and B4222

are not payable beyond a maximum of 31 units within a

month.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Tape, HCPCS codes A4450 and A4452, are not payable

when billed by a DME provider without modifiers AU,

AV, AW.

1/01/2018

Durable Medical Equipment

and Supplies Policy

30-day pharmacy dispensing fee codes, HCPCS code

G0333 or Q0513, are not payable when billed more than

once per month.

1/01/2018

Durable Medical Equipment

and Supplies Policy

HCPCS codes E2300 and E2301 are non-covered services.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Dual mode battery charger, HCPCS code E2367, is not

payable.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 43 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Durable Medical Equipment

and Supplies Policy

Drainage bags, HCPCS code A4357, are not payable

when billed individually or as part of the catheter

change (HCPCS codes A4314-A4316, A4354), for more

than six units within a three-month span.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Tape, HCPCS codes A4450 and A4452, are not payable

when billed with modifier AU (Urological Supply) on the

same day as a male external catheter (HCPCS codes

A4326 or A4349).

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Battery for use with ventricular assist device,

replacement [not lithium-ion], HCCPS codes Q0496 or

Q0503, are not payable if billed more than once within a

six-month span.

1/01/2018

Durable Medical Equipment

and Supplies Policy

VAD accessories are not payable when billed more than

one unit per year, unless billed with modifier RA or RB.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Disposable home glucose monitor, HCPCS code A9275, is

not payable. This is a convenience item that does not

meet definition of DME.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Replacement batteries for an owned external infusion

pump, HCPCS codes A4602 or K0601-K0605 are not

payable when billed on the same day or within the

previous month of an infusion pump rental (HCPCS

codes E0779, E0781, E0784, E0791, or K0455) by any

provider.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Non-sealed lead acid battery, HCPCS codes E2358,

E2360, E2362, E2364, E2372, are not covered.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Automatic external defibrillator (with integrated

electrocardiogram analysis), HCPCS codes K0606 or

E0617) are not payable when billed by a DME supplier

without modifier KX.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Any code billed by a DME provider that is not a DME

code will not be paid.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Ambulatory infusion pump, insulin (HCPCS code E0784)

or insulin for administration through DME (HCPCS code

J1817) is not payable when billed without modifier KX.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Power wheelchair accessories are not payable when

billed with a manual wheelchair.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Manual wheelchair accessories are not payable when

billed with a power wheelchair.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Claims for HCPCS codes L1810-L1860 (Knee orthosis),

L2275, L2320, L2330, L2385, L2390-L2397, L2405-L2492,

L2750, L2755, L2780-L2830, L2999, L4002, or L9900

(Orthotic additions) that are missing required modifiers

KX, GA, or GZ will deny.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 44 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Durable Medical Equipment

and Supplies Policy

Insulin infusion supplies (HCPCS code A4224) are not

payable when billed with previously paid infusion set for

external insulin pump (HCPCS code A4230 or A4231)

within one month's time.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Any service billed with a DME rental modifier (BR, RR, KI,

KJ, KR, LL) or a DME purchase modifier (BP, NU, UE) is

not payable if the same code has previously been billed

for the same date of service with either a DME rental

modifier or a DME purchase modifier.

1/1/2018

F, P

Durable Medical Equipment

and Supplies Policy

Skin barrier, wipes or swabs, each (HCPCS code A5120)

or Ostomy skin barrier, liquid (HCPCS code A4369) are

not payable when billed within the same month, by any

provider.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Durable Medical Equipment (DME) repair is not payable

when billed with a frequently serviced rental item

appended with modifier RR.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Services related to the uterus that are performed after a

total hysterectomy has been performed by any provider

are not payable.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Compounded inhalation solutions (HCPCS codes J7604,

J7607, J7609, J7610, J7615, J7622, J7624, J7627, J7628,

J7629, J7632, J7634, J7635, J7636, J7637, J7638, J7640,

J7641, J7642, J7643, J7645, J7647, J7650, J7657, J7660,

J7667, J7670, J7676, J7680, J7681, J7683, J7684, or

J7685) are not payable when billed.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Pharmacy supply fees are not payable when oral anti-

cancer, oral anti-emetic or immunosuppressive drugs

are not billed on the same claim.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Sterile water/saline (HCPCS code A4217) or distilled

water (HCPCS code A7018) is not payable when billed

with HCPCS code E0580 (Nebulizer, durable, for use with

regulator of flowmeter) by any provider.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Additions included in primary procedure are not payable

when billed with a prefabricated or custom fabricated

base orthosis.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

National Correct Coding Initiative (NCCI) column two

codes are not payable when billed with column one

code.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Orthotic accessories (HCPCS codes L4002-L4130, or

L4392) are not payable when billed with ankle foot

orthotic (AFO) or knee ankle orthotic (KAFO) when

provided at the same time.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Subsequent home blood glucose monitors (HCPCS codes

E0607, E2100, E2101) are not payable when billed in any

combination more than once within a year by any

provider.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 45 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Durable Medical Equipment

and Supplies Policy

Negative wound therapy pressure pump (HCPCS codes

A6550, A7000 or E2402) are not payable if reported

without modifier KX, GA, or GZ.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Electric heat pad, moist (HCPCS code E0215), water

circulating heat pad with pump (HCPCS code E0217),

pump for water circulating pad (HCPCS code E0236), or

pad for water circulating heat unit, for replacement only

(HCPCS code E0249) are not payable when billed.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Urological supplies (HCPCS codes A4310-A4328, A4332-

A4360, A5102-A5114 or K1010-K1012) are not payable

when billed without modifier KX.

1/01/2018

Durable Medical Equipment

and Supplies Policy

Ankle-foot orthosis/knee-ankle-foot orthosis (HCPCS

codes L1900-L1990, L2000-L2038, L2106-L2136, L2180-

L2850, L2999, L4350-L4387, L4396-L4398 or L4631) are

not payable when billed by a DME provider and modifier

GA, GZ or KX is not reported.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Group I, Group II, or Group III pressure reducing support

surface devices are not payable when billed without

modifier KX, GA, or GZ.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Commode chair mobile or stationary (HCPCS codes

E0163-E0171) is not payable when billed without

modifier KX, GA, or GZ.

1/01/2018

Durable Medical Equipment

and Supplies Policy

DMEPOS items are not payable when billed by a

DMEMAC provider and the place of service is not 01

(Pharmacy), 04 (Homeless shelter), 09 (Prison), 12

(Home), 13 (Assisted living facility), 14 (Group home), 16

(Temporary Lodging), 33 (Custodial care facility), 54

(Intermediate care facility/individuals with intellectual

disabilities), 55 (Residential substance abuse treatment

facility), 56 (Psychiatric residential treatment center), or

65 (End stage renal disease (ESRD) treatment facility

(POS valid for parenteral nutritional therapy)).

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Orthotic or prosthetic base procedures are not payable

when billed and the same procedure has been paid

within the previous five years by any provider.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Therapeutic shoes/inserts/modifications for diabetics

only (HCPCS codes A5500-A5507 or A5512-A5514) are

not payable when billed without modifier KX or GY.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 46 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Durable Medical Equipment

and Supplies Policy

Diabetic footwear (A5500-A5501) are not payable when

more than 2 units are billed within a calendar year

1/01/2018

Updated to include

Facility (HMOC,

HMOMR,

HMOMD) effective

11/16/2021

Updated to include

CNY, PPOC,

PPOMR Effective

8/01/2022

F, P

Durable Medical Equipment

and Supplies Policy

HCPCS "Pair" codes are not payable when billed with

modifier RT or LT.

1/01/2018

Updated to include

PPOC, PPOMR

Effective

8/01/2022

F, P

Durable Medical Equipment

and Supplies Policy

Capped rental HCPCS codes are not payable when billed

without modifier RR.

1/01/2018

Updated to include

PPOC, PPOMR

effective

8/01/2022

F, P

Durable Medical Equipment

and Supplies Policy

Osteogenesis stimulator (HCPCS codes E0747-E0748,

E0760, E0766) are not payable when billed without

modifier KF.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Prosthesis or orthosis codes are not payable when billed

with modifier 50.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Catheter/tube anchoring device (HCPCS code A5200) is

not payable when billed the same day or within a month

of an indwelling catheter (HCPCS codes A4311-A4316,

A4338-A4346) and enteral nutrition (HCPCS codes

B4081-B4088, B4149-B4162) has not been billed.

1/01/2018

F, P

Durable Medical Equipment

and Supplies Policy

Urological supplies (HCPCS codes A4310-A4328, A4332-

A4360, A5102-A5114 or K1010-K1012) are not payable

when billed without modifier GA, GY, GZ or KX.

1/01/2018

End Stage Renal Disease

(ESRD) Policy

Hemodialysis (CPT codes 90935 and 90937) are not

payable when billed by any provider more than three

times weekly with Place of Service 11 (Office), 12

(Home), 16 (Temporary lodging), 19 (Outpatient hospital

- off campus), 22 (Outpatient hospital-on campus), or 65

(End-Stage Renal Disease treatment facility).

1/01/2018

F, P

ENT Policy

Removal of impacted cerumen (CPT codes 69209, 69210

or HCPCS code G0268) are not payable when billed

without a diagnosis of impacted cerumen.

1/01/2018

ENT Policy

Audiologic function tests (CPT codes 92561-92564,

92571-92572, 92575-92576) as non-covered services.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 47 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Evaluation and Management

Services Policy

Telephone evaluation and management service provided

to an established patient (CPT/HCPCS 99441-99443) or

(HCPCS G2010, G2012 or G2252) are not payable when

an E/M service has been billed on the same day,

previous seven days, or following day with the same

primary diagnosis to the 3rd digit by the same group

practice (same Tax ID, any specialty).

3/01/2022

Evaluation and Management

Services Policy

Initial observation care codes (CPT codes 99218-99220)

or codes that include the initial observation care (CPT

codes 99234-99236) are not payable when an initial

observation care code has been billed for the previous

day by any provider.

1/01/2018

Evaluation and Management

Services Policy

Reimbursement for additional services considered part

of the pediatric critical care inter-facility transport codes

(CPT codes 99466-99467) and critical care codes (CPT

codes 99291-99292) is not allowed.

1/01/2018

F, P

Evaluation and Management

Services Policy

Reimbursement for services considered part of the

pediatric critical care interfacility transport E/M, CPT

code 99466, are not payable.

1/01/2018

F, P

Evaluation and Management

Services Policy

Care management services (CPT codes 99487, 99489-

99490, and HCPCS code G2058) are not payable when

billed within the same calendar month and certain

services have already been paid.

1/01/2018

F, P

Evaluation and Management

Services Policy

Preventive medicine initial or periodic visits (CPT code

99382 or 99392) is not payable when billed in any

combination more than seven times in a four-year

period and the patient is between one and four years of

age.

1/01/2018

F, P

Evaluation and Management

Services Policy

Preventive medicine initial or periodic visits (CPT code

99381 or 99391) is not payable when billed in any

combination more than eight times in one year and the

patient is less than one year of age.

1/1/2018

F, P

Evaluation and Management

Services Policy

Transitional Care Management (TCM) services (CPT

codes 99495-99496) are not payable when billed within

29 days of another TCM service and a discharge service

has not been billed in the previous 30 days by any

provider.

1/01/2018

F, P

Evaluation and Management

Services Policy

Transitional Care Management (TCM) services (CPT

codes 99495-99496) are not payable when billed by any

provider ID, within the same Tax ID and specialty, within

29 days of another TCM service.

1/01/2018

F, P

Evaluation and Management

Services Policy

Certain services are not payable when billed within the

same month as care management services (CPT codes

99487, 99489-99490, G2058).

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

Proprietary information of EmblemHealth. 2024 EmblemHealth & Affiliates

Page 48 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Evaluation and Management

Services Policy

Transitional Care Management (TCM) services (CPT

codes 99495-99496) are not payable when billed and a

facility E/M service has not been billed by any provider

for the same date of service or in the previous 30 days,

unless POS 21 is reported with any service for the same

day or in the previous 30 days.

1/01/2018

Evaluation and Management

Services Policy

Services such as monitoring vital signs, cardiac output

evaluation, chest x-rays, pulse oximetry measurement,

blood gas, ECGs, intubation, temporary pacing,

ventilation oversight, and any required vascular access

are considered part of pediatric critical care interfacility

transport E/M, CPT code 99466, and are not separately

payable.

1/01/2018

F, P

Evaluation and Management

Services Policy

Reimbursement for additional services considered part

of the pediatric critical care inter-facility transport codes

(99466-99467) and critical care codes (99291-99292) are

not allowed.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Evaluation and Management

Services Policy

Initial observation care codes (99218-99220) or codes

that include the initial observation care (99234-99236)

are not payable when an initial observation care code

has been billed for the previous day by any provider.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Evaluation and Management

Services Policy

Peak expiratory flow rate physician services, HCPCS code

S8110, are considered a component of the E/M or

overall physician service, unless a distinct services

modifier is appended to either code.

1/01/2018

F, P

Evaluation and Management

Services Policy

Hospital discharge services (99238-99239) are not

payable when 99238 or 99239 has been billed the

previous day.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Evaluation and Management

Services Policy

Outpatient/office consultation services, CPT codes

99241-99245, billed in the office setting are not payable

when any other evaluation and management service has

been billed in any place of service in the previous year.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Evaluation and Management

Services Policy

Second initial hospital care service (99221-99223) are

not payable when subsequent hospital care (99231-

99233), or another initial hospital care service has been

billed in the previous week for the same place of service,

and a discharge service (99238-99239) has not also been

reported in the previous week.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Evaluation and Management

Services Policy

New patient visits are not payable when any face-to-face

service has previously been billed by the same physician

or a physician from the same group practice (with the

same specialty and subspecialty) within the last three

years.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Evaluation and Management

Services Policy

HCPCS G0101 (Cervical or vaginal cancer screening;

pelvic and clinical breast examination) or Q0091

(Screening papanicolaou smear; obtaining, preparing

and conveyance of cervical or vaginal smear to

laboratory) are not payable when billed with 99384-

99387 or 99394-99397 (Preventive medicine visits) by

the same physician.

1/01/2018

Evaluation and Management

Services Policy

When multiple preventive medicine E/M services are

billed for the same date of service, the preventive

medicine E/M service with the lower RVU price will be

denied.

1/01/2018

Evaluation and Management

Services Policy

Deny evaluation and management codes with the lowest

RVU price when multiple evaluation and management

services are billed for the same date of service and same

revenue code.

1/01/2018

Evaluation and Management

Services Policy

EKG reports are not separately payable when billed with

an E/M service in the hospital setting.

1/01/2018

F, P

Evaluation and Management

Services Policy

Bilateral quantitative visual acuity screening test, CPT

code 99173 is not payable when reported with routine

ophthalmological examinations (HCPCS codes S0620 or

S0621)

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Evaluation and Management

Services Policy

HCPCS codes S0610-S0613 are not payable when billed

with 99384-99387 or 99394-99397.

1/01/2018

Evaluation and Management

Services Policy

E/M code with the lower RVU price is not payable,

when multiple E/M services are billed for the same date

of service, provider group and specialty, except when

modifier 25 is appended to the additional E/M service.

1/01/2018

Evaluation and Management

Services Policy

Problem-oriented E/M services are not payable when

billed with preventive medicine services, unless the E/M

service is billed with modifier 25.

1/01/2018

Evaluation and Management

Services Policy

E/M services are not payable when billed the same date

as electromyography, nerve conduction tests, or reflex

tests.

1/01/2018

Evaluation and Management

Services Policy

E/M services are not payable when billed the same date

of service as cardiovascular services (93260-93261,

93282-93284, 93287, 93289, 93292).

1/01/2018

Evaluation and Management

Services Policy

E/M services (99201-99215, 99221-99223, 99231-99233,

99460) are not separately payable when billed with

critical care service (99291) and the place of service is

the same, except when evaluation and management

services (including critical care services) are appended

with modifier 25.

1/01/2018

F, P

Evaluation and Management

Services Policy

New patient visit, or an initial care visit are not payable

when billed in excess of one unit.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Reimbursement Policy:

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(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Evaluation and Management

Services Policy

Observation care discharge service, CPT code 99217, is

not payable when billed and 99218-99220 (Initial

observation care admission service), 99224-99226

(Subsequent observation care) or a 0, 10 or 90-day

global service has not been billed by any provider within

the previous three days.

1/01/2018

F, P

Evaluation and Management

Services Policy

Inpatient hospital consult (99251-99255) is not payable

if any type of inpatient visit (initial inpatient admission,

inpatient hospital consult, subsequent hospital care) has

been billed in the previous week for the same place of

service, and an inpatient discharge visit (99238-99239)

has not also been billed. Refer to a subsequent

inpatient visit (99231-99233)

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Evaluation and Management

Services Policy

Any combination of 99477-99480 (Neonatal intensive

care) is limited to one unit per date of service by any

provider.

1/01/2018

F, P

Evaluation and Management

Services Policy

Initial neonatal and pediatric critical care codes 99468,

99471, and 99475 are not payable when the patient has

had inpatient critical care services the previous day.

Refer to subsequent neonatal and pediatric critical care

codes 99475 to 99469, 99472, and 99476.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Evaluation and Management

Services Policy

Initial neonatal intensive care service 99477 is not

payable when reported subsequent to the date of

admission.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Evaluation and Management

Services Policy

Any combination of 99468-99476 (Neonatal and

pediatric critical care) is limited to one unit per date of

service by any provider.

1/01/2018

Evaluation and Management

Services Policy

G0101 (Cervical or vaginal cancer screening; pelvic and

clinical breast examination) or Q0091 (Screening

papanicolaou smear; obtaining, preparing and

conveyance of cervical or vaginal smear to laboratory)

are not payable when billed with S0610-S0612 (Annual

GYN exam) by the same physician.

1/01/2018

Evaluation and Management

Services Policy

Evaluation and management services reported with

modifier 25 (same code) are limited to one unit when

reported by the same provider ID.

1/01/2018

Evaluation and Management

Services Policy

Observation services 99218-99220, 99224-99226,

99234-99236 are not payable when billed for more than

one unit per date of service in any combination by any

provider and the place of service is 19 (Outpatient

hospital - off campus), 21 (Inpatient hospital), 22

(Outpatient hospital - on campus), 23 (Emergency

department), 24 (Ambulatory Surgical Center).

1/01/2018

Reimbursement Policy:

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(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Evaluation and Management

Services Policy

Hospital discharge services (99238-99239) are not

payable when 99238 or 99239 has been billed for the

same date of service.

