Here are the latest updates to our payment policies. You’ll need to log in to see the policy updates.
July 19, 2018
Inpatient Acute Transfers from DRG Hospitals
A sentence was added to the Policy section statement that indicates that stop loss cases would be handled per the provider’s contract terms
Organ Acquisition Costs (Medicare Advantage policy)
Annual review, no changes
Annual Health Review Visits
Policy archived; program using these codes terminated 01/01/2017; claim run-out period expired
Multiple Diagnostic Cardiovascular Services Reduction
Annual review; no changes
Multiple Diagnostic Imaging Reductions
Deleted the last paragraph in the Policy section regarding “Multiple Procedures Rendered during multiple “separate and distinct” session encounters” due to time period submission period expired
Durable Medical Equipment/Home Medical Equipment
A new subsection was added at the end of the Policy statement indicating how to correctly submit “Unlisted DME and Misc. Supplies and services.” This paragraph mirrors the same information in the “Unlisted Codes” policy. Added new section “Codes/Coding Guidelines” to the policy to provide full description of the codes referenced in the Policy statement
Modifier 22-Increased Procedural Service
Clarification to the 3rd paragraph to indicate clinical staff reviews the medical records and makes a decision whether increased reimbursement is warranted
Modifier 50-Bilateral Procedure
Clarified the industry sourcing used to identify those procedures that qualify for bilateral surgery billing
Modifier 52-Reduced Services
Removed the list of maternity delivery codes in the Policy section and moved them to the new section Codes/Coding Guidelines with a full description of the code
Modifier 53-Discontinued Procedure
Annual review; no changes
Modifier 54/55/56-Surgical Care Only/Postoperative Management/Preoperative Management Only Services
Annual Review; no changes
Modifier 62-Two Surgeons
Clarified the industry sourcing used to identify those procedures that qualify for two/co-surgeon billing. Added a new paragraph that indicates that the operative report must clearly identify which portion of the surgery was done by each of the two surgeons
Modifier 78-Unplanned Return to the OR for a Related Procedure
Annual review; no changes
Unlisted, Non-Specific and Miscellaneous Procedure Codes
Expanded the subsection “Supporting Documentation Requirement” to add a paragraph regarding adding a reference to a “like” code or service as part of the documentation
Added two new subsections:
- Unlisted Durable Medical Equipment and Miscellaneous Supplies and Services: This is the original text that was copied into the DME Payment Policy; it reads the same as the DME policy and also states how to correctly submit unlisted DME and miscellaneous supplies
- Unlisted, Miscellaneous or Not otherwise Classified/Specified Drugs: This was added to address the submission of the gene therapy drugs using unlisted codes till they were assigned a specific code. This section also calls out the correct steps to submit unlisted or not otherwise classified drugs and reiterates the need/requirement for the submission of an NDC number as well in order to be reimbursed.
Added new section Codes/Coding Guidelines: Lists of the codes referenced in the POLICY section and their full code descriptions added. Also added a table to call out the different Code Categories and the Type of Documentation Required for the submission and subsequent processing of these unlisted codes.