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  • The following Payment Policy has been withdrawn: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.

    November 21, 2019

    Contract Exclusions/Disallowed Charges-Inpatient Facility Services

    Effective 3/01/2020, the following additional services and service categories will be not separately reimbursable:

    • Blood and blood product administration services
    • Nursing care and treatment expanded to include outpatient services such as:
      • Injections, subcutaneous, and intramuscular
      • Nasogastric tube insertions
      • Point of care/bedside testing (i.e. blood count, arterial blood gas, clotting time, glucose monitoring), bladder scans
      • Dietary services
      • Minor medical/surgical supplies
      • Medical and psychiatric social services
      • Venipuncture performed by a nurse
    • Equipment considered required component of level of care room charge: oxygen per day charges
    • Operating Room/Surgical suite-expanded to include outpatient services:
      • Use of operating room, professional and technical personnel and related surgical medical supplies, personal care items
    • Central supplies issued to other departments
    • Emergency room supply and service charges
    • Pharmacy charges furnished to patient

    Modifier 57 - Decision for Surgery
    Added a definition of “pre-operative period” in the second paragraph of the policy statement

    Modifier 63 - Procedure performed on Infants less than 4kg
    Added additional qualifiers in the policy section as to appropriate use of modifier 63, paragraphs 3 and 5

    Modifier 66 – Surgical Team
    Clarified in the second paragraph documentation requirements for each surgeon’s participation in the surgery

    Modifier 73 – Discontinued ASC Procedure Prior to Administration of Anesthesia

    • Clarified the kinds of applicable anesthesia in the first paragraph
    • In the second paragraph, indicated that rationale for the discontinuation must be present in the medical records
    • Added statement that the modifier cannot be used if patient elects to discontinue procedure

    Modifier 74 – Discontinued ASC Procedure after Administration of Anesthesia

    • Clarified the kinds of applicable anesthesia in the first paragraph
    • In the second paragraph, indicated that a rationale for the discontinuation of the procedure must be present in the medical records

    Modifier 76 – Repeat Procedure by the Same Provider
    Added the second and third paragraphs in the Policy section to clarify the documentation requirements to support the need for the repeat procedure and to identify scenarios of inappropriate usage of modifier 76

    Modifier 77 – Repeat Procedure by another Provider
    Added the second paragraph to indicate that the reason for a repeat procedure should be documented

    Modifier TH – Obstetrical treatment/services

    • Revised the first paragraph for clarity
    • Added second paragraph to indicate visits four and greater would need appropriate prenatal visit codes rather than office visit codes

    Multiple Deliveries/Births
    In the examples discussing the second and subsequent deliveries, added a recommendation of the modifier to use when submitting these additional deliveries

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