1/01/2018

F, P

Evaluation and Management

Services Policy

A new patient visit is not payable when billed by a non-

physician practitioner and any face-to-face service has

previously been billed by the same group practice (same

Tax ID, any specialty) within the last three years and the

primary diagnosis on the new patient visit matches any

diagnosis on the previous face-to-face service.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Evaluation and Management

Services Policy

CPT 99487, 99489-99491, G2058 (Care management

services) are not payable when billed without a

secondary diagnosis.

1/01/2018

F, P

Evaluation and Management

Services Policy

Medication therapy management; initial 15 minutes,

new patient (CPT 99605) is not payable if billed within

one year of a previous for 99605 or 99606.

1/01/2018

Evaluation and Management

Services Policy

Digital rectal examination (HCPCS code G0102) is not

payable when billed with preventive medicine E/M

codes (CPT codes 99381-99387, 99391-99397, G0402) or

wellness visits (HCPCS codes G0438-G0439).

1/01/2018

F, P

Evaluation and Management

Services Policy

Observation care discharge (CPT code 99217) or hospital

discharge day management (CPT codes 99238-99239)

are not payable when billed and observation or inpatient

hospital care including admission and discharge on the

same day (CPT codes 99234-99236) was billed the

previous day.

1/01/2018

Evaluation and Management

Services Policy

Interprofessional telephone/Internet consultation (CPT

code 99446-99449, 99451) are not payable when billed

and a diagnosis for health supervision or routine

examination is present.

1/01/2018

F, P

Evaluation and Management

Services Policy

Observation care discharge day (CPT code 99217) is not

payable when billed with CPT codes 99221-99223 (Initial

hospital care) on the same date of service by the same

provider.

1/01/2018

Evaluation and Management

Services Policy

Direct contact prolonged physician service in the

inpatient or observation setting (CPT code 99356) is not

payable if billed outside of an inpatient or observation

facility setting.

1/01/2018

Evaluation and Management

Services Policy

Observation care discharge day (CPT code 99217) is not

payable when an initial hospital care service (CPT codes

99221-99223) was billed the previous day.

1/01/2018

F, P

Evaluation and Management

Services Policy

Initial hospital or birthing center care code (CPT code

99460) is not payable when the newborn has received

initial or subsequent newborn care services the previous

day.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Evaluation and Management

Services Policy

Initial hospital or birthing center care, per day for

evaluation and management of normal newborn infant

admitted and discharged on same date (CPT code

99463) is not payable when billed and the newborn has

previously received newborn care services the previous

day.

1/01/2018

Evaluation and Management

Services Policy

Initial care, per day, for evaluation and management of

normal newborn infant seen in other than hospital or

birthing center (CPT code 99461) is not payable when

billed and the newborn has previously received newborn

care services the previous day.

1/01/2018

F, P

Evaluation and Management

Services Policy

Preventive medicine services are not payable when the

problem-oriented E/M service has been previously

processed for payment and modifier 25 was not

reported.

1/01/2018

Evaluation and Management

Services Policy

In accordance with CMS, complexity add-on code G2211

is not payable when reported with the outpatient/office

Evaluation and Management visit (Codes 99202, 99205,

99211-99215) with payment modifier 25.

1/1/2024

Evaluation and Management

Services Policy

CPT Code 99459 is not payable when billed with

Preventive medicine visits (CPT codes 99391-99397) or

illness-related E/M services (CPT codes 99211-99215).

CPT code 99459 was published by the American Medical

Association (AMA) to report, “Pelvic examination (List

separately in addition to code for primary procedure).”

The AMA published this code as an add-on code to be

used in conjunction with illness-related office Evaluation

and Management (E/M) codes and preventive services

E/M codes. It is intended to account for four minutes of

staff time spent chaperoning a pelvic exam. The practice

expense relative value unit (RVU) of existing E/M codes,

both illness-related E/M codes (99211-99215) and

preventive services E/M codes, accounts for clinical staff

time.

It is not consistent with RVU pricing to separate the staff

time spent chaperoning a pelvic exam from other staff

time included in E/M services. Therefore, the payment

for CPT code 99459 is considered to be included for both

preventive E/M Services and illness-related E/M

services. No separate payment will be made and 99459

will deny.

1/1/2024

F, P

Female Only Diagnosis Codes

Identifies claims containing diagnoses that are

inconsistent with the member's gender

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Fragmented Procedures

Policy

Procedures identified as a separate component of a

more comprehensive procedure or service are not

payable when submitted and review of the current claim

or history claim determines another component code

within the same family of codes was also billed and paid

for the same date of service by the provider.

All PPO 1/01/2022

HMOMR and

HMOC 03/17/2021

HMOMD

10/01/2021

Frequency Policy

Care plan oversight and care coordination services are

not payable when billed within the same calendar

month of a monthly ESRD services code.

1/01/2018

F, P

Frequency Policy

HCPCS G0179 Physician recertification for home health

services is not payable if billed more than once every

two months.

1/01/2018

Frequency Policy

Non-Pre-Diabetic Screening Services: Diabetes screening

tests are not payable with a diagnosis of screening for

diabetes mellitus when billed more than once every

year.

6/30/2020

F, P

Frequency Policy

Cardiovascular disease screening laboratory services

with a screening diagnosis are not payable when billed

more than once within a five-year period.

1/01/2018

Frequency Policy

Nursing assessment evaluations are not payable when

billed more than once a month.

1/01/2018

Frequency Policy

CPT 80305-80307 (Presumptive drug testing) is not

payable when billed more than one combined unit per

day.

1/01/2018

Frequency Policy

HCPCS G0480-G0483, G0659 (Definitive drug testing) are

not payable when billed more than one combined unit

per day.

1/01/2018

F, P

Frequency Policy

Chiropractic manipulative treatment (CPT codes 98940-

98942) are not payable when billed more than once per

day, when billed by any provider.

1/01/2018

F, P

Frequency Policy

Care plan oversight and care coordination services are

not payable when billed within the same calendar

month of a monthly ESRD services code.

1/01/2018

Gastroenterology Policy

CPT 43264 (Endoscopic retrograde removal of

calculus/calculi from biliary and/or pancreatic duct[s]) is

not payable when billed with 43274-43276 (Endoscopic

retrograde cholangiopancreatography [ERCP] with

placement of stent; removal of stent or foreign body;

stent exchange; balloon dilation).

1/01/2018

F, P

Gastroenterology Policy

CPT 45335 (Sigmoidoscopy, flexible; with directed

submucosal injection(s)) is not payable when billed with

45333, 45338, or 45346 (Sigmoidoscopy, flexible).

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Gastroenterology Policy

CPT 45381 (Colonoscopy, flexible; with injection(s)) is

not payable when billed with 45383-45385, 45388, or

G6024 (Colonoscopy).

1/01/2018

Updated to include

CNY effective

8/01/2022

F, P

Gender-Procedure Codes

Identifies claim lines containing Procedure Codes that

are inconsistent with the member's gender.

1/01/2018

F, P

General Surgery Policy

Incision and drainage of pilonidal cyst (CPT codes 10080-

10081) or excision of pilonidal cyst or sinus (CPT codes

11770-11772) are not payable when billed without a

diagnosis of pilonidal cyst or pilonidal sinus on the claim.

1/01/2018

General Surgery Policy

CPT 10080-10081 (Incision and drainage of pilonidal

cyst) or 11770-11772 (Excision of pilonidal cyst or sinus)

are not payable when billed without a diagnosis of

pilonidal cyst or pilonidal sinus on the claim.

1/01/2018

General Surgery Policy

CPT 15850 or 15851 (Removal of sutures under

anesthesia [other than local]) is not payable when the

patient's age is greater than 12 years.

1/01/2018

F, P

General Surgery Policy

Proctosigmoidoscopy (CPT codes 45300, 45303, 45317),

or sigmoidoscopy (CPT codes 45330, 45334) are not

payable when billed with partial or total colectomy (CPT

codes 44140-44160) or laparoscopic partial or total

colectomy (CPT codes 44204-44213).

1/01/2018

F, P

Genetic Testing Policy

Molecular pathology procedure; physician interpretation

and report (HCPCS code G0452) is not payable when

billed without modifier 26.

1/01/2018

F, P

Global Component

Identifies claim lines for which the sum of all

payments (total, professional, technical) exceeds

the payment expected for the total procedure. This

rule will also detect when duplicate

submissions have occurred for the total procedure

or its components, across providers.

The following scenarios are audited:

• Global vs. Global

• Global vs. Professional

• Global vs. Technical

• Professional vs. Global

• Technical vs. Global

• Professional vs. Professional

• Technical vs. Technical

Auditing could vary based upon a Facility or Non-

facility claim.

2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 55 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Global Obstetrical Policy

Subsequent billings of antepartum care only codes (CPT

code 59425 or 59426) is not payable when either code

has been previously billed.

1/01/2018

Global Obstetrical Policy

Global delivery codes are not payable when the provider

has billed antepartum care in the last eight months.

1/01/2018

Global Obstetrical Policy

Subsequent delivery codes are not payable if more than

one delivery code is billed for the same date of service

or within the previous six months by any provider or

specialty.

1/01/2018

Global Obstetrical Policy

Separate reimbursement for those services which are

included in the global obstetrical package for

uncomplicated maternity cases are not payable when

billed on the same day as the delivery.

1/01/2018

Global Obstetrical Policy

Global delivery codes are not payable when a different

provider group has billed for antepartum care only

services in the last eight months.

1/01/2018

Global Obstetrical Policy

Cerclage removal as included in the delivery fee, when

the removal of a cerclage (CPT code 59871) is not

payable when billed on the same date of service as the

delivery code.

1/01/2018

F, P

Global Obstetrical Policy

Global delivery codes are not payable when a different

provider group has billed for antepartum care only

services in the last eight months.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Global Obstetrical Policy

Cerclage removal (59871) is not separately payable

when billed on the same date of service as the delivery

code.

1/01/2018

Global Obstetrical Policy

Services which are included in the global obstetrical

package for uncomplicated maternity cases are not

separately payable when billed on the same day as the

delivery.

1/01/2018

F, P

Global Obstetrical Policy

Subsequent delivery codes are not payable if more than

one delivery code is billed for the same date of service

or within the previous six months by any provider or

specialty.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Global Obstetrical Policy

Global delivery codes including antepartum care is not

payable if the provider has billed antepartum care in the

last eight months.

1/01/2018

F, P

Global Obstetrical Policy

Subsequent billings of antepartum care only codes

(59425 or 59426) are not payable when either code has

been previously billed.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Global Obstetrical Policy

E/M services or postpartum care are not payable when

billed within 42 days (6 weeks) by the same Tax ID and

specialty that performed a delivery that includes

postpartum care.

1/01/2018

Reimbursement Policy:

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(Commercial, Medicare & Medicaid)

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Page 56 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

Global Obstetrical Policy

Antepartum care services for a normal pregnancy are

not payable when billed for the same date of service or

within 240 days (8 months) prior to the date of a

delivery that includes antepartum care.

1/01/2018

F, P

Global Obstetrical Policy

Antepartum services billed with a date of service up to

one week following a previous delivery is not payable.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Global Obstetrical Policy

Evaluation and Management services are not payable

when billed five months after the billing of antepartum

only services and the diagnosis is normal pregnancy and

there is no intervening history of ectopic pregnancy

(59100-59151) or abortion (59812-59857, S0199, S2260,

S2265-S2267).

1/01/2018

Global Obstetrical Policy

C-section delivery (CPT codes 59510-59515, 59618-

59622) are not payable when billed more than once for

the same date of service by any provider and the

diagnosis is multiple gestation.

1/01/2018

Global Obstetrical Policy

Global package via vaginal delivery (CPT code 59400) is

not payable when billed with global package via

cesarean delivery (CPT code 59510) and the diagnosis is

multiple gestation.

1/01/2018

Global Obstetrical Policy

Second global package via vaginal delivery (CPT code

59400) is not payable when billed with another global

package via vaginal delivery (CPT code 59400) and the

diagnosis is multiple gestation.

1/01/2018

Global Obstetrical Policy

Routine vaginal birth after cesarean (CPT code 59610) is

not payable when billed with global cesarean delivery

procedure (CPT code 59618) and the diagnosis is

multiple gestation.

1/01/2018

F, P

Global Obstetrical Policy

Global package via vaginal delivery (CPT code 59400) is

not payable when billed with global package via

cesarean delivery (CPT code 59510) and the diagnosis is

NOT multiple gestation.

1/01/2018

Global Obstetrical Policy

Second global vaginal delivery procedure (CPT code

59610) is not payable when the diagnosis is multiple

gestation.

1/01/2018

Global Surgery Policy

Daily management of epidural or subarachnoid drug

administration (CPT code 01996) is not payable when

billed with a 0-day, 10-day or 90-day surgical procedure.

1/01/2018

Global Surgery Policy

0-day, 10-day or 90-day surgical procedures with

modifier 47 or P1-P6 are not payable when the same

procedure has also been billed without modifier 47 or

P1-P6.

1/01/2018

Reimbursement Policy:

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Claim Type

Medical Policy

Rule Description

Effective Date

Global Surgery Policy

Evaluation and management services are not payable

performed within 10 postoperative days of a 10-day

medical or surgical service billed by the same Provider ID

regardless of Tax ID and Specialty.

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

when billed with modifier 25 on the same day as a

procedure with a 0-day, 10-day, or 90-day postoperative

period with the same primary diagnosis when also billed

within 2 months of a face-to-face service with the same

diagnosis.

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

when billed with modifier 25 on the same day as a

procedure with a 0-day, 10-day, or 90-day postoperative

period with the same primary diagnosis when also billed

within 2 months of a face-to-face service with the same

diagnosis.

1/01/2018

Global Surgery Policy

Care management services (CPT codes 99487-99491 and

HCPCS codes G2058, G2064-G2065) or transitional care

management services (CPT codes 99495-99496) are not

payable when performed within 10 postoperative days

of a 10-day medical or surgical service (CMS).

1/01/2018

Global Surgery Policy

Procedure codes with 0, 10 or 90-day global surgery

periods billed with modifier 47 or P1-P6 are not payable

when the same procedure has also been billed without

modifier 47 or P1-P6 (CMS).

1/01/2018

Global Surgery Policy

CPT 01996 (Daily management of epidural or

subarachnoid drug administration) is not payable when

billed with a 0-day, 10-day or 90-day surgical procedure

(CMS).

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

when billed the same day as a medical or surgical service

by an Outpatient Facility. (CMS-1450)

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Global Surgery Policy

Evaluation and management services are not payable

when billed on the same day as a 0-day medical or

surgical service.

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

when performed the same day as a 10-day medical or

surgical service.

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

performed within 10 postoperative days of a 10-day

medical or surgical service element.

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

when performed the day prior to a 90-day medical or

surgical service.

1/01/2018

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Claim Type

Medical Policy

Rule Description

Effective Date

Global Surgery Policy

Evaluation and management services are not payable

when performed the same day as a 90-day medical or

surgical service.

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

when performed within 90 postoperative days of a 90-

day medical or surgical service.

1/01/2018

Global Surgery Policy

0, 10 or 90-day surgical procedures are not payable

when performed within 90 days of a 90-day surgical

procedure.

1/01/2018

Global Surgery Policy

Separate reimbursement for services typically

considered part of a minor 10-day surgical procedure

(CMS + Cotiviti Supplement).

1/01/2018

Global Surgery Policy

Deny separate reimbursement for services typically

considered part of a major 90-day surgical procedure

(CMS + Cotiviti Supplement).

1/01/2018

Global Surgery Policy

Evaluation and management services when performed

the same day as a 90-day medical or surgical service are

not payable when billed by the same Provider ID,

regardless of Tax ID and Specialty.

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

when performed within 90 postoperative days of a 90-

day medical or surgical service when billed by a non-

physician practitioner (NPP) with the same Tax ID,

regardless of Provider ID and Specialty, and the E/M

service has a primary diagnosis associated to the 90-day

medical or surgical service (CMS).

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

when performed within 90 postoperative days of a 90-

day medical or surgical service when billed by a non-

physician practitioner (NPP) with the same Tax ID,

regardless of Provider ID and Specialty, and the

diagnosis is a complication of surgical and medical care

or an aftercare diagnosis (CMS).

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

when performed within 10 postoperative days of a 10-

day medical or surgical service when billed by a non-

physician practitioner (NPP) with the same Tax ID,

regardless of Provider ID and Specialty, and the E/M

service has a primary diagnosis associated to the 10-day

medical or surgical service (CMS).

1/01/2018

Reimbursement Policy:

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(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Global Surgery Policy

Evaluation and management services are not payable

when performed within 10 postoperative days of a 10-

day medical or surgical service when billed by a non-

physician practitioner (NPP) with the same Tax ID,

regardless of Provider ID and Specialty, and the

diagnosis is a complication of surgical and medical care

or an aftercare diagnosis (CMS).

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

when billed with modifier 24 and a major surgical

procedure with a 90-day postoperative period has been

billed in the previous 90 days and the E/M service has a

primary diagnosis associated to the 90-day medical or

surgical service. (CMS + Cotiviti Supplement)

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

when billed with modifier 24 and a major surgical

procedure with a 90-day postoperative period has been

billed in the previous 90 days and the E/M diagnosis is a

complication of surgical and medical care or an aftercare

diagnosis. (CMS + Cotiviti Supplement)

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

when billed with modifier 24 and a minor surgical

procedure with a 10-day postoperative period has been

billed in the previous 10 days and the E/M service has a

primary diagnosis associated to the 10-day medical or

surgical service. (CMS + Cotiviti Supplement)

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

when billed with modifier 24 and a minor surgical

procedure with a 10-day postoperative period has been

billed in the previous 10 days and the E/M diagnosis is a

complication of surgical and medical care or an aftercare

diagnosis. (CMS + Cotiviti Supplement)

1/01/2018

Global Surgery Policy

Supplies are not payable if billed on the same date of

service as a 0-day, 10-day, or 90-day surgical procedure.

1/01/2018

Global Surgery Policy

Evaluation and management services performed within

90 postoperative days of a 90-day medical or surgical

service is not payable when billed by the same Provider

ID, regardless of Tax ID and Specialty.

1/01/2018

Global Surgery Policy

Evaluation and management services are not payable

when performed the day prior to a 90-day medical or

surgical service and billed by the same Provider ID,

regardless of Tax ID and Specialty.

1/01/2018

Global Surgery Policy

0-day and 10-day surgical procedures performed within

10 postoperative days of a 10-day surgical procedure are

not payable when submitted by the same provider ID,

regardless of Tax ID and Specialty.

1/01/2018

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Claim Type

Medical Policy

Rule Description

Effective Date

Global Surgery Policy

Evaluation and management services when performed

the same day as a 10-day medical or surgical service for

the same Provider are not payable when submitted with

any Tax Group or Specialty.

