Payment Policy Updates June 2019

The following Payment Policy has been withdrawn: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.

June 20, 2019

The following June Payment Policies received their Annual Review with NO changes:

• Ambulatory Surgery Center (ASC) facility Services – Modifier SG and Place of Service Code 24
• Modifier 22 – Increased Procedural Services
• Modifier 53 – Discontinued Services
• Modifier 54/55/56 – Surgical Care Only, Post Op Care Only, Preop Care Only
• Unlisted, Non-Specific and Miscellaneous Procedure Codes

The following June Payment Policies received their Annual Review and HAD changes as summarized below (see specific policy for details):

• Durable Medical Equipment (DME)
  Added a cross referenced to the “Unlisted, Non-specific and Miscellaneous Procedure Codes” Payment Policy in the sub-section on unlisted codes.
• Modifier 50 – Bilateral Procedure
  Clarified the descriptions for the Bilateral Surgery Flags taken form the CMS document reviewing the field on the National Physician Fee Schedule file
• Modifier 52 – Reduced Services
  Expanded on the second paragraph providing guidelines on how to bill for timed codes
• Modifier 62 – Two Surgeons
  Clarified that the two surgeons performing the surgical procedure are usually of different specialties and different surgical skills
• Modifier 78 – Unplanned return to the Operating Room for a Related Procedure
  Identified where to find the reference to “Global Days” in the CMS National Physician Fee Schedule

June 6, 2019

The following payment policies received their Annual Review with NO changes:

• Modifier 90 – Reference (Outside) Laboratory
• Multiple Diagnostic Cardiovascular Services Reductions
• Multiple Diagnostic Imaging Reductions
• Organ Acquisition Costs (MA Policy)
• Preadmission Testing

The following Payment Policies received their Annual Review and HAD changes as summarized below (see specific policy for details):

Add-On Codes
In the POLICY and EXCEPTION sections, added reference to the CPT Codebook instructions which indicate certain add-on codes can be billed either on the same date of service as the primary code or on a different date of service than the primary code.

Drug Assay Services
Added references to the new Proprietary Lab Analysis (PLA) codes added for 2019.

Inpatient Acute Transfers from DRG Hospitals
Clarified that the transfers are from one acute care facility to another acute care facility.

Modifier JW – Drug Amount discarded/not administered to any patient
Revised the POLICY statement to make it more readable and added instructions on NDC code billing. Created a new sub-section in the POLICY statement for “Adverse Drug Reactions”.

Serious Adverse Events – Inpatient Facility Services
Removed references to ICD-9 coding as it’s no longer appropriate (run out was the end of 2016). Deleted the section under “Present on Admission (POA) Indicators” as Providers are required to submit POA indicators on their claims.

Back to News