Payment Policy Updates

  • The following Payment Policy has been withdrawn:

    Blood Draw/Venipuncture with Office Visit E&M Code
    Premera has chosen to not move forward with enforcing the Payment Policy titled “Blood Draw/Venipuncture with Office Visit E&M Code” that was to become effective as of 06/09/2019. The policy has been removed from the external Provider portals and at this time no future editing will be developed for this coding scenario.

    Here are the latest updates to our payment policies. You’ll need to log in to see the policy updates.

    December 5, 2019

    Removed the footnotes and combined the paragraphs on new and established E&M visits into a single paragraph. Added references in the Codes/Coding Guidelines section to key information from Payment Policies for New and Established Patients and Modifier 25.

    Manipulation Services
    Removed footnotes in Policy statement. Clarified the Policy section to indicate that E&M services must be billed in compliance with New/Established patient guidelines and consistent with modifier 25 policy guidelines.

    Modifier 26-Professional Component
    Added new section, definitions, and included a statement on professional component, technical components, global service and standalone procedure codes that are discussed in the policy section.

    In the policy section, the following changes were made:

    • 1st Paragraph: Provided additional information as to what the professional component includes
    • 2nd paragraph: Provided additional information of the Professional/Technical split as well as a reference to global; clarified that codes not eligible for reimbursement
    • 3rd paragraph: Added location as to which codes this PC/TC split apply to
    • 4th paragraph: Expanded the description of the PC/TC Indicator flags

    Added new section codes/coding guidelines discussing the PC/TC indicator flags, identifying which can/cannot be billed with 26/TC modifiers; added some statements on inappropriate use of these modifiers.

    Modifier TC – Technical Component
    Revisions called out in Modifier 26 policy apply to this policy as well

    Modifier SU – Procedures Performed in Physician’s Office (Facility and Equipment)
    Revised paragraph 2, pulling out the first sentence and adding it as a separate paragraph 3

    Multiple Endoscopy Procedure Reductions
    Added Payment Policy Modifier 51 as a resource in the cross-reference section and referenced Modifier 51 in the policy.

    Multiple Modifiers
    Annual review; no changes

    Multiple Surgical Reductions
    Added Payment Policy Add-On Codes and Modifier 51 in the cross-reference section. Referenced Modifier 51 in the surgical procedures subsection on the policy statement. Referenced the need for an appropriate primary code when billing an add-on code in the add-on surgical procedures subsection in the policy statement. Referenced Modifier 51 in the first paragraph in the exempt procedures subsection in the policy statement.

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