1/01/2018

Global Surgery Policy

0, 10 or 90-day surgical procedures billed by the same

provider ID, regardless of Tax ID and Specialty within 90

days of a 90-day surgical procedure are not payable.

1/01/2018

Global Surgery Policy

Evaluation and management services when performed

the same day as a 0-day medical or surgical service are

not payable when billed by the same Provider ID,

regardless of Tax ID and Specialty.

1/01/2018

Healthplan Policy

Covid-19 specimen collection services (HCPCS codes

G2023 and G2024) are considered integral to the

performance of Covid testing. As such, the separate

reimbursement is not warranted when a Covid is

rendered.

3/1/2020

Healthplan Policy

CPT 99174 1 unit in 12-month period. Exception:

Hospital, Ophthalmologist, Optometrist, Neurology, and

Pediatric Neurology.

1/01/2018

Healthplan Policy

G0471 (Collection of venous blood by venipuncture or

urine sample by catheterization from an individual in a

skilled nursing facility (SNF) or by a laboratory on behalf

of a home health agency (HHA)) is not payable when

billed in Place of Service 11, 19, 21, 22, 23, or 24

1/01/2018

Healthplan Policy

In accordance with our policy, colonoscopies,

sigmoidoscopies, and proctosigmoidoscopies are only

covered with specific indications. Please refer to our

policy for additional details- Colonoscopy Procedures-

EmblemHealth

1/01/2018

Healthplan Policy

Procedure codes with a CMS Physician Fee schedule

indicator of "B" are considered bundled services that are

mutually exclusive to other services performed on the

same day and are not separately payable under any

circumstance.

1/01/2018

Healthplan Policy

COVID-19 specimen collection services (HCPCS codes

G2023 and G2024) are considered integral to the

performance of COVID testing. As such, the separate

reimbursement is not warranted when a COVID test is

rendered.

3/1/2020

Healthplan Policy

Change 36410 (Venipuncture, age 3 years or older,

necessitating physician's skill [separate procedure], for

diagnostic or therapeutic purposes [not to be used for

routine venipuncture]) to 36415 (routine venipuncture)

when billed without a covered diagnosis.

1/1/2018

Terminated for

Medicare effective

9/24/2023

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Claim Type

Medical Policy

Rule Description

Effective Date

Inappropriate Age Code Use

Policy

Procedures with an age/age range designation are not

payable when submitted and the member’s age does

not correspond with the age/age range of the

procedure.

1/01/2022

Inappropriate Age Code Use

Policy

Diagnosis codes with an age/age range designation are

not payable when submitted and the member’s age

does not correspond with the age/age range of the

diagnosis code.

1/01/2022

Inappropriate Use of

Modifier Policy

Procedures that are submitted with modifier 26, 50 or

TC and are designated as professional, bilateral or

technical component as “not permitted for this

procedure” or “concept does not apply” are not payable

per the Payment Indicators within the CMS Medicare

National Physician Fee Schedule Relative Value File

(NPFSRVF).

All PPO

1/01/2022

HMOMR and

HMOC 03/17/2021

HMOMD

10/01/2021

Inappropriate Use of

Modifier Policy

Procedures that are not designated for

telehealth/telemedicine are not payable when

submitted with modifiers G0, GQ, GT, or 95.

1/01/2022

Incident To Services Policy

An "incident to" services are not payable when billed

with a place of service code 02, 19, 21, 22, 23, 24, 26, 31,

34, 41, 42, 51, 52, 53, 56, or 61.

1/01/2018

Incident To Services Policy

Procedures designated as an "incident to" service are

not payable when billed with a place of service code 02,

19, 21, 22, 23, 24, 26, 31, 34, 41, 42, 51, 52, 53, 56, or

61.

1/01/2018

Interprofessional

Telephone/Internet

Consultations

CPT codes 99446-99449, or 99451 (Interprofessional

telephone/Internet consultation) are not payable when

billed and any face-to-face service has been billed on the

same date or within the previous 14 days.

1/26/2021

Interprofessional

Telephone/Internet

Consultations

CPT codes 99446-99449, or 99451 (Interprofessional

telephone/Internet consultation), in any combination,

are limited to one unit within seven days.

1/26/2021

Invalid Revenue Code/

Procedure Code

Combination

Claims submitted with invalid HCPCS/CPT and Revenue

code combinations are not payable and will be denied

10/1/2022

F, P

Laboratory-Pathology Policy

Any procedure billed with modifier QW (CLIA waived

test) not designated as a CLIA waived test on the clinical

laboratory fee schedule is not payable.

1/01/2018

Laboratory-Pathology Policy

Supplies (e.g. urine dipsticks for glucose or ketones,

syringes, alcohol wipes, betadine or iodine swabs etc)

are inherent to a laboratory Service when the supply

must be routinely available for performance of the

reported service.

1/1/2018

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exam (CPT code

88305, 88307, or 88309) is not payable when the only

diagnosis on the claim line is a hemorrhoid diagnosis

code.

1/01/2018

F, P

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exam (CPT code

88305, 88307, or 88309) is not payable when the only

diagnosis on the claim line is a hydrocele or

spermatocele diagnosis code.

1/01/2018

F, P

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exam (CPT code

88307, or 88309) is not payable when the only diagnosis

on the claim line is polyp of stomach and duodenum.

1/01/2018

F, P

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exam (CPT code

88305, 88307, or 88309) is not payable when the only

diagnosis on the claim line is a cornea diagnosis code.

1/01/2018

F, P

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exam (CPT code

88305, 88307, or 88309) is not payable when the only

diagnosis on the claim line is ganglion cyst.

1/01/2018

F, P

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exam (CPT code

88305, 88307, or 88309) is not payable when the only

diagnosis on the claim line is an appendix diagnosis

code.

1/01/2018

F, P

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exam (CPT code

88305, 88307, or 88309) is not payable when the only

diagnosis on the claim line is a gallbladder diagnosis

code.

1/01/2018

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exams (88305,

88307, or 88309) are not payable when the only

diagnosis on the claim line is a gallbladder diagnosis

code

1/01/2018

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exams (88305,

88307, or 88309) are not payable when the only

diagnosis on the claim line is an appendix diagnosis code

1/01/2018

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exams (88305,

88307, or 88309) are not payable when the only

diagnosis on the claim line is a ganglion cyst diagnosis

code

1/01/2018

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exams (88305,

88307, or 88309) are not payable when the only

diagnosis on the claim line is a cornea diagnosis code

1/01/2018

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exams (88305,

88307, or 88309) are not payable when the only

diagnosis on the claim line is a polyp diagnosis code

1/01/2018

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exams (88305,

88307, or 88309) are not payable when the only

diagnosis on the claim line is a hydrocele or

spermatocele diagnosis code

1/01/2018

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Claim Type

Medical Policy

Rule Description

Effective Date

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exams (88305,

88307, or 88309) are not payable when the only

diagnosis on the claim line is a hemorrhoid diagnosis

code

1/01/2018

Laboratory-Pathology Policy

Modifier QW (CLIA waived test) is not payable when

billed with a procedure code that is not designated as a

CLIA waived test on the clinical laboratory fee schedule.

1/01/2018

Laboratory-Pathology Policy

Travel allowance one way in connection with medically

necessary laboratory specimen (HCPCS codes P9603 or

P9604) are not payable when billed without a specimen

collection code.

1/01/2018

Laboratory-Pathology Policy

Supplies (e.g. urine dipsticks for glucose or ketones,

syringes, alcohol wipes, betadine or iodine swabs etc)

are inherent to a laboratory service when the supply

must be routinely available for performance of the

reported service.

1/01/2018

F, P

Laboratory-Pathology Policy

CPT code 86769 (Antibody; severe acute respiratory

syndrome coronavirus 2 (SARS-CoV-2)) is not payable

when billed with 0224U (Antibody; severe acute

respiratory syndrome coronavirus 2, includes titer(s),

when performed) by any provider.

2/01/2022

F, P

Laboratory-Pathology Policy

CPT code U0004 (COVID-19 lab test non-CDC high

throughput) is not payable when billed with U0002

(COVID-19 lab test non-CDC) by any provider.

2/01/2022

F, P

Laboratory-Pathology Policy

Nucleic-acid based SARS-CoV-2 viral tests (CPT codes

87631, 87635-87637, 87811, 0240U, 0241U, U0001, and

U0003) will be limited to one unit per day, unless

reported with modifier 59, by any provider.

2/01/2022

F, P

Laboratory-Pathology Policy

CPT code U0003 (COVID-19 infectious agent detection

by nucleic acid, high throughput) is not payable when

billed with 87635 (COVID-19 Infectious agent detection

by nucleic acid) by any provider.

2/01/2022

F, P

Laboratory-Pathology Policy

CPT code 0224U (Antibody; severe acute respiratory

syndrome coronavirus 2, includes titer(s)) is not payable

when billed and 86769 (Antibody; severe acute

respiratory syndrome coronavirus 2 (SARS-CoV-2) has

been previously billed and paid on the same date of

service by any provider.

2/01/2022

F, P

Laboratory-Pathology Policy

CPT code U0002 (Covid-19 lab test non-CDC) is not

payable when billed and U0004 (Covid-19 lab test non-

CDC high throughput) has been previously billed and

paid on the same date of service by any provider.

2/01/2022

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Laboratory-Pathology Policy

CPT code 87635 (COVID-19 Infectious agent detection by

nucleic acid) is not payable when billed and U0003

(COVID-19 infectious agent detection by nucleic acid,

high throughput) has been previously billed and paid on

the same date of service by any provider.

2/01/2022

F, P

Laboratory-Pathology Policy

Surgical pathology gross & microscopic exam (88304,

88305, 88307 or 88309) are not payable when the only

diagnosis on the claim line is an encounter for

sterilization (Z30.2).

3/15/2023

F, P

LCD_PXDX_FREQ_MULTIDX

Identifies Professional and Outpatient Facility claim lines

for certain procedure codes associated with a single

diagnosis code/multiple diagnosis codes or no diagnosis

code, modifier, age and frequency requirement where

the procedure is not considered medically necessary,

payable, or has payment constraints according to Local

Coverage Determinations (LCDs).

LCD’s applicable to Connecticut, Massachusetts and New

York are posted and maintained by NGS Medicare at the

Medical Policy Center. https://www.ngsmedicare.com/

10/01/2021

F, P

LCD_MED_NEC_ICD10

Identifies Professional and Outpatient Facility claim lines

for certain procedure codes associated with diagnoses

where the procedure is not considered medically

necessary, payable, or has payment constraints

according to Part A and Part B Local Coverage

Determinations (LCDs).

LCD’s applicable to Connecticut, Massachusetts and New

York are posted and maintained by NGS Medicare at the

Medical Policy Center. https://www.ngsmedicare.com/

10/01/2021

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Male Only Diagnosis Codes

Identifies claims containing diagnoses that are

inconsistent with the member's gender.

1/01/2018

F, P

Manifestation Codes

All services received with a manifestation codes billed in

the primary, first listed or principal diagnosis position

are not payable.

8/31/2021

F, P

Manifestation Diagnosis

Code Policy

Diagnoses designated as manifestation codes are not

payable when submitted as the primary diagnosis.

1/01/2022

Maximum Units Policy

Codes billed for a number of units that exceeds the

allowed number of units are not payable.

9/29/2020

Maximum Units Policy

Claims for a certain number of units that exceed the

annual assigned allowable unit(s) for that procedure and

the same member are not payable.

1/01/2018

Maximum Units Policy

Excess units are not payable when any provider bills a

number of units that exceed the daily assigned allowable

unit(s) for that procedure for the same member.

1/01/2018

Maximum Units Policy

As per the ICD manual, Maternal Fetal Medicine services

59000, 59020, 74713, 76802, 76810, 76812, 76814,

76816, 76818-78621, or 76825-76828 are payable based

on diagnosis.

1/01/2018

Maximum Units Policy

Surgeries that allow multiple assistant surgeons are not

payable when billed by same or different provider.

1/01/2018

Maximum Units Policy

Units of service greater than 1 are not payable when

billed by any provider for a code with an anatomical

modifier (E1-E4, FA-F9, TA-T9).

1/01/2018

Maximum Units Policy

Procedures are not payable when the same provider

bills a certain number of units of team surgery or co-

surgery that exceed the daily assigned allowable unit(s)

for that procedure for the same member.

1/01/2018

Maximum Units Policy

As per the ICD-10 Manual, Obstetrical procedure codes

74713, 76802, 76810, 76812, 76814 are not payable

when billed without the requisite diagnosis.

1/01/2018

Maximum Units Policy

"Certain procedures based on the code description or

code guidelines, regardless of appended modifier, are

limited to one unit per day. (CMS-1500)

1/01/2018

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Claim Type

Medical Policy

Rule Description

Effective Date

Maximum Units Policy

Excess units are not payable when any provider bills a

certain number of units that exceed the daily assigned

allowable unit(s) for that procedure for the same

member.

1/01/2018

Maximum Units Policy

Excess units are not payable when any provider bills a

certain number of units that exceed the annual assigned

allowable unit(s) for that procedure for the same

member.

1/01/2018

Medicaid - New York State

Policy

According to New York Medicaid coding guidelines, CDT

D1206 or CPT 99188 (Topical application of fluoride

varnish) is limited to one unit in a three-month period

when billed by any provider for a patient between six

months and six years of age.

10/20/2019

Medicaid - New York State

Policy

CPT 91110 (Gastrointestinal tract imaging, intraluminal

[e.g. capsule endoscopy], esophagus through ileum) is

not payable when billed and the only diagnosis on the

claim is hematemesis.

1/01/2018

Medicaid - New York State

Policy

According to New York Medicaid, CPT 59400-59410

(Vaginal Delivery), 59510-59515 (Cesarean Delivery) or

59610-59622 (VBAC Delivery) are not payable when

billed without modifier U7, U8, or U9

1/01/2018

Medicaid - New York State

Policy

Vaginal Delivery (CPT codes 59400-59410), cesarean

delivery (CPT codes 59510-59515) or VBAC delivery (CPT

codes 59610-59622) are not payable when billed

without modifier U7, U8, or U9.

1/01/2018

Medicaid - New York State

Policy

Topical application of fluoride varnish (CPT code 99188)

is not payable beyond one unit in a three-month period

when billed by any provider for a patient between six

months and six years of age.

1/01/2018

Medicaid - New York State

Policy

Gastrointestinal tract imaging, intraluminal [e.g. capsule

endoscopy], esophagus through ileum (CPT code 91110)

is not payable when billed and the only diagnosis on the

claim is hematemesis.

1/01/2018

Medicaid - New York State

Policy

According to New York Medicaid guidelines, durable

medical equipment, orthotics, prosthetics and supplies

(DMEPOS) have been assigned a maximum number of

units that may be billed regardless of the provider within

a designated time frame.

When the total number of billed units exceed the

assigned number allowed, the units will be adjusted to

match the assigned allowed units and the excess units

will be denied when billed by any provider.

9/13/2023

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Claim Type

Medical Policy

Rule Description

Effective Date

Medicaid - New York State

Policy

According to New York Medicaid guidelines, modifier RB

(Replacement of part of a DME, orthotic or prosthetic

item furnished as part of a repair) is not required when a

code is available for a specific replacement part.

Therefore, codes indicated as replacement parts will be

denied when appended with modifier RB.

10/15/2024

Medicaid - New York State

Policy

According to New York Medicaid guidelines, allergy

testing, when billed by a provider specialty of alternative

medicine, audiology, chiropractor, home health, nurse

practitioner, physician assistant, midwife, occupational

therapy, optometry, physical therapy, speech therapy or

psychology, is not payable and will be denied.

10/15/2024

Medically Unlikely Edits

(MUE)- Outpatient

Identifies claim lines where the CMS Facility MUE has

been exceeded for a CPT/HCPCS code with MUE

adjudication indicator (MAI) = 1, 2 or 3, reported by the

same provider, for the same member, on the same date

of service. This rule will evaluate date ranges to

determine if the MUE has been met or not.

• MAI = 1 claim line edit. If a claim line quantity

exceeds the MUE allowed value, that single

claim line will be denied.

• MAI = 2 date of service edits (based on policy).

No Modifier override is allowed and will not be

considered if appealed.

• MAI = 3 date of service edits (based on clinical

benchmarks). Modifier 59 will not override

MAI of 3. Clinical documentation to support

reimbursement for additional units may be

submitted as an appeal.

10/01/2021

Medically Unlikely Edits

(MUE)- Practitioner

Identifies claim lines where the CMS Professional MUE

has been exceeded for a CPT/HCPCS code with MUE

adjudication indicator (MAI) = 1, 2 or 3, reported by the

same provider, for the same member, on the same date

of service. This rule will evaluate date ranges to

determine if the MUE has been met or not.

• MAI = 1 claim line edit. If a claim line quantity

exceeds the MUE allowed value, that single

claim line will be denied.

• MAI = 2 date of service edits (based on policy).

No Modifier override is allowed and will not be

considered if appealed.

• MAI = 3 date of service edits (based on clinical

benchmarks). Modifier 59 will not override MAI of 3.

10/01/2021

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Claim Type

Medical Policy

Rule Description

Effective Date

Clinical documentation to support reimbursement

for additional units may be submitted as an appeal.

F, P

Modifier Policy

Intravenous home infusion codes are not payable when

billed with modifier SJ (third or more concurrently

administered infusion therapy) and another intravenous

home infusion code has not been previously billed for

the same date of service with modifier SH (second

concurrently administered infusion therapy).

1/01/2018

Updated to include

PPOC, PPOMR

effective

8/01/2022

F, P

Modifier Policy

Procedures or services that are incompatible with

modifier 92 are not payable.

1/01/2018

Updated to include

PPOC, PPOMR

effective

8/01/2022

F, P

Modifier Policy

X-ray transportation services are not payable when

reported without an x-ray transportation modifier.

1/01/2018

Updated to include

PPOC, PPOMR

effective

8/01/2022

Modifier Policy

Procedure codes that are inappropriately billed with

anatomical modifiers are not payable.

1/01/2018

F, P

Modifier Policy

Procedure codes defined as requiring an anatomical

modifier that are billed without an associated

anatomical modifier are not payable.

1/01/2018

Updated to include

Facility (HMOC,

HMOMR,

HMOMD) effective

11/16/2021

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Modifier Policy

Services billed with invalid modifier to procedure code

combinations are not payable.

1/01/2018

Modifier Policy

All claims submitted with modifiers that are not

recognized by the Centers of Medicare and Medicaid

Services (CMS) or the American Medical Association

(AMA) will be deemed as invalid.

7/01/2020

Modifier Policy

Anesthesia codes (00100-01999, 99100-99140 or D9223)

inappropriately billed with distinct service modifiers are

not payable.

1/01/2018

Modifier Policy

Procedures appended with modifier 76 (Repeat

procedure/same physician) are not payable when the

same procedure code has not been billed by the same

Provider ID on the same date of service, or within the

post-operative period of the billed procedure. (CMS)

1/01/2018

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Modifier Policy

CPT 90476-90750, 90756 (Vaccines, toxoids), J3530

(Nasal vaccine inhalation), Q2034-Q2039 (Influenza virus

vaccine, split vaccine) or S0195 (Pneumococcal

conjugate vaccine, polyvalent, intramuscular, for

children from five years to nine years of age who have

not previously received the vaccine) are not payable

when billed with modifier SL (State supplied vaccine)

and the allowed amount is more than $0.01.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Modifier Policy

Procedure codes defined as requiring an anatomical

modifier are not payable when billed without an

associated anatomical modifier.

1/01/2018

Modifier Policy

Any procedures billed with modifier 27, 73, 74 or CA are

not payable under a professional claim.

1/01/2018

F, P

Modifier Policy

Procedures appended with modifier 77 (Repeat

procedure/different physician) are not payable when the

same procedure code has not been billed by a different

Provider ID on the same date of service or within the

post-operative period of the billed procedure.

1/01/2018

F, P

Modifier Policy

Procedures appended with modifier 78 are not payable

when the same or different 0, 10 or 90 day-procedure

code has not been billed on the same day for a 0-day

post-operative period, on the same day or in the

previous 10-days for a code with a 10-day post-operative

period, or on the same day or in the previous 90 days for

a code with a 90-day post-operative period.

1/01/2018

Modifier Policy

Deny HPSA modifier QU after January 1, 2006.

1/01/2018

F, P

Modifier Policy

Procedures appended with modifier 77 (Repeat

procedure/different physician) are not payable when the

same procedure code has been billed by the same

Provider ID on the same date of service or within the

post-operative period of the original procedure billed.

1/01/2018

Modifier Policy

Services billed with modifier 53 (Discontinued service)

are not payable when billed with Bill Type 0120-012Z

(Inpatient-part B), 0130-013Z (Outpatient hospital),

0140-014Z (Outpatient hospital-other), or 0830-083Z

(Ambulatory surgical center).

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

F, P

Modifier Policy

All evaluation and management services are not payable

when billed with modifier 53.

1/01/2018

Modifier Policy

Laboratory panel codes are not payable when billed with

modifier 52 or 53.

1/01/2018

F, P

Modifier Policy

Physical medicine and rehabilitation services are not

payable when billed without therapy modifiers GN, GO

or GP.

1/01/2018

F, P

Modifier Policy

Services that are inappropriately billed with telehealth

services modifier GQ (Telehealth services via

1/01/2018

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Rule Description

Effective Date

asynchronous telecommunications system) are not

payable.

F, P

Modifier Policy

Services reported with modifier 95 (Synchronous

telemedicine service rendered via a real-time interactive

audio and video telecommunications system) are not

payable when billed with any code other than an

approved telemedicine service code.

1/01/2018

F, P

Modifier Policy

Procedures appended with modifier 79 are not payable

when the same or different 0, 10 or 90-day procedure

code has not been billed on the same day for a code

with a 0-day post-operative period, on the same day or

in the previous 10 days for a code with a 10-day post-

operative period, or on the same day or in the previous

90 days for a code with a 90-day post-operative period.

1/01/2018

Multiple Endoscopy – Pay

Percent

Identifies multiple endoscopy procedures, reported

within the same family, and applies the multiple

endoscopy reduction, per CMS guidelines. In addition, if

more than one endoscopy family is reported and/or

surgery procedures are reported, the rule will apply the

multiple surgery cutback to the appropriate endoscopy

family or families and surgery procedures.

This rule will also recommend payment adjustments for

other applicable payment modifiers and assign the

appropriate pay percentage to the eligible line(s).as well

as bilateral*, multiple quantity*, and assign the

appropriate pay percentage to the eligible line(s).

9/01/2021

Multiple Procedure

Reduction Policy

Modifier 51 appended to a procedure code not subject

to Multiple Procedure Reduction based on CMS fee

schedule is not payable.

1/01/2018

National Correct Coding

Initiative Policy

Column two procedure codes are not payable when

billed with an associated column one procedure code.

1/01/2018

National Correct Coding

Initiative Policy

Column two procedure codes are not payable when

billed with an associated mutually exclusive column one

procedure code.

1/01/2018

National Correct Coding

Initiative Policy

Column one procedure codes with revenue code 0960-

0989 are not payable when the column two procedure

code has been previously paid.

1/01/2018

National Correct Coding

Initiative Policy

Column one procedure codes with revenue code 0960-

0989 are not payable when the column two procedure

code has been previously paid.

1/01/2018

National Correct Coding

Initiative Policy

Column one procedure codes are not payable when

billed by the same Provider ID, regardless of Tax ID or

Specialty, and the Column two Code has been previously

paid.

1/01/2018

National Correct Coding

Initiative Policy

Column two procedure codes are not payable when

billed with associated column one procedure code.

1/01/2018

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Rule Description

Effective Date

National Correct Coding

Initiative Policy

Column two procedure codes are not payable when

billed with associated column one procedure code that

is billed by the same Provider ID regardless of Tax ID and

Specialty.

1/01/2018

National Correct Coding

Initiative Policy

Column one procedure codes are not payable when

mutually exclusive Column two procedure code has

been previously paid. (CMS 1450)

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

National Correct Coding

Initiative Policy

Column one procedure codes are not payable when a

Column two procedure code has been previously paid.

1/01/2018

National Correct Coding

Initiative Policy

NCCI PTP edits: Column two procedure code when billed

with associated Mutually Exclusive Column one

procedure code are not payable.

1/01/2018

National Correct Coding

Initiative Policy

NCCI PTP edits: Column two procedure code when

billed with associated Column one procedure code are

not payable. Non-Mutually Exclusive Edits.

1/01/2018

National Correct Coding

Initiative Policy

CMS NCCI column two procedure codes are not payable

when billed with associated Column one procedure code

when billed by the same Provider ID regardless of Tax ID

and Specialty. Non-Mutually Exclusive Edits.

1/01/2018

National Correct Coding

Initiative Policy

NCCI Column two procedure code is not separately

payable when billed with associated Mutually Exclusive

Column one procedure code when billed by the same

Provider ID regardless of Tax ID and Specialty.

1/01/2018

National Correct Coding

Initiative Policy

Column one procedure codes are not payable when a

Column two procedure code has been previously paid

for the same date of service. Non-Mutually Exclusive

Edits.

1/01/2018

National Correct Coding

Initiative Policy

CMS NCCI Mutually Exclusive code pair edits will result

in denial of a Column two code when billed with column

one code. (CMS-1450)

1/01/2018

National Correct Coding

Initiative Policy

CMS NCCI non-Mutually Exclusive code pair edits will

result in denial of a Column two code when billed with

column one code. (CMS-1450)

1/01/2018

National Correct Coding

Initiative Policy

IV infusion services billed without modifier 59 or

modifier XE are not payable when billed with IV

chemotherapy administration service codes.

1/01/2018

F, P

National Correct Coding

Initiative Policy

Deny Column one procedure code when the Column two

procedure code has been previously paid. Non-Mutually

Exclusive Edits. (CMS-1450)

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

National Correct Coding

Initiative Policy

Transesophageal echocardiography (TEE) (CPT codes

93318 or 93355) are not payable when billed with

anesthesia services.

1/01/2018

Reimbursement Policy:

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Rule Description

Effective Date

F, P

National Correct Coding

Initiative Policy

DME Column two codes are not payable when billed

with an associated DME Column one code. Non-

Mutually Exclusive Edits.

1/01/2018

F, P

National Correct Coding

Initiative Policy

Transesophageal echocardiography (TEE) (CPT codes

93312-93317) when billed without a distinct services

modifier are not payable when billed with anesthesia

services (CPT codes 00100-01992).

1/01/2018

Updated to include

PPOMR effective

8/01/2022

National Correct Coding

Initiative Policy

Column one procedure codes are not payable when a

Column two procedure code has been previously paid.

1/01/2018

F, P

National Correct Coding

Initiative Policy

Column one procedure codes are not payable when

billed by the same Provider ID, regardless of Tax ID or

Specialty, and the Column two Code has been previously

paid.

1/01/2018

F, P

National Correct Coding

Initiative Policy

Column one procedure codes are not payable when

billed by the same Provider ID, regardless of Tax ID or

Specialty, and the Column two Code has been previously

paid.

1/01/2018

National Correct Coding

Initiative Policy

Column two procedure codes are not payable when

billed with an associated Column one procedure code

and the revenue code is 0960-0989.

1/01/2018

National Correct Coding

Initiative Policy

Column two procedure codes are not payable when

billed with associated mutually exclusive column one

procedure code and the revenue code is 0960-0989.

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

National Correct Coding

Initiative Policy

Column one procedure codes are not payable when the

column two procedure code has been previously paid.

1/01/2018

National Correct Coding

Initiative Policy

Column one procedure codes are not payable when

billed by the same Provider ID, regardless of Tax ID or

Specialty, and the column two code has been previously

paid.

1/01/2018

National Correct Coding

Initiative Policy

Column two procedure codes are not payable when

billed with associated mutually exclusive column one

procedure code.

1/01/2018

National Correct Coding

Initiative Policy

Column two procedure codes are not payable when

billed with an associated mutually exclusive column one

procedure code by the same Provider ID regardless of

Tax ID and Specialty.

1/01/2018

F, P

National Correct Coding

Initiative Policy

Durable medical equipment column two procedure

codes are not payable when billed with an associated

mutually exclusive column one procedure code.

1/01/2018

F, P

National Correct Coding

Initiative Policy

Durable medical equipment (DME) column one

procedure codes are not payable when the DME column

two procedure code has been previously paid.

1/01/2018

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Rule Description

Effective Date

F, P

National Correct Coding

Initiative Supplemental

Policy

Temporary during COVID-19 Pandemic: CMS NCCI

Column two procedure code is not payable when billed

with associated Column one procedure code based on

NCCI in place pre-pandemic.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

National Correct Coding

Initiative Supplemental

Policy

Temporary during COVID-19 Pandemic: CMS NCCI

Column two procedure code is not payable when billed

with associated Column one procedure code based on

NCCI in place pre-pandemic.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

National Correct Coding

Initiative Supplemental

Policy

Temporary during COVID-19 Pandemic: CMS NCCI

Column two procedure code is not payable when billed

with associated Column one procedure code based on

NCCI in place pre-pandemic.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

National Correct Coding

Initiative Supplemental

Policy

Temporary during COVID-19 Pandemic: CMS NCCI

Column two procedure code is not payable when billed

with associated Column one procedure code based on

NCCI in place pre-pandemic.

1/01/2018

National Correct Coding

Initiative Supplemental

Policy

Temporary during COVID-19 Pandemic: CMS NCCI

Column two procedure code is not payable when billed

with associated Column one procedure code based on

NCCI in place pre-pandemic.

1/01/2018

National Correct Coding

Initiative Supplemental

Policy

Temporary during COVID-19 Pandemic: CMS NCCI

Column two procedure code is not payable when billed

with associated Column one procedure code based on

NCCI in place pre-pandemic.

1/01/2018

National Correct Coding

Initiative Supplemental

Policy

Temporary during COVID-19 Pandemic: CMS NCCI

Column two procedure code is not payable when billed

with associated Column one procedure code based on

NCCI in place pre-pandemic.

1/01/2018

National Correct Coding

Initiative Supplemental

Policy

Temporary during COVID-19 Pandemic: CMS NCCI

Column two procedure code is not payable when billed

with associated Column one procedure code based on

NCCI in place pre-pandemic.

1/01/2018

National Correct Coding

Initiative Supplemental

Policy

Temporary during COVID-19 Pandemic: CMS NCCI

Column two procedure code is not payable when billed

with associated Column one procedure code based on

NCCI in place pre-pandemic.

1/01/2018

National Correct Coding

Initiative Supplemental

Policy

Temporary during COVID-19 Pandemic: CMS NCCI

Column two procedure code is not payable when billed

with associated Column one procedure code based on

NCCI in place pre-pandemic.

1/01/2018

National Correct Coding

Initiative Supplemental

Policy

Temporary during COVID-19 Pandemic: CMS NCCI

Column two procedure code is not payable when billed

with associated Column one procedure code based on

NCCI in place pre-pandemic.

1/01/2018

Reimbursement Policy:

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Rule Description

Effective Date

National Correct Coding

Initiative Supplemental

Policy

Temporary during COVID-19 Pandemic: CMS NCCI

Column two procedure code is not payable when billed

with associated Column one procedure code based on

NCCI in place pre-pandemic.

1/01/2018

National Correct Coding

Initiative Supplemental

Policy

Consultation codes are not separately payable when

billed with a primary procedure unless the consultation

code is billed with modifier 25 and the clinical

documentation supports the use of modifier 25.

1/01/2018

National Correct Coding

Initiative Supplemental

Policy

Consultation codes are not separately payable when

billed with a primary procedure unless the consultation

code is billed with modifier 25 and the clinical

documentation supports the use of modifier 25.

1/01/2018

National Correct Coding

Manual Policy

Intravenous infusions of lidocaine hydrochloride (HCPCS

J2001) are not payable when billed with any service on

the same day.

1/01/2018

National Correct Coding

Manual Policy

E/M Services (99201-99239, 99281-99443, 99450-99499

or S0280-S0281) without modifier 25 are not separately

payable when billed with 95004-95199 (Allergy testing

or allergy immunotherapy).

1/01/2018

National Correct Coding

Manual Policy

E/M services are not separately payable when billed on

the same day as a cardiac stress test.

1/01/2018

National Correct Coding

Manual Policy

CPT 69990 (Operating microscope) is payable only when

billed with a code from the list of allowed procedures.

1/01/2018

F, P

National Correct Coding

Manual Policy

Deny procedures considered to be inappropriately

coded based on National Correct Coding Initiative

Policies and Guidelines.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

National Correct Coding

Manual Policy

E/M Services (99201-99499) are not payable when billed

with Anesthesia Services (00100-01999) the day prior to

or the day of surgery.

1/01/2018

National Correct Coding

Manual Policy

Evaluation and management services are not payable

when billed with a 0, 10, or 90 day global radiology

service and the provider specialty is radiology.

1/01/2018

F, P

National Correct Coding

Manual Policy

Daily hospital management of epidural or subarachnoid

continuous drug administration (CPT code 01996) is not

payable beyond one unit per date of service when

reported by any provider.

1/01/2018

F, P

National Correct Coding

Manual Policy

Urinalysis (CPT codes 81000-81003, 81005, 81099),

creatinine (CPT code 82570), pH; body fluid (CPT code

83986), or spectrophotometry (CPT code 84311) are not

payable when billed with toxicology procedures (CPT

codes 0007U, 0051U), presumptive drug screen tests

(CPT codes 80305-80307), or definitive drug tests (CPT

codes 0006U, 0082U, 0093U, 0143U-0150U, 80320-

80377, 83992, or HCPCS codes G0480-G0483, G0659).

1/01/2018

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Rule Description

Effective Date

NCCI Comprehensive

Component Policy

Procedures categorized as a Column II code are not

payable when submitted by the same provider, for the

same date of service as an associated comprehensive

Column I code.

All PPO 1/01/2022

HMOMR and

HMOC 03/17/2021

HMOMD

10/01/2021

NCCI Mutually Exclusive

Policy

Procedures categorized as a Column II code are not

payable when submitted by the same provider, for the

same date of service as an associated mutually exclusive

Column I code.

All PPO 1/01/2022

HMOMR and

HMOC 03/17/2021

HMOMD

10/01/2021

NCCI PTP Facility Policy

Procedures categorized as a Column II code are not

payable when submitted on the same date of service

and by the same provider as the designated Column I

code.

All PPO 1/01/2022

HMOMR and

HMOC 03/17/2021

HMOMD

10/01/2021

F, P

NCD Procedure to Diagnosis:

EXCLUSIONARY Lab Policy

(NCD Exclusionary)

Identifies Professional and Outpatient Facility claim lines

where laboratory procedures are not considered

medically necessary or payable according to the Centers

for Medicare and Medicaid Services (CMS) National

Coverage Policy for Laboratory Procedures located at

https://www.cms.gov/medicare/coverage/coveragegeni

nfo/downloads/manual201701_icd10.pdf

This Exclusionary policy is based on the CMS defined list

of "ICD-10-CM Codes That Do Not Support Medical

Necessity."

Denial of the procedure code will occur because of its

submission with an ICD-10 diagnosis code that is part of

the non-payable conditions list OR because of its

submission with an ICD-10 diagnosis code that is part of

the CMS defined list of "Non-covered ICD-10-CM Codes

for All NCD Edits" in the Medicare National Coverage

Determinations (NCD) Coding Policy Manual and Change

Report.

10/01/2021

F, P

NCD Procedure to Diagnosis:

Inclusionary Lab Policy

NCD_INCLUSIONARY

Identifies Professional and Outpatient Facility claim lines

where laboratory procedures are not considered

medically necessary or payable according to the Centers

for Medicare and Medicaid Services (CMS) National

Coverage Policy for Laboratory Procedures located at

https://www.cms.gov/medicare/coverage/coveragegeni

nfo/downloads/manual201701_icd10.pdf

This Inclusionary policy is based on the CMS defined list

of "ICD-10-CM Codes Covered by Medicare Program".

Denial of the procedure code will occur because of its

submission with an ICD-10 diagnosis code that is not

10/01/2021

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Claim Type

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Rule Description

Effective Date

part of the payable list OR because of its submission

with an ICD-10 diagnosis code that is part of the CMS

defined list of "Non-covered ICD-10-CM Codes for All

NCD Edits" in the Medicare National Coverage

Determinations (NCD) Coding Policy Manual and Change

Report.

F, P

NCD Procedure to Diagnosis:

Non-Covered

(NCD_POLICY_EXCL)

Identifies Professional and Outpatient Facility claim lines

submitted for procedure codes paired with specific

diagnoses for which that code pair is defined as non-

covered or not payable according to the Centers for

Medicare and Medicaid Services (CMS) National

Coverage Determination Policy (NCD). CMS established

National Coverage policies to evaluate clinical evidence

to determine whether the evidence is of sufficient

quality to support a finding that an item or service that

falls within a benefit category is reasonable and

necessary for the diagnosis or treatment of illness or

injury or to improve the functioning of the body.

The Coverage Determinations manual is located at

https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Internet-Only-Manuals-

IOMs-Items/CMS014961

10/01/2021

F, P

NCD Procedure to Diagnosis:

Covered (NCD_POLICY_INCL)

Identifies Professional and Outpatient Facility claim lines

for procedure codes not submitted with a covered

diagnosis and is therefore defined as non-covered or not

payable according to the Centers for Medicare and

Medicaid Services (CMS) National Coverage

Determination Policy (NCD). CMS established National

Coverage policies to evaluate clinical evidence to

determine whether the evidence is of sufficient quality

to support a finding that an item or service that falls

within a benefit category is reasonable and necessary for

the diagnosis or treatment of illness or injury or to

improve the functioning of the body.

The Coverage Determinations manual is located at

https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Internet-Only-Manuals-

IOMs-Items/CMS014961

10/01/2021

F, P

NCD Procedure to Diagnosis

Coverage

(NCD_PXDX_COVERAGE)

Identifies Professional and Outpatient Facility claim lines

for certain procedure codes associated with a single

diagnosis code/multiple diagnosis codes or no diagnosis

code, modifier, age and frequency requirement where

10/01/2021

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Rule Description

Effective Date

the procedure is not considered medically necessary,

payable, or has payment constraints according to

National Coverage Determinations (NCDs).

The Coverage Determinations manual is located at

https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Internet-Only-Manuals-

IOMs-Items/CMS014961

Neurology Policy

CPT 95957 (EEG for epileptic spike analysis) is not

payable when billed on same date of service as 95700-

95726 (Long-term EEG monitoring) by any provider.

1/01/2018

F, P

Neurology Policy

Needle electromyography services (CPT codes 95963

and 95864) are not payable when the only diagnosis

associated to the procedures is carpal tunnel syndrome.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Neurology Policy

Needle electromyography services (CPT codes 95963

and 95864) are not payable when the only diagnosis

associated to the procedures is tarsal tunnel syndrome.

1/01/2018

F, P

Neurology Policy

Neuromuscular junction testing, each nerve, any 1

method (CPT code 95937) is not payable beyond three

units per day when the diagnosis on the claim is

myoneural disorders.

1/01/2018

F, P

Neurology Policy

Neuromuscular junction testing, each nerve, any 1

method (CPT code 95937) is not payable beyond two

units per day when the diagnosis on the claim is motor

neuron disease, muscular dystrophies and other

myopathies, weakness, fatigue, cramps, or involuntary

movements, and a diagnosis which allows a higher study

frequency is not also present.

1/01/2018

F, P

Neurology Policy

Polysomnography (CPT codes 95782, 95783, 95808,

95810 or 95811) are not payable when billed in any

combination more than one unit per date of service by

any provider.

1/01/2018

F, P

Neurology Policy

Polysomnography (CPT codes 95782, 95783, 95808,

95810 or 95811) are not payable when billed in any

combination more than one unit in a two consecutive

day period by any provider.

1/01/2018

Terminated

effective

9/24/2023

Neurology Policy

Digital analysis of electroencephalogram [EEG] (CPT

code 95957) is not payable when billed on same date of

service as long-term EEG monitoring (CPT codes 95700-

95726) by any provider.

1/01/2018

F, P

Never Events

Any procedure billed with modifier PA (Surgical or other

invasive procedure on wrong body part), PB (Surgical or

other invasive procedure on wrong patient), or PC

9/01/2021

Updated to include

PPOMR effective

8/01/2022

Reimbursement Policy:

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Claim Type

Medical Policy

Rule Description

Effective Date

(Wrong surgery or other invasive procedure on patient)

is not payable.

New Patient Code Frequency

Policy

New patient codes are not payable when submitted and

review of the current claim OR patient's history

determines a new patient code was previously billed and

paid by the same provider within the past three (3) years

All PPO 1/01/2022

HMOMR and

HMOC 03/17/2021

HMOMD

10/01/2021

F, P

Observation Services Policy

Observation services are not payable when billed with a

bill type other than 13X or 85X.

1/01/2018

Updated to include

PPOMR effective

8/01/2022

Updated to include

Facility claims

effect. 12/01/2021

Observation Services Policy

Claims for HCPCS code G0379 will be denied when billed

without a history of an allowed claim for HCPCS code

G0378. (CMS-1450)

1/01/2018

Updated to include

PPOMR effective

8/01/2022

F, P

Observation Services Policy

99217 (Observation care discharge) or 99238-99239

(Hospital discharge day management) are not payable

when 99234-99236 (Observation or inpatient hospital

care including admission and discharge on the same day)

was billed the previous day.

1/01/2018

Updated to include

Facility (HMOC,

HMOMR,

HMOMD) effective

11/16/2021

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

F, P

Obsolete Procedure Code

Policy

Procedures that are deemed invalid are not payable.

All PPO 1/01/2022

HMOMR and

HMOC 03/17/2021

HMOMD

10/01/2021

Obstetrics and Gynecology

Policy

Colposcopy of the cervix including upper/adjacent

vagina; with endocervical curettage (CPT code 57456),

endocervical curettage (CPT code 57505) and

cauterization of cervix (CPT code 57510) are not payable

when billed with colposcopy of the cervix including

upper/adjacent vagina (CPT code 57460).

1/01/2018

Terminated

effective

3/30/2021

Obstetrics and Gynecology

Policy

Pregnant uterus ultrasound services, CPT codes 76801-

76812, are payable when billed with abortion services

(CPT codes 59812-59857 or S2260-S2267).

1/01/2018

Terminated

effective

3/30/2021

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Rule Description

Effective Date

F, P

Obstetrics and Gynecology

Policy

Complete and limited non-obstetric pelvic ultrasounds,

CPT codes 76856 and 76857, are not covered when

billed with transvaginal ultrasounds, CPT code 76830,

during the same visit.

1/01/2018

Obstetrics and Gynecology

Policy

Non-obstetric transvaginal ultrasound, CPT code 76830,

is not payable when billed with obstetric transabdominal

ultrasound, CPT code 76810, during the same visit.

1/01/2018

Terminated

effective

3/30/2021

F, P

Obstetrics and Gynecology

Policy

Initial obstetric ultrasound services, CPT codes 76805 or

76810-76812 are not payable when a previous initial

obstetric ultrasound has been billed in the past five

months.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Obstetrics and Gynecology

Policy

Transvaginal ultrasound, CPT code 76817, is not payable

when billed with transabdominal ultrasound, CPT codes

76801-76812.

1/01/2018

Terminated

effective

3/30/2021

Obstetrics and Gynecology

Policy

Complete non-obstetric pelvic ultrasounds, CPT code

76856, are not payable when billed with saline infusion

sonohysterography (SIS), CPT code 76831, during the

same visit.

1/01/2018

F, P

Obstetrics and Gynecology

Policy

CPT 76801 or 76802 (Pregnant uterus ultrasound

services) is not payable when 76801 or 76802 has been

previously billed in the past three months.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Obstetrics and Gynecology

Policy

Trachelorrhaphy (CPT code 57720), dilation of cervical

canal (CPT code 57800), subcutaneous infusion (CPT

code 96369) or intra-arterial injection (CPT code 96373)

are not payable when billed with abortion services.

1/01/2018

F, P

Obstetrics and Gynecology

Policy

Detailed fetal anatomic ultrasound (CPT code 76811 or

76812) is not payable when billed and the only diagnosis

on the claim is supervision of normal pregnancy, routine

screening for malformations using ultrasonics, fetal

anatomic survey, or antenatal screening of mother.

1/01/2018

Once Per Lifetime Services

Policy

Subsequent claims after initial reimbursement is made

for once in a lifetime services by any provider are not

payable.

1/01/2018

Once Per Lifetime Services

Policy

Codes for once in a life-time-procedures are not payable

when previously reimbursed.

1/01/2018

F, P

Once Per Lifetime Services

Policy

Certain services related to the uterus are not payable

when reported after a total hysterectomy has been

performed by any provider.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Once Per Lifetime Services

Policy

Subsequent claims are not payable after initial

reimbursement is made for once in a lifetime services by

any provider.

1/01/2018

Reimbursement Policy:

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(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Once Per Lifetime Services

Policy

Subsequent claims are not payable by any provider after

initial reimbursement is made for once in a lifetime

services per National CMS policy.

1/01/2018

F, P

Ophthalmology Policy

Scanning computerized ophthalmic diagnostic imaging,

retina (CPT code 92134) is not payable when billed more

than once within a 28-day period when the diagnosis is

retinal disease.

1/01/2018

Updated to include

PPOC, PPOMR

effective

8/01/2022

Terminated

effective

9/24/2023

Ophthalmology Policy

Extended ophthalmoscopy with a retinal/optic nerve

drawing, CPT codes 92201-92202, are not payable when

billed and an appropriate diagnosis is not present on the

claim.

4/28/2020

Ophthalmology Policy

Extended ophthalmoscopy with a retinal/optic nerve

drawing, unilateral or bilateral (CPT codes 99201 and

99202) are not payable when billed with fundus

photography (CPT code 92250).

2/25/2020

Ophthalmology Policy

Extended ophthalmoscopy with a retinal/optic nerve

drawing, unilateral or bilateral (CPT codes 99201 and

99202) are not payable when billed more than two times

per eye per year without an appropriate diagnosis on

the claim.

2/25/2020

Ophthalmology Policy

Extended ophthalmoscopy with a retinal/optic nerve

drawing, unilateral or bilateral (CPT codes 99201 and

99202) are not payable when billed more than four

times per eye per year with a neoplasm diagnosis.

2/25/2020

Ophthalmology Policy

Extended ophthalmoscopy with a retinal/optic nerve

drawing, unilateral or bilateral (CPT codes 99201 and

99202) are not payable when billed more than six times

per eye per year with a diagnosis of disorders of the

globe, choroid, retina, iris and ciliary body, or glaucoma.

2/25/2020

Ophthalmology Policy

Extended ophthalmoscopy with a retinal/optic nerve

drawing, unilateral or bilateral (CPT codes 99201 and

99202) are not payable when billed more than 12 times

per eye per year with a diagnosis of exudative senile

macular degeneration.

2/25/2020

Ophthalmology Policy

CPT 92250 (Fundus photography) is not payable when

billed more than two units within one year except when

specific diagnoses are present.

1/01/2018

F, P

Ophthalmology Policy

Comprehensive ophthalmological services are not

payable when a previous comprehensive

ophthalmological service has been billed in the previous

six months. See Ophthalmology Reimbursement Policy.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Reimbursement Policy:

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(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Ophthalmology Policy

CPT 76514 (Ophthalmic ultrasound, diagnostic; corneal

pachymetry) is not payable when billed more than once

in a patient's lifetime with a diagnosis of glaucoma or

ocular hypertension (OHT).

1/01/2018

Ophthalmology Policy

Extended ophthalmoscopy with a retinal/optic nerve

drawing, unilateral or bilateral (CPT codes 99201 and

99202) are not payable when billed more than six times

per eye per year with a diagnosis of disorders of the

globe, choroid, retina, iris and ciliary body, or glaucoma.

2/25/2020

F, P

Ophthalmology Policy

As per CMS LCD Article A56551, Visual field examination

(CPT codes 92081-92083) are not payable when billed

without a requisite diagnosis.

1/01/2018

F, P

Ophthalmology Policy

Scanning computerized ophthalmic diagnostic imaging,

anterior segment (CPT code 92132) is not payable when

billed and an appropriate diagnosis is not present on the

claim.

1/01/2018

F, P

Ophthalmology Policy

Scanning computerized ophthalmic diagnostic imaging,

posterior segment (CPT code 92133 or 92134) is not

payable when billed and an appropriate diagnosis is not

present on the claim.

1/1/2018

F, P

Ophthalmology Policy

Ophthalmic ultrasound, anterior segment ultrasound,

bio-microscopy (CPT code 76513) is not payable when

billed with a diagnosis of glaucoma as the only diagnosis

on the claim.

1/01/2018

Ophthalmology Policy

Extended ophthalmoscopy with a retinal/optic nerve

drawing, unilateral or bilateral (CPT codes 92201-92202)

are not payable when billed and an appropriate

diagnosis is not present on the claim.

1/01/2018

Ophthalmology Policy

Extended ophthalmoscopy with a retinal/optic nerve

drawing, unilateral or bilateral (CPT codes 92201-92202)

are not payable when billed with fundus photography

(92250).

1/01/2018

Ophthalmology Policy

Extended ophthalmoscopy with a retinal/optic nerve

drawing, unilateral or bilateral (CPT codes 92201-92202)

are not payable when billed more than two times per

eye, per year, without an appropriate diagnosis on the

claim.

1/01/2018

Ophthalmology Policy

Extended ophthalmoscopy with a retinal/optic nerve

drawing, unilateral or bilateral (CPT codes 92201-92202)

are not payable when billed more than four times per

eye, per year, with a neoplasm diagnosis.

1/01/2018

Ophthalmology Policy

Extended ophthalmoscopy with a retinal/optic nerve

drawing, unilateral or bilateral (CPT codes 92201-92202)

are not payable when billed more than six times per eye,

per year, with a diagnosis of disorders of the globe,

choroid, retina, iris and ciliary body, or glaucoma.

1/01/2018

Reimbursement Policy:

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(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Ophthalmology Policy

Extended ophthalmoscopy with a retinal/optic nerve

drawing, unilateral or bilateral (CPT codes 92201-92202)

are not payable when billed more than 12 times per eye,

per year, with a diagnosis of exudative senile macular

degeneration.

1/01/2018

Ophthalmology Policy

CPT 66821 (Discission of secondary membranous

cataract) is not payable when billed within three months

of cataract surgery (66820-66821, 66830-66940, 66982-

66984, 66987-66988).

2015

Terminated

effective

9/24/2023

Orthopedic Policy

Any service billed with a DME rental modifier (BR, RR, KI,

KJ, KR, LL) or a DME purchase modifier (BP, NU, UE) is

not payable if the same code has previously been billed

for the same date of service with either a DME rental

modifier or a DME purchase modifier.

1/01/2018

F, P

Orthopedic Policy

Skin barrier, wipes or swabs, each (HCPCS code A5120)

or ostomy skin barrier, liquid (HCPCS code A4369) is not

payable when billed within the same month, by any

provider.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Orthopedic Policy

Arthroscopy of knee with abrasion arthroplasty (CPT

code 29879) is not payable when billed with 29880-

29881 (Arthroscopy of knee with meniscectomy).

1/01/2018

F, P

Orthopedic Policy

Arthroscopy, knee, diagnostic, with or without synovial

biopsy (CPT code 29870) is not payable when billed with

arthrotomy, knee; including joint exploration, biopsy, or

removal of loose or foreign bodies (CPT code 27331).

1/01/2018

F, P

Orthopedic Policy

Arthroscopy of knee with abrasion arthroplasty (CPT

code 29879) is not payable when billed with an

arthroscopy of knee with meniscectomy (CPT codes

29880-29881).

1/01/2018

Orthopedic Policy

Intraoperative services are not payable when billed with

an orthopedic procedure.

1/01/2018

Pain Management Policy

Implantable neurostimulator electrode, each (HCPCS

code L8680) is not payable when billed with

percutaneous implantation of neurostimulator electrode

array, epidural (CPT code 63650).

1/01/2018

F, P

Pain Management Policy

Any combination of trigger point injections (CPT codes

20552 and 20553) are not payable when billed more

than three times within a 90-day period.

1/01/2018

Reimbursement Policy:

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Claim Type

Medical Policy

Rule Description

Effective Date

PAY_PERCENT_PROF_EM

This rule applies pay percent recommendations to

professional claims when a well visit/preventive exam,

and any other Evaluation and Management (E&M)

code(s), are billed for the same patient, same provider,

and same date of service regardless of any modifiers.

Same provider is defined as providers of the same group

practice who have the same Federal Tax Identification

Number (FTIN) and same primary specialty.

Pay percent recommendations apply to procedure code

groups with one well visit E&M and one or more other

E&Ms.

Groups are sorted and ranked based on the RVU value in

the CMS Physician Relative Value file.

• Rank 1 procedures with the highest RVU will

receive a pay percent recommendation of

100%,

• Rank 2 procedures with the next highest RVU

will receive a pay percent recommendation of

50%,

• Rank 3 to 5 procedures receive a pay percent

recommendation of 0%.

10/01/2021

Pay Percent Reduction-

Cardiology

Identifies claim lines that are eligible for a Multiple

Procedure Payment Reduction- Technical Component

(TC) of Diagnostic Cardiovascular Procedures. Assigns

appropriate pay percentage to the eligible line(s),

including adjustments for multiple procedure, as well as

bilateral, multiple quantity, and additional payment

modifiers.

8/14/2016

Performance and

Supervision of

Electromyographic Testing

Policy

In accordance with the recommendation of the

American Association of Neuromuscular &

Electrodiagnostic Medicine (AANEM), all needle

electromyographic (EMG) examination services, nerve

conduction studies, and associated services (CPT codes

95860-95887, 95905-95913, 96003-96004, and G0255)

must be performed by a physician specially trained in

electrodiagnostic (EDX) medicine.

1/7/2020

Physical Medicine Policy

CPT 95992 (Canalith repositioning procedure) is not

payable when the diagnosis on the claim is not benign

paroxysmal vertigo.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Physician Visit Frequency

Policy

Multiple office visits with a related diagnosis are not

payable when submitted by the same provider for the

same date of service.

All PPO 1/01/2022

HMOMR and

HMOC 03/17/2021

HMOMD

10/01/2021

Place of Service Policy

Professional radiology services when billed by a provider

other than an anesthesiologist, cardiologist, multi-

specialist, neurologist, physical medicine specialist,

radiologist, or radiation oncologist in the inpatient or

outpatient hospital setting are not payable.

1/01/2018

Place of Service Policy

Medical and surgical supplies and DME are not payable

when reported by professional providers with inpatient

or facility places of service. (CMS-1500)

1/01/2018

Place of Service Policy

New and established office/outpatient visit (99201-

99205 or 99211-99215) are not payable when billed in

any place of service other than 01 (Pharmacy), 02

(Telehealth), 03 (School), 04 (Homeless shelter), 05

(Indian health service free-standing facility), 06 (Indian

health service provider-based facility), 07 (Tribal 638

free-standing facility), 08 (Tribal 638 provider-based

facility), 09 (Prison/correctional facility), 11 (Office), 14

(Group home), 15 (Mobile unit), 16 (Temporary lodging),

17 (Walk-in retail health clinic), 18 (Place of

employment/worksite), 19 (Outpatient hospital - off

campus), 20 (Urgent care facility), 22 (Outpatient

hospital - on campus), 23 (Emergency room), 24

(Ambulatory surgical center), 25 (Birthing center), 26

(Military treatment facility), 49 (Independent clinic), 50

(Federally qualified health center), 53 (Community

mental health center), 57 (Non-residential substance

abuse treatment facility), 58 (Non-residential opioid

treatment facility), 60 (Mass immunization center), 62

(Comprehensive outpatient rehabilitation facility), 65

(End-stage renal disease treatment facility), 71 (State on

local public health clinic), 72 (Rural health clinic), or 99

(Other place of service).

1/01/2018

Place of Service Policy

Evaluation and management services for inpatient

neonatal and pediatric critical care (99468-99476) or

initial and continuing intensive care (99477-99480) are

not payable when billed in a place of service other than

02 (Telehealth) or 21 (Inpatient hospital).

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Place of Service Policy

Domiciliary/rest home E/M services (99324-99340) are

not payable when billed in any place of service other

than 13 (Assisted living facility), 14 (Group home), 33

(Custodial care facility), 55 (Residential substance abuse

facility), or 99 (Other place of service), except when E/M

services codes 99324-99328 or 99334-99337 are billed in

POS 02 (Telehealth).

1/01/2018

Place of Service Policy

Emergency department visits (99281-99285, G0380-

G0384) when billed in any place of service other than 23

(Emergency Department) are not payable, except when

emergency department visit codes 99281-99285 are

billed in POS 02 (Telehealth).

1/01/2018

Place of Service Policy

Initial hospital care services (99221-99223), follow-up

hospital care services (99231-99233), and hospital

discharge services (99238-99239) are not payable when

billed in any place of service other than 02 (Telehealth),

06 (Indian health service provider-based facility), 08

(Tribal 638 provider-based facility), 21 (Inpatient

hospital), 25 (Birthing center), 26 (Military treatment

facility), 34 (Hospice), 51 (Psychiatric inpatient facility),

52 (Psychiatric partial hospitalization facility), and 61

(Comprehensive rehab facility), except when E/M

services 99221-99223 or 99238-99239 are billed in POS

02 (Telehealth).

1/01/2018

Place of Service Policy

Nursing Facility E/M services (99304-99310, 99315-

99316 or 99318) are not payable when billed in a place

of service other than 31 (Skilled nursing facility), 32

(Nursing facility), 34 (Hospice), 54 (Intermediate care

facility/individuals with intellectual disabilities), or 56

(Psychiatric residential treatment facility), except when

Nursing Facility E/M services codes 99304-99310 or

99315-99316 are billed in POS 02 (Telehealth).

1/01/2018

Place of Service Policy

Outpatient observation services (99217-99220),

subsequent observation care (99224-99226),

observation or inpatient hospital care (99234-99236) are

not payable when billed in any place of service other

than 02 (Telehealth), 19 (Outpatient hospital - off

campus), 21 (Inpatient hospital), 22 (Outpatient hospital

- on campus), 23 (Emergency department), 24

(Ambulatory Surgical Center), 25 (Birthing center), 26

(Military treatment facility), 51 (Psychiatric inpatient

facility), or 52 (Psychiatric facility partial hospitalization),

except when E/M services codes 99217-99220 or 99234-

99236 are billed in POS 02 (Telehealth).

1/01/2018

Reimbursement Policy:

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Claim Type

Medical Policy

Rule Description

Effective Date

Place of Service Policy

Outpatient consultation services (99241-99245) are not

payable when billed with a place of service 21 (Inpatient

hospital).

1/01/2018

Place of Service Policy

Certain casting and strapping procedures provided by a

physical or occupational therapist are not payable in a

skilled nursing facility (SNF).

1/01/2018

Place of Service Policy

Inpatient only procedures (CMS) billed by professional

providers with any place of service other than 21 are not

payable.

10/29/2019

Place of Service Policy

Inpatient only, non-separate procedures (CMS), are not

payable when billed by an outpatient hospital, unless it

is reported with modifier CA.

1/01/2018

Updated to include

PPOMR effective

8/01/2022

Place of Service Policy

Inpatient only, separate procedures (CMS), when billed

by an outpatient hospital are not payable. (CMS-1450)

1/01/2018

Updated to include

PPOMR effective

8/01/2022

Place of Service Policy

Any services billed on the same date of service as an

inpatient only, non-separate procedure (CMS) and no

other surgical, non-inpatient only procedures are billed,

the claim will deny.

1/01/2018

Updated to include

PPOMR effective

8/01/2022

Place of Service Policy

HCPCS "C "codes are not payable when billed with any

bill type other than 0120-012Z (Hospital inpatient part

B), 0130-013Z (Hospital outpatient), 0140-014Z (Hospital

other part B), 0830-083Z (Hospital outpatient [ASC]), or

0850-085Z (Critical access hospital).

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

F, P

Place of Service Policy

HCPCS codes beginning with "C" are not payable when

billed on claim type P (Professional).

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Place of Service Policy

Posterior chamber IOL, HCPCS code V2632, astigmatism

correcting IOL, HCPCS code V2787, or presbyopia

correcting IOL, HCPCS code V2788, is not payable when

billed and the place of service is 11 (Office) and a

cataract removal surgery, CPT codes 66982-66988, has

not also been billed.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Place of Service Policy

Deny 99466-99467 (Critical care services delivered by a

physician, face-to-face, during interfacility transport of a

critically ill or critically injured pediatric patient) when

billed in a place of service other than 41 (Ambulance -

land) or 42 (Ambulance - air or water).

1/01/2018

Place of Service Policy

Physician direction of emergency medical systems [EMS]

emergency care, advanced life support, CPT code 99288,

supervision by control physician of interfacility transport

care of the critically ill or critically injured pediatric

patient, CPT codes 99485-99486, or trauma response

1/01/2018

Reimbursement Policy:

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Claim Type

Medical Policy

Rule Description

Effective Date

team associated with hospital critical care services,

HCPCS code G0390, are not payable when billed in a

place of service other than 21 (Inpatient hospital) or 23

(Emergency Room).

Place of Service Policy

Newborn care other than hospital or birthing center,

CPT code 99461, is not payable when billed and the

place of service is 21 (Inpatient hospital) or 25 (Birthing

center).

1/01/2018

Place of Service Policy

Newborn care, CPT codes 99460, 99462-99465, are not

payable when billed in a place of service other than 21

(Inpatient hospital) and 25 (Birthing center).

1/01/2018

Place of Service Policy

Comprehensive preventive medicine services, CPT codes

99381-99397, are not payable when billed in a place of

service other than 03 (School), 04 (Homeless shelter),

05 (Indian health service free-standing facility), 06

(Indian health service provider-based facility), 07 (Tribal

638 free-standing facility), 08 (Tribal 638 provider-based

facility), 09 (Prison), 11 (Office), 12 (Home), 13 (Assisted

living facility), 14 (Group home), 15 (Mobile Unit), 16

(Temporary lodging), 17 (Walk-in retail health clinic), 18

(Place of employment/worksite), 19 (Outpatient hospital

- off campus ), 22 (Outpatient hospital - on campus), 26

(Military treatment facility), 33 (Custodial care facility),

49 (Independent clinic), 50 (Federally qualified health

center), 71 (State or local public health clinic) or 72

(Rural health clinic).

1/01/2018

Place of Service Policy

Diagnostic imaging procedures 70370, 70371, and 74230

are not payable when billed in any place of service other

than 11 (Office), 19 (Outpatient hospital-off campus), 21

(Inpatient hospital), 22 (Outpatient hospital-on campus),

23 (Emergency room), 61 (Comprehensive inpatient

rehab facility), or 62 (Comprehensive outpatient rehab

facility). (CMS-1500)

1/01/2018

Terminated

effective

9/24/2023

Place of Service Policy

Any service billed with modifier 53 (Discontinued

service) is not payable when billed with Bill Type 0120-

012Z (Inpatient-part B), 0130-013Z (Outpatient hospital),

0140-014Z (Outpatient hospital-other), or 0830-083Z

(Ambulatory surgical center [ASC]).

1/01/2018

Place of Service Policy

Laboratory services (80000-89999) are not payable

when billed in Place of Service 19 (Outpatient hospital-

off campus), 21 (Inpatient hospital), 22 (Outpatient

hospital-on campus), 23 (Emergency department), or 24

(ASC) by a provider with a specialty other than

Dermatology, Genetics, Hematology, Laboratory, or

Pathology.

1/01/2018

Reimbursement Policy:

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(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Place of Service Policy

Any service (other than inpatient care) billed by any

professional provider on the same date of service as

inpatient care but with a different place of service, is not

payable when the member also received inpatient care

the previous day and was not discharged on the same

day, or on the subsequent day.

1/01/2018

Place of Service Policy

Any service billed in place of service 19 (Outpatient

Hospital - Off campus), 22 (Outpatient Hospital - On

campus) or 23 (Emergency Room - Hospital) by any

professional provider on the same date of service as

inpatient care, is not payable when the member also

received inpatient care the previous day and was not

discharged.

1/01/2018

Place of Service Policy

Medical/surgical supplies and DMEs are not payable

when billed with professional fee revenue codes (0960-

0989) in an outpatient facility or inpatient facility

setting.

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Place of Service Policy

Removal of benign skin lesions (CPT codes 11200-11201,

11300-11313, 11400-11446, 17106-17108, or 17340) are

not payable when billed in an inappropriate place of

service.

1/01/2018

Place of Service Policy

Radiology services (CPT codes 70010-79999) are not

payable when billed with Bill Type 0140-014Z (Hospital-

laboratory services to non-patients).

1/01/2018

Place of Service Policy

Destruction, benign or premalignant lesions (CPT codes

17000-17004, or 17110-17111) is not payable when

billed in an inappropriate place of service.

1/01/2018

Place of Service Policy

Procedures billed with modifier Q0 (Investigational

clinical service provided in a clinical research study that

is in an approved clinical research study) or modifier Q1

(Clinical research study service) are not payable when

condition code 30 (Qualifying clinical trial) and Bill Type

0130-013Z (Hospital-outpatient) are not present on the

claim.

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Place of Service Policy

Professional radiology services are not payable when

billed by a provider other than an anesthesiologist,

cardiologist, multi-specialist, neurologist, physical

medicine specialist, radiologist, or radiation oncologist in

the inpatient or outpatient hospital setting.

1/01/2018

Place of Service Policy

Medical and surgical supplies and DME are not payable

when reported by professional providers with inpatient

or facility places of service.

1/01/2018

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Claim Type

Medical Policy

Rule Description

Effective Date

Place of Service Policy

Evaluation and management add-on codes (CPT code

99050, 99051, 99053, 99056, 99058, or 99060) is not

payable when billed with a place of service 20 (Urgent

care facility) or when the provider specialty is urgent

care.

1/01/2018

Place of Service Policy

Evaluation and management add-on codes (CPT codes

99026, 99050, 99051, 99053, 99056, 99058, or 99060)

are not payable when billed with an emergency

department visit (CPT codes 99281-99285, G0380-

G0384) by a provider with the specialty of emergency

medicine and place of service 23 (ER-hospital) or 20

(Urgent care facility).

1/01/2018

Place of Service Policy

New and established office/outpatient visit (CPT codes

99202-99205, 99211-99215) are not payable when billed

in any place of service other than 01 (Pharmacy), 02

(Telehealth), 03 (School), 04 (Homeless shelter), 05

(Indian health service free-standing facility), 06 (Indian

health service provider-based facility), 07 (Tribal 638

free-standing facility), 08 (Tribal 638 provider-based

facility), 09 (Prison/correctional facility), 11 (Office), 14

(Group home), 15 (Mobile unit), 16 (Temporary lodging),

17 (Walk-in retail health clinic), 18 (Place of

employment/worksite), 19 (Outpatient hospital - off

campus), 20 (Urgent care facility), 22 (Outpatient

hospital - on campus), 23 (Emergency room), 24

(Ambulatory surgical center), 25 (Birthing center), 26

(Military treatment facility), 49 (Independent clinic), 50

(Federally qualified health center), 53 (Community

mental health center), 57 (Non-residential substance

abuse treatment facility), 58 (Non-residential opioid

treatment facility), 60 (Mass immunization center), 62

(Comprehensive outpatient rehabilitation facility), 65

(End-stage renal disease treatment facility), 71 (State on

local public health clinic), 72 (Rural health clinic), or 99

(Other place of service).

1/01/2018

Place of Service Policy

Evaluation and management services for inpatient

neonatal and pediatric critical care (CPT codes 99468-

99476) or initial and continuing intensive care (CPT

codes 99477-99480) are not payable when billed in a

place of service other than 02 (Telehealth) or 21

(Inpatient hospital).

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Place of Service Policy

Domiciliary/rest home E/M services (CPT codes 99324-

99340) are not payable when billed in any place of

service other than 13 (Assisted living facility), 14 (Group

home), 33 (Custodial care facility), 55 (Residential

substance abuse facility), or 99 (Other place of service),

except when E/M services codes 99324-99328 or 99334-

99337 are billed in POS 02 (Telehealth).

1/01/2018

Place of Service Policy

Emergency department visits (CPT codes 99281-99285,

G0380-G0384) are not payable when billed in any place

of service other than 23 (Emergency Department),

except when emergency department visit codes 99281-

99285 are billed in POS 02 (Telehealth).

1/01/2018

Place of Service Policy

Home visit E/M services (CPT codes 99341-99350) are

not payable when billed in any place of service other

than 02 (Telehealth) or 12 (Patient's home).

1/01/2018

Place of Service Policy

Initial hospital care services (CPT codes 99221-99223),

follow-up hospital care services (CPT codes 99231-

99233), and hospital discharge services (CPT codes

99238-99239) are not payable when billed in any place

of service other than 02 (Telehealth), 06 (Indian health

service provider-based facility), 08 (Tribal 638 provider-

based facility), 21 (Inpatient hospital), 25 (Birthing

center), 26 (Military treatment facility), 34 (Hospice), 51

(Psychiatric inpatient facility), 52 (Psychiatric partial

hospitalization facility), and 61 (Comprehensive rehab

facility), except when E/M services 99221-99223 or

99238-99239 are billed in POS 02 (Telehealth).

1/01/2018

Place of Service Policy

Nursing Facility E/M services (CPT codes 99304-99310,

99315-99316 or 99318) are not payable when billed in a

place of service other than 31 (Skilled nursing facility),

32 (Nursing facility), 34 (Hospice), 54 (Intermediate care

facility/individuals with intellectual disabilities), or 56

(Psychiatric residential treatment facility), except when

Nursing Facility E/M services codes 99304-99310 or

99315-99316 are billed in POS 02 (Telehealth).

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Place of Service Policy

Initial inpatient consultation, CPT codes 99251-99255, is

not payable when billed in a place of service other than

02 (Telehealth), 06 (Indian health service, provider-

based facility), 08 (Tribal 638 provider-based facility), 21

(Inpatient hospital), 25 (Birthing center), 26 (Military

treatment facility), 31 (Skilled nursing facility), 32

(Nursing facility), 34 (Hospice), 51 (Psychiatric inpatient

facility), 52 (Psychiatric partial hospitalization facility), 54

(Intermediate care facility/individuals with intellectual

disabilities), 55 (Residential treatment center), 56

(Psychiatric residential treatment center), 61

(Comprehensive rehab facility), 99 (Other place of

service).

1/01/2018

Place of Service Policy

Outpatient observation services (CPT codes 99217-

99220), subsequent observation care (CPT codes 99224-

99226), observation or inpatient hospital care (CPT

codes 99234-99236) are not payable when billed in any

place of service other than 02 (Telehealth), 19

(Outpatient hospital - off campus), 21 (Inpatient

hospital), 22 (Outpatient hospital - on campus), 23

(Emergency department), 24 (Ambulatory Surgical

Center), 25 (Birthing center), 26 (Military treatment

facility), 51 (Psychiatric inpatient facility), or 52

(Psychiatric facility partial hospitalization), except when

E/M services codes 99217-99220 or 99234-99236 are

billed in POS 02 (Telehealth).

1/01/2018

Place of Service Policy

Outpatient consultation services (CPT codes 99241-

99245) are not payable when billed with a place of

service 21 (Inpatient hospital).

1/01/2018

Reimbursement Policy:

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(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Place of Service Policy

Office/outpatient consultation, CPT codes 99241-99245,

is not payable when billed in a place of service other

than 01 (Pharmacy), 02 (Telehealth), 03 (School), 04

(Homeless shelter), 05 (Indian health service free-

standing facility), 06 (Indian health service provider-

based facility), 07 (Tribal 638 free-standing facility), 08

(Tribal 638 provider-based facility), 09 (Prison-

Correctional Facility), 11 (Office), 12 (Home), 13

(Assisted living facility), 14 (Group home), 15 (Mobile

Unit), 16 (Temporary lodging), 17 (Walk-in retail health

clinic), 18 (Place of employment/worksite),

19 (Outpatient hospital - off campus), 20 (Urgent care

facility), 22 (Outpatient hospital - on campus), 23

(Emergency room hospital), 24 (Ambulatory surgical

center), 25 (Birthing center), 26 (Military treatment

facility), 33 (Custodial Care Facility), 49 (Independent

clinic), 50 (Federally qualified health center), 53

(Community mental health center), 54 (Intermediate

care facility/individuals with intellectual disabilities), 57

(Non-residential substance abuse treatment facility), 58

(Non-residential opioid treatment facility), 60 (Mass

immunization center), 62 (Comprehensive outpatient

rehabilitation facility), 65 (End-stage renal disease

treatment facility), 71 (State or local public health clinic),

72 (Rural health clinic), 99 (Other place of service).

1/01/2018

Place of Service Policy

Certain casting and strapping procedures provided by a

physical or occupational therapist in a skilled nursing

facility (SNF) are not payable.

1/01/2018

Place of Service Policy

Inpatient only procedures billed by professional

providers with any place of service other than 21.

1/01/2018

Place of Service Policy

Services with a Non-Facility NA Indicator of “N/A” are

not payable when billed with place of service 11. (CMS)

1/01/2018

Podiatry Policy

CPT 11055-11057, 11719-11721, or G0127 (Routine foot

care) are not payable when billed more than once within

a two-month period.

6/25/2019

Podiatry Policy

As per CMS LCD Article A57759, CPT 11055-11057,

11719-11721, or G0127 (Nail paring, cutting,

debridement, trimming) are not payable when billed

without a requisite diagnosis on the claim.

1/01/2018

F, P

Post-Operative Nasal

Endoscopies

Post-operative nasal endoscopies with debridement

(CPT Code 31237), after sinus surgery or sinus surgery

combined with nasal surgery are not payable when

billed more than 3 times within the six weeks following

surgery. CPT code 31231 (diagnostic endoscopy) will not

be reimbursed separately following a surgical procedure

with a 10-day or 90-day global period.

8/30/2022

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Primary Care Policy

Chest x-ray (CPT code 71045 or 71046) is not payable

when the only diagnosis on the claim is screening for

respiratory tuberculosis or testing for latent tuberculosis

infection.

1/01/2018

Primary Care Policy

Influenza vaccines are not payable when the same or

different vaccine code has been billed and paid within

the previous three months and the patient is nine years

of age or older.

1/01/2018

Primary Care Policy

Influenza vaccine is not payable when paid more than

twice within the same calendar year and the patient is

nine years of age or older.

1/01/2018

Primary Care Policy

HPV vaccinations (CPT codes 90649, 90650 or 90651) are

not payable when billed and the patient is less than nine

years of age.

1/01/2018

Primary Care Policy

HPV vaccination (CPT code 90651) is not payable when

billed and the patient is 46 years of age or older.

1/01/2018

Primary Care Policy

HPV vaccination (CPT codes 90649, 90650 or 90651) is

not payable when billed more than three times in the

patient's lifetime by any provider.

6/25/2019

F, P

Procedure-Age Policy

Procedures submitted that are inconsistent with the

patient's age based on the nature or indication for the

procedure are not payable.

1/01/2018

F, P

Procedure-Age Policy

Procedures submitted that are inconsistent with the

patient's age based on the code definition are not

payable.

1/01/2018

F, P

Procedure-Age Policy

Procedures submitted that are inconsistent with the

patient's age based on the code definition are not

payable.

1/01/2018

F, P

Procedure-Age Policy

Procedures submitted that are inconsistent with the

patient's age based on the code definition are not

payable.

1/01/2018

Procedure-Age Policy

Procedures that are inconsistent with the patient's age

based on the code definition are not payable.

1/01/2018

Procedure-Age Policy

Procedure codes that are inconsistent with the patient's

age based on the code definition are not payable.

1/01/2018

Procedure-Age Policy

Procedure codes that are inconsistent with the patient's

age based on the code definition are not payable when a

more appropriate code is available.

2/1/2019

Procedure-Age Policy

Procedures that are inconsistent with the patient's age

based on the code definition are not payable.

1/01/2018

Procedure-Age Policy

Procedures submitted that are inconsistent with the

patient's age based on the nature or indication for the

procedure are not payable.

1/01/2018

F, P

Procedure Code Definition

Policy

Procedures billed out of sequence are not payable.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Procedure Code Definition

Policy

Procedures are not payable when used against CPT and

HCPCS procedure code definition.

1/01/2018

Procedure Code Definition

Policy

Procedure codes and/or their related guidelines contain

specific descriptive criteria for use. Services are not

payable if they do not meet the code criteria.

Examples: G0266 and 93298 are for a 30-day period;

G0268 requires an audiologic function testing on same

date of service; 93294 has a 90-day global period.

1/01/2018

F, P

Procedure Code Definition

Policy

Procedures billed out of sequence are not payable.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Procedure Code Definition

Policy

Procedure codes and/or their related guidelines contain

specific descriptive criteria for use. Services are not

payable if they do not meet the code criteria. Example,

CPT 17004 "Destruction (e.g., laser surgery,

electrosurgery, cryosurgery, chemosurgery, surgical

curettement), premalignant lesions (e.g., actinic

keratoses), 15 or more lesions" should not be reported

with diagnosis B08.1 "Molluscum contagiosum".

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Procedure Code Definition

Policy

Procedure codes and/or their related guidelines contain

specific descriptive criteria for use. Services are not

payable if they do not meet the code criteria.

Example: 71045 X-ray exam chest 1-view and 74019 X-

ray exam abdomen 2-views should instead be coded as

74022 X-ray exam complete abdomen.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Procedure Code Definition

Policy

HCPCS G0008, G0009, or G0010 are not payable if billed

without the appropriate, corresponding vaccine code.

1/01/2018

F, P

Procedure Code Definition

Policy

CPT codes for procedures billed out of sequence are not

payable.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Procedure Code Guideline

Policy

Services that are coded inappropriately based on

CPT/HCPCS Procedure Code Guidelines are not payable.

1/01/2018

F, P

Procedure Code Guideline

Policy

Procedures billed out of sequence are not payable.

1/01/2018

Procedure Code Guideline

Policy

Services that are coded inappropriately based on

CPT/HCPCS Procedure Code Guidelines are not payable.

1/01/2018

F, P

Procedure Code Guideline

Policy

Services that are coded inappropriately such as

unbundled, when there is a single code that represents

the unbundled services, will be denied based on

CPT/HCPCS Procedure Code Guidelines.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Procedure Code Guideline

Policy

Modifier 63 are not payable when billed with procedure

codes to which this modifier does not apply, based on

CPT/HCPCS Procedure Code Guidelines.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Procedure Code Guideline

Policy

Immunization administration (CPT codes 90460-90461,

90471-90474) are not payable when billed without a

vaccine/toxoid code (90476-90750, 90756, J3530,

Q2033-Q2039, or S0195) by any provider on the same

date of service.

1/01/2018

HMOC and

HMOMR in effect

1/01/2022

Procedure Code Guideline

Policy

E/M services are not separately payable when billed

with 94010-94799 (Pulmonary function testing), unless

the E/M code is billed with modifier 25 and the clinical

documentation supports the use of modifier 25.

1/01/2018

Procedure Code Guideline

Policy

CPT 77371-77373 (Radiation treatment delivery,

stereotactic radiosurgery), G0339 or G0340 (Image-

guided robotic linear accelerator-based stereotactic

radiosurgery) are not payable when billed more than

five combined units in two weeks.

1/01/2018

Procedure-Diagnosis

Incompatibility Policy

Procedures submitted with a diagnosis code that is not

compatible with CMS National Government Services

National Coverage and Local Coverage Determinations

(NCD/LCD) are not payable.

1/1/2022

HMOMR

03/17/2021

Procedure Code Guideline

Policy

CPT 99483 (Assessment of and care planning for patient

with cognitive impairment) is not payable if billed more

than once in a 180-day period.

9/1/2022

Procedure Inconsistent with

Place of Service Policy

Procedures not related to Telehealth/Telemedicine, as

per CMS, are not payable when reported with place of

service "02".

1/01/2022

Professional, Technical, and

Global Services Policy

Diagnostic tests or radiology services are not payable

when submitted by a provider in a facility place of

service and modifier 26 is not appended.

1/1/2018

Professional, Technical, and

Global Services Policy

Reimbursement of diagnostic tests and radiology

services are not payable beyond the amount for the

global service.

1/01/2018

F, P

Professional, Technical, and

Global Services Policy

Clinical laboratory services with modifier 26 for those

codes that do not have a separately payable professional

service (CMS).

1/01/2018

Professional, Technical, and

Global Services Policy

Separate reimbursement for radiology services with a

modifier 26 is not payable when billed with an E/M

service in the office.

1/01/2018

Professional, Technical, and

Global Services Policy

Diagnostic tests or radiology services are not payable

when billed with modifier TC in the inpatient or

outpatient facility setting.

1/01/2018

F, P

Professional, Technical, and

Global Services Policy

Procedures billed with modifier TC are not payable when

submitted on a technical component only procedure

code.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Professional, Technical, and

Global Services Policy

Procedures billed with modifier 26 are not payable when

submitted with a code that is defined as professional

component only.

1/01/2018

Professional, Technical, and

Global Services Policy

X-ray services (which are also a diagnostic tests or

radiology services) are not payable when billed with

modifier TC in POS 12, 13, 31 or 32 and HCPCS codes

R0070 and R0075 are not also present.

1/01/2018

Professional, Technical, and

Global Services Policy

Modifier 26 submitted with a code that is defined as

professional component only (CMS) is not payable.

1/01/2018

Professional, Technical, and

Global Services Policy

Codes billed with modifier TC when submitted on a

technical component only procedure code are not

payable.

1/01/2018

Professional, Technical, and

Global Services Policy

Diagnostic tests or radiology services billed with

modifier TC is not payable to a professional provider in

the inpatient or outpatient facility setting.

1/01/2018

Professional, Technical, and

Global Services Policy

Radiology services with a modifier 26 are not payable

when billed with an E/M service in the office.

1/01/2018

Professional, Technical, and

Global Services Policy

Clinical laboratory services with modifier 26 are not

payable for those codes that do not have a separately

payable professional service (CMS).

1/01/2018

F, P

Professional, Technical, and

Global Services Policy

Reimbursement of diagnostic tests and radiology

services is limited to no more than the amount for the

global service (CMS).

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Professional, Technical, and

Global Services Policy

Diagnostic tests or radiology services billed without

modifier 26 are not payable when submitted by a

provider in a facility place of service. (CMS)

1/01/2018

F, P

Professional, Technical, and

Global Services Policy

Professional component procedures are not payable

when billed by a facility and the Revenue Code is not

0960-0989 (Professional fees). (CMS-1450)

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Updated to include

Facility claims

effect. 12/01/2021

F, P

Professional, Technical, and

Global Services Policy

Technical components are not payable when billed with

Revenue Codes 0960-0989 (Professional fees).

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Updated to include

Facility claims

effect. 12/01/2021

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Professional, Technical, and

Global Services Policy

Technical component only procedures are not payable

to professional providers in the inpatient or outpatient

facility setting (CMS).

1/01/2018

Professional, Technical, and

Global Services Policy

Physician service codes that do not have an associated

professional or technical component (CMS) are not

payable when billed with modifier 26.

1/01/2018

Professional, Technical, and

Global Services Policy

Modifiers 26 and TC are not payable when appended to

the same claim line.

1/01/2018

F, P

Professional, Technical, and

Global Services Policy

Physician service codes that do not have an associated

professional or technical component are not payable

when billed with modifier TC (CMS).

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Professional, Technical, and

Global Services Policy

Technical component only services are not payable

when billed with modifier 26 (CMS).

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Professional, Technical, and

Global Services Policy

Professional component only procedures are not

payable when billed with modifier TC (CMS).

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Professional, Technical, and

Global Services Policy

A Global Only code as identified in the CMS Physician

Fee Schedule with PC/TC status '4', is not payable when

billed by a professional in a facility setting. Only the

professional component of this service is payable in the

facility setting. It should be reported with the correct

code.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Professional, Technical, and

Global Services Policy

A Global Only code as identified in the CMS Physician

Fee Schedule with PC/TC status '4', is not payable when

billed by a facility. Only the technical component of this

service is payable in the facility setting. It should be

reported with the correct code.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Professional, Technical, and

Global Services Policy

A Global Only code as identified in the CMS Physician

Fee Schedule with PC/TC status '4', is not payable when

billed by a professional in a facility setting. Only the

professional component of this service is payable in the

facility setting. It should be reported with the correct

code.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Professional, Technical, and

Global Services Policy

A Global Only code as identified in the CMS Physician

Fee Schedule with PC/TC status '4', is not payable when

billed by a facility. Only the technical component of this

service is payable in the facility setting. It should be

reported with the correct code.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 98 of 110

Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Professional, Technical, and

Global Services Policy

A Global Only code as identified in the CMS Physician

Fee Schedule with PC/TC status '4', is not payable when

billed by a professional in a facility setting. Only the

professional component of this service is payable in the

facility setting. It should be reported with the correct

code.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Professional, Technical, and

Global Services Policy

A Global Only code as identified in the CMS Physician

Fee Schedule with PC/TC status '4', is not payable when

billed by a facility. Only the technical component of this

service is payable in the facility setting. It should be

reported with the correct code.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Professional, Technical, and

Global Services Policy

X-ray services (which are also diagnostic tests or

radiology services) billed without modifier 26 are not

payable when submitted by a provider in POS 12, 13, 31,

or 32 and R0070 and R0075 are not also present (CMS).

1/01/2018

Professional, Technical, and

Global Services Policy

Codes reported with modifier 26 or modifier TC are not

payable when the professional/technical component

concept does not apply.

1/01/2018

Professional, Technical, and

Global Services Policy

Technical component only services are not payable

when billed with modifier 26.

1/01/2018

Psychiatry-Psychology Policy

Subsequent TMS is not payable when billed and 90867

(TMS, initial), 90868 or 90869 (TMS, subsequent) has not

been billed in the previous week.

1/01/2018

F, P

Psychiatry-Psychology Policy

Therapeutic repetitive transcranial magnetic stimulation

(TMS) treatment is not payable when billed without a

diagnosis of major depressive disorder without psychotic

features for a patient 18 years of age or older.

1/01/2018

F, P

Pulmonary Policy

Chest x-ray (CPT codes 71045-71048) are not payable

when billed and the only diagnosis on the claim is for

lung cancer screening or nicotine use/dependence.

1/01/2018

Quality of Care Policy

Any procedure billed by an audiologist that is outside of

the scope of audiology practice is not payable.

1/01/2018

Quality of Care Policy

Deny any procedure billed by a physical therapist that is

outside the scope of physical therapy practice.

1/01/2018

Quality of Care Policy

Medical evaluation and management services as these

are not considered within the scope of practice for

Clinical Psychologists (CPs’) and Clinical Social Workers

(CSWs’). According to the Centers for Medicare and

Medicaid Services (CMS), E/M services are medical in

nature and therefore may not be furnished by

psychologists or social workers.

1/01/2018

Quality of Care Policy

Procedures billed by a pathologist that are outside the

scope of pathology practice are not payable.

1/01/2018

Quality of Care Policy

Procedures billed by a podiatrist that is outside the

scope of podiatry practice are not payable.

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Quality of Care Policy

Manipulation of spine requiring anesthesia, any region

(CPT code 22505) is not payable under the Chiropractor

specialty.

1/01/2018

Quality of Care Policy

Determination of refractive state (CPT code 92015) is

not payable if the provider specialty not Ophthalmology

or Optometry.

1/01/2018

Radiation Oncology Policy

Radiation treatment management (CPT code 77427) is

not payable when billed more than once in a five-day

period by any provider.

1/01/2018

F, P

Radiology Policy

Abdominal ultrasound (CPT codes 76700-76705) are not

payable when billed and the only diagnosis on the claim

is infectious mononucleosis.

1/01/2018

F, P

Radiology Policy

Dual energy X-ray absorptiometry [DXA], bone density

study (CPT code 77080 or 77081) is not payable when

the only diagnosis on the claim is osteoporosis screening

and the member is a male less than 70 years of age.

1/01/2018

F, P

Radiology Policy

Chest x-ray (CPT code 71045 or 71046) is not payable

when billed and the only diagnosis on the claim is a

general medical exam, pre-admission, administrative or

pre-operative exam.

1/01/2018

Terminated

effective

9/24/2023

F, P

Radiology Policy

CPT 71101-LT (X-ray, ribs, unilateral, three views; left) is

not payable when billed with 71101-RT (X-ray, ribs,

unilateral, three views; right). CPT71111 (X-ray, ribs,

bilateral, four views) is for bilateral.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Radiology Policy

Additional rib x-ray series are not payable when another

rib x-ray series (71100, 71101, 71110 or 71111) has been

previously paid for the same date of service.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Radiology Policy

CPT 71101-LT (X-ray, ribs, unilateral, three views; left) is

not payable when billed with 71101-RT (X-ray, ribs,

unilateral, three views; right). CPT71111 (X-ray, ribs,

bilateral, four views) is for bilateral.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Radiology Policy

CPT 71101-LT (X-ray, ribs, unilateral, three views; left) is

not payable when billed with 71101-RT (X-ray, ribs,

unilateral, three views; right). CPT71111 (X-ray, ribs,

bilateral, four views) is for bilateral.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

F, P

Radiology Policy

CPT 71100 (X-ray, ribs, unilateral; 2 views) appended

with modifier 50 is not payable.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Radiology Policy

72100 (Radiologic exam, spine, lumbosacral, AP and

lateral) is not payable when billed with 72040

(Radiologic exam, spine, cervical, AP and lateral) and

72070 (Radiologic exam, spine, thoracic; AP and lateral).

72084 (Radiologic exam, spine, entire thoracic and

lumbar, including skull, cervical and sacral spine if

performed) is the comprehensive code.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Radiology Policy

Radiologic examination, knee; 1 or 2 views (CPT code

73560) or radiologic exam, knee, three views OR

complete (CPT codes 73562-73564) is not payable when

billed on the same date of service as radiologic

examination, knee; both knees, standing,

anteroposterior (CPT code 73565) and the modifiers are

the same or blank.

1/01/2018

F, P

Related Services- to a

Noncovered Procedure

Certain procedures are deemed to be non- covered by

health plans based on their medical and/or payment

policies. This rule identifies procedure codes or revenue

codes billed by the same or a different provider, on the

same or a different claim ten-days prior to, the same day

as or within seven days after a non-covered service. The

rule requires a match on the first three digits of a line’s

diagnosis code to determine if the deny line procedure

or revenue code is related to the non-covered service.

The rule also looks to see if the non-covered procedure

was denied for payment. If the non-covered procedure

was paid, then the related service would not be

recommended for denial via this rule. This rule audits

both facility and non-facility claims. The content of this

rule is intended to be supplied by the health plan and

should be based on their medical and/or payment

policies. A “starter set” of data for this rule is provided

and it contains procedures such as all lab, anesthesia,

radiology, revenue and evaluation and management

codes; HCPCS “J” codes for drugs; HCPCS “A” codes for

supplies; select CPT surgery and medicine codes such as

venipuncture and EKGs among others.

2016

Revenue Code Policy

Home health or hospice visits are not payable when the

HCPCS code and the revenue code do not match.

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Reimbursement Policy:

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Claim Type

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Rule Description

Effective Date

Revenue Code Policy

Evaluation and Management services reported with

Revenue Code 0450 are not payable when billed with

another evaluation and management service reported

with Revenue Code 0451 or 0452.

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Revenue Code Policy

Claim lines submitted with Bill Type 0140-014Z and

without Revenue Code 0300-0319 are not payable.

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Revenue Code Policy

Claims where the revenue code is 0300-0319

(Laboratory/pathology) and the HCPCS code does not

match are not payable.

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

F, P

Revenue Code Policy

Home health or hospice visits are not payable when the

HCPCS code and the revenue code do not match.

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Updated to include

Facility claims

effect. 12/01/2021

Revenue Code Policy

Revenue codes that CMS indicates requires a HCPCS

code are not payable when submitted with Bill Type

0120-012Z or 0140-014Z, without Condition Code 41,

and without a HCPCS code.

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Revenue Code Policy

Revenue code 0452 is not payable when billed without

revenue code 0451.

1/01/2018

Updated to include

CNY, PPOC,

PPOMR effective

8/01/2022

Reimbursement Policy:

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Claim Type

Medical Policy

Rule Description

Effective Date

Revenue Codes Requiring

CPT or HCPCS Codes

The Centers for Medicare and Medicaid Services (CMS)

Outpatient Prospective Payment System (OPPS) Detailed

Program Edits require certain revenue codes to be

reported with a Healthcare Common Procedure Coding

System (HCPCS) code. Revenue codes are summary

billing codes required on the UB-92 claim form to

represent the type of service provided and where it was

performed. According to CMS OPPS Detailed Program

Edits, for certain bill types and certain revenue codes a

HCPCS code must also be submitted. This rule

recommends the denial of claim lines submitted with a

revenue code that requires a HCPCS code and no HCPCS

code is present. The OPPS Detailed Program Edits do not

provide instruction as to which HCPCS code should be

submitted with each revenue code. Therefore, this edit

only fires if there is no HCPCS code on the claim.

1/1/2018

Secondary Diagnosis Codes

Procedures or services received with a secondary

diagnosis code as the principal or primary diagnosis are

not payable.

8/31/2021

F, P

Separate Procedures Policy

Separate procedures are not payable when billed with

the associated major procedures.

1/01/2018

Separate Procedures Policy

Procedures designated as a “separate procedure” are

not payable when submitted with a related major

procedure by the same provider for the same date of

service.

All PPO 1/01/2022

HMOMR and

HMOC 03/17/2021

HMOMD

10/01/2021

Separate Procedures Policy

Add-on CPT codes are not payable when submitted and

the primary code has not been billed AND paid for the

same date of service by the same provider.

1/01/2022

Separate Procedures Policy

Procedures or services that are designated as a

bundled/incidental or packaged per the CMS National

Physician Fee Schedule Relative Value File (NPFSRVF),

Outpatient Prospective Payment System (OPSI), or

Ambulatory Payment Classifications (APC) are not

payable.

All PPO 1/01/2022

HMOMR and

HMOC 03/17/2021

HMOMD

10/01/2021

Smoking and Tobacco Use

Cessation Counseling

CPT code 99406 or 99407 (Smoking and tobacco use

cessation counseling visit) are not when billed without a

diagnosis of tobacco or nicotine dependence.

9/15/2021

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

F, P

Split Surgical Care Policy

Fracture or dislocation care codes billed in the office

within 10 days of the same fracture or dislocation care

code by any provider are not payable.

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Split Surgical Care Policy

Fracture or dislocation care codes billed in the office

within two weeks of a different fracture or dislocation

care code by any provider are not payable.

1/01/2018

Split Surgical Care Policy

Procedures billed with either modifier 54, 55 or 56 are

not payable when another provider has billed the same

code globally without a modifier.

1/01/2018

Split Surgical Care Policy

Procedures with a 90-day global surgical period are not

payable to Emergency Medicine physician in the

emergency room setting (POS 23) (CMS), unless billed

with modifier 54 (Surgical care only).

1/01/2018

F, P

Split Surgical Care Policy

Procedures with a 90-day global surgery period are not

payable when billed in the provider's office when any

provider has billed this procedure code in the previous

90 days. (CMS)

1/01/2018

Updated to include

Facility claims

effect. 12/01/2021

Split Surgical Care Policy

Procedures billed without modifier 54, 55 or 56 are not

payable when another provider has billed the same

procedure with modifier 54, 55 or 56.

1/01/2018

Split Surgical Care Policy

Procedures inappropriately billed with modifiers 54, 55,

and 56 are not payable.

1/01/2018

Split Surgical Care Policy

10-day fracture or dislocation care codes are not

payable when it is billed in the office within 10 days of

the same fracture or dislocation care code by any

provider.

1/01/2018

Split Surgical Care Policy

Fracture or dislocation care codes are not payable when

it is billed in the office within 2 weeks of a different

fracture or dislocation care code billed by any provider.

1/01/2018

Split Surgical Care Policy

Procedures billed with either modifier 54, 55 or 56 are

not payable when another provider has billed the same

code globally without a modifier.

1/01/2018

Split Surgical Care Policy

Procedure codes with modifier 54 (Surgical care only) is

not payable when billed by an Emergency Medicine

physician in the emergency room setting (POS 23).

1/01/2018

Split Surgical Care Policy

Major procedures are not payable when billed in the

provider's office by any provider who has billed this

procedure code in the previous 90 days.

1/01/2018

Surgical Global Fee Period

Policy

Physician visits or procedures/services are not payable

when billed by the operative provider with a related

diagnosis within the postoperative period of a surgical

procedure as defined within the CMS National Physician

Fee Schedule Relative Value File (NPFSRVF).

All PPO 1/01/2022

HMOMR and

HMOC 03/17/2021

HMOMD

10/01/2021

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Team Surgery Policy

CPT codes not designated as allowed for Team Surgery

are not payable when billed with modifier 66.

1/01/2018

Team Surgery Policy

Procedure billed without modifier 66 (Team Surgery) are

not payable when there exists a previously processed

claim for the same procedure code with modifier 66 by

any provider (CMS).

1/01/2018

Team Surgery Policy

Medical and surgical procedures are not payable when

billed with modifier 66 and the Team Surgery concept

does not apply. (CMS)

1/01/2018

Team Surgery Policy

Procedures billed with modifier 66 are not payable when

there exists a previously processed claim for the same

procedure code without modifier 66 by any provider.

1/01/2018

Telehealth Services

Telehealth services are not payable when billed with

modifier GQ (Via asynchronous telecommunications

system) and the place of service is not 02 (Telehealth).

3/01/2020

Telehealth Services

Modifiers G0, GQ and 95

Services that are inappropriately billed with telehealth

services modifier G0 (Telehealth services for diagnosis,

evaluation, or treatment, of symptoms of an acute

stroke) are not payable.

3/01/2020

Telehealth Services

Modifiers G0, GQ and 95

Services billed with Revenue Code 0960-0989

(Professional Services) that are inappropriately billed

with telehealth services modifier G0 (Telehealth services

for diagnosis, evaluation, or treatment, of symptoms of

an acute stroke) are not payable.

3/01/2020

Telehealth Services

Modifiers G0, GQ and 95

Services reported with modifier 95 (Synchronous

telemedicine service rendered via a real-time interactive

audio and video telecommunications system) when

billed with any code other than an approved

telemedicine service code are not payable.

3/01/2020

Unbundled Pair- AMA

According to April 1991 CPT Assistant, evaluation of x-

rays by a consulting or primary physician is considered to

be an integral component of the global evaluation and

management services for a patient. Thus, the reporting

of CPT code 76140 with an evaluation and management

service represents an overlap of service and duplication

of effort that does not warrant separate reimbursement.

1/1/2018

Unbundled Pair- AMA

According to the November 1999 CPT Assistant, "when

acuity is measured as part of a general ophthalmological

service or of an E/M service of the eye, it is part of the

diagnostic examination and not a screening test".

Screening test of visual acuity (CPT codes 99172 and

99173) is considered a component of a comprehensive

1/1/2018

Reimbursement Policy:

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(Commercial, Medicare & Medicaid)

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Claim Type

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Rule Description

Effective Date

evaluation and management visit, and does not warrant

separate reimbursement. If a separate and distinct

screening of visual acuity is performed in addition to a

problem-oriented E/M service which did not involve eye

or vision testing additional reimbursement may be

warranted for this unique clinical scenario. (Check code

pair edits and make sure preventive E/Ms are excluded)

Unbundled Pair- AMA

According to CPT guidelines for radiation treatment

management (CPT code 77427), evaluation and

management services are not reported separately. Thus,

the reporting of an office visit with radiation treatment

management represents overlapping of services, and

does not warrant separate reimbursement.

1/1/2018

Unbundled Pair- AMA

According to CPT guidelines, surgical preparation (CPT

codes 15002-15005), are not to be reported with wound

management and debridement services.

1/1/2018

Unbundled Pair- AMA

CPT code 37617 is used to describe the tying off of an

abdominal artery completely (ligation), proximal and

distal to the site of injury. According to CPT guidelines, if

during an abdominal procedure involving the removal of

tissue (organ) ligation of an artery is deemed necessary,

the ligation of vessels would not be separately reported.

1/1/2018

Unbundled Pair- CMS/AMA

Intraoperative neurophysiological monitoring is utilized

during the performance of surgical procedures in order

to assure that the nervous system has not been

compromised or damaged during the primary surgical

procedure. According, to CPT guidelines, when the

monitoring service is performed by the operating

surgeon or anesthesiologist, the professional services

are included in the surgeon's or anesthesiologist's

primary service codes for the procedure and should not

be reported separately. In addition, nerve monitoring

procedures will only be reimbursed when they are

performed as a diagnostic service. This logic is also

supported by the CMS guideline for Standard of

Medical/Surgical Practice found in the National Correct

Coding Policy Manual for Part B Medicare Carriers,

Chapter I that states, "Examples of services integral to a

large number of procedures include: isolation of

structures limiting access to the surgical field such as

bone, blood vessels, nerve, and muscles including

stimulation for identification or monitoring."

1/1/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

Unbundled Pair- CMS/AMA

Intraoperative neurophysiology testing services shall not

be reported by the physician performing an operative or

anesthesia procedure since it is included in the global

package of the primary surgical procedure.

1/1/2018

Unbundled Pair- CMS

Identifies claim lines containing Procedure Codes that

are typically not recommended for reimbursement

when submitted with certain other Procedure Codes on

the same date of service.

Provider matching will be based on TIN and Specialty.

Modifier override will include both the deny line and

support line.

This includes Incidental, Mutually Exclusive, Ultimate

Parent Rebundling, and Visit codes that are not

separately payable.

The sources of this edit are the AMA CPT code

guidelines, and/or CMS NCCI Policy Manual, and/or CMS

Claims Processing Manual.

Examples of incidental services are:

• CPT 36415 Venipuncture when also billing for

laboratory procedure codes.

• CPT 81002 Urinalysis dipstick with an Evaluation

and Management code unless appended with

modifier 25

10/01/2021

Unbundled Pair- AMA

According to April 1991 CPT Assistant, evaluation of x-

rays by a consulting or primary physician is considered

to be an integral component of the global evaluation

and management services for a patient. Thus, the

reporting of CPT code 76140 with an evaluation and

management service represents an overlap of service

and duplication of effort that does not warrant separate

reimbursement

1/1/2018

Unbundled Pair – AMA

According to the November 1999 CPT Assistant, "when

acuity is measured as part of a general ophthalmological

service or of an E/M service of the eye, it is part of the

diagnostic examination and not a screening test".

Screening test of visual acuity (CPT codes 99172 and

99173) is considered a component of a comprehensive

evaluation and management visit and does not warrant

separate reimbursement.

1/1/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

If a separate and distinct screening of visual acuity is

performed in addition to a problem-oriented E/M

service which did not involve eye or vision testing

additional reimbursement may be warranted for this

unique clinical scenario. (Check code pair edits and make

sure preventive E/Ms are excluded)

Unbundled Pair – AMA

CPT code 37617 is used to describe the tying off of an

abdominal artery completely (ligation), proximal and

distal to the site of injury. According to CPT guidelines, if

during an abdominal procedure involving the removal of

tissue (organ) ligation of an artery is deemed necessary,

the ligation of vessels would not be separately reported.

1/01/2018

Unbundled Pair – AMA

According to CPT guidelines, surgical preparation (CPT

codes 15002-15005), are not to be reported with wound

management and debridement services.

1/01/2018

Unbundled Pair – AMA

According to CPT guidelines for radiation treatment

management (CPT code 77427), evaluation and

management services are not reported separately. Thus,

the reporting of an office visit with radiation treatment

management represents overlapping of services and

does not warrant separate reimbursement.

1/01/2018

Unbundled Pair – CMS/AMA

Intraoperative neurophysiology testing services shall not

be reported by the physician performing an operative or

anesthesia procedure since it is included in the global

package of the primary surgical procedure.

1/01/2018

Unbundled Pair – CMS/AMA

Intraoperative neurophysiological monitoring is utilized

during the performance of surgical procedures in order

to assure that the nervous system has not been

compromised or damaged during the primary surgical

procedure.

According, to CPT guidelines, when the monitoring

service is performed by the operating surgeon or

anesthesiologist, the professional services are included

in the surgeon's or anesthesiologist's primary service

codes for the procedure and should not be reported

separately. In addition, nerve monitoring procedures will

only be reimbursed when they are performed as a

diagnostic service.

This logic is also supported by the CMS guideline for

Standard of Medical/Surgical Practice found in the

National Correct Coding Policy Manual for Part B

Medicare Carriers, Chapter I that states, "Examples of

services integral to a large number of procedures

include: isolation of structures limiting access to the

1/01/2018

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Claim Type

Medical Policy

Rule Description

Effective Date

surgical field such as bone, blood vessels, nerve, and

muscles including stimulation for identification or

monitoring."

Urology Policy

CPT 76857 (Ultrasound, pelvic [non-obstetric], limited or

follow-up) is not payable when billed on same date of

service as 51725-51729 (Simple or complex CMG), 51736

(Simple uroflowmetry), or 51741 (Complex

uroflowmetry). Refer to CPT 51798 (Measurement of

post-voiding residual urine and/or bladder capacity by

ultrasound, non-imaging.

1/01/2018

Urology Policy

Nocturnal penile rigidity test (CPT code 54250) is not

payable beyond two units in three consecutive days

when billed by any provider.

1/01/2018

Revision history:

DATE

REVISION

7/30/2024

• Update highlighted in yellow in policy above

1 new edit effective 12/6/2024

6/18/2024

Updates highlighted in yellow in policy above

• 6 new edits effective 10/15/2024

6/6/2024

Update highlighted in yellow in policy above

• 1 new edit effective 1/1/2024

4/29/2024

• Updated edit to include HCPCS code A4553; now reads: “Elastic garment/covering,

each (HCPCS code A4466), surgical leggings (HCPCS codes A4490-A4510),

incontinence garment (HCPCS code A4520), disposable underpads (HCPCS codes

A4553 and A4554) , surgical face mask (HCPCS code A4928), exercise equipment

(HCPCS code A9300), bath and toilet aids (HCPCS codes E0240-E0245), bed boards

(HCPCS code E0273), over bed tables (HCPCS code E0274), bed accessory: board,

table, or support device, any type (HCPCS code E0315), patient lift, bathroom

(HCPCS code E0625), whirlpool, portable (HCPCS code E1300), whirlpool tub, walk-

in, portable (HCPCS code K1003), and diapers (HCPCS codes T4521-T4545) are non-

covered services.”

3/24/2024

• Updated edit “In accordance with our policy, colonoscopies, sigmoidoscopies, and

proctosigmoidoscopies are only covered with specific indications. Please refer to

our policy for additional details” with EmblemHealth policy hyperlink for

clarification

3/8/2024

• Bilateral Procedures – Modifiers 50, RT, LT (Codes with Bilateral Indicator 1) edit

rule description updated to clarify that “If the same code is reported once with

modifier RT and once with modifier LT this is not allowed. Instead, the code should

be reported with modifier 50 for 1 unit. The 150% payment adjustment will apply.”

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 109 of 110

DATE

REVISION

12/11/2023

Updates highlighted in yellow in policy above

• 2 new edits effective 4/15/2024

• 1 new edit effective 1/1/2024

10/23/2023

• Typo corrected in Procedure Code Definition Policy edit “Procedure codes and/or

their related guidelines contain specific descriptive criteria for use. Services are not

payable if they do not meet the code criteria.

Examples: G0266 and 93298 are for a 30-day period; G0268 requires an audiologic

function testing on same date of service; 93294 has a 9-day global period.”

Corrected to read “90-day global period.”

9/28/2023

• Termed Ophthalmology edit “Scanning computerized ophthalmic diagnostic

imaging, retina (CPT code 92134) is not payable when billed more than once within

a 28-day period when the diagnosis is retinal disease” effective 9/24/2023

9/11/2023

• 1 edit termed for Commercial, Medicare, & Medicaid effective 3/26/2023

• 5 edits termed for Commercial, Medicare, & Medicaid effective 9/24/2023

• 1 edit termed for Medicare effective 9/24/2023

9/1/2023

• Termed Allergy Testing edit “CPT code 86003 (Allergen specific IgE) is limited to 30

units per year when billed by any provider” as of 2/28/2023

• Added edit “CPT code 86003 (Allergen specific IgE) is limited to 40 units per year

when billed by any provider” with effective date 3/1/2023

7/17/2023

• Updated to correct typo for National Correct Coding Manual Policy edit; corrected

“1000” to “81000”

6/12/2023

• Corrected edit “Complete and limited non-obstetric pelvic ultrasounds, CPT codes

76856 and 76857, are not covered when billed with transvaginal ultrasounds, CPT

code 76830, during the same visit” to include Facility claim type

6/5/2023

• Added update to edit “Claim lines reported with mutually exclusive code

combinations according to ICD-10-CM Excludes 1 Notes guideline policy are not

payable” indicating that edit will apply to preventative services effective 9/15/2023

5/11/2023

• Updated policy to include 5 new edits effective 9/13/2023

1/30/2023

• Line of Business (LOB) column removed

11/09/2022

• 1 new edit effective 3/15/2023

10/04/2022

• Catalog of current Cotiviti edits updated

• 1 new edits effective 1/01/2023

9/20/2022

• Ophthalmology Policy (CPT 92134) edit rule description updated to clarify that

“Scanning computerized ophthalmic diagnostic imaging, retina (CPT code 92134) is not

payable when billed more than once within a 28-day period when the diagnosis is

retinal disease”.

7/14/2022

• Catalog of current ClaimsXten and Cotiviti edits updated

5/02/2022

• Edits for outpatient services updated to include City of NY Commercial (CNY), PPO

Commercial (PPOC), and/or PPO Medicare (PPOMR) lines of business effective

8/01/2022.

Reimbursement Policy:

Coding Edit Rules

(Commercial, Medicare & Medicaid)

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Page 110 of 110

DATE

REVISION

1/24/2022

• 1 new edit effective 3/01/2022

• 3 edits terminated effective 1/01/2020

1/13/2022

• Catalog of current ClaimsXten and Cotiviti edits updated

• Bilateral Procedures- Modifiers 50, RT, LT rule updated with clarification regarding CMS

bilateral indicators 0, 2, 3 and 9

11/2021

• Updated policy to include one new edit effective 3/01/2022

10/2021

Corrections to effective dates noted in 9/2021:

• 7 edits effective 2/01/2022

• 21 edits effective 1/01/2022

9/2021

• Updated policy to include 28 edits effective 1/01/2022

7/2021

•

Updated policy to indicate 4 edits terminated effective 3/30/2021

•

Updated policy to include one new edit effective 1/01/2022

•

Updated edits to include Facility claims effective 12/01/2021

•

Updated policy to include 5 edits effective 9/15/2021

6/2021

•

Updated policy to include 13 new edits effective 9/01/2021

•

Updated policy to include 11 new edits effective 10/01/2021

•

Catalog of ClaimsXten, Cotiviti, and/or Zelis coding edit rules; transferred content to new

template with new Reimbursement Policy Number