Payment Policy Updates March 2019

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

March 21, 2019

The following policies received their annual review without any changes to the policy content:

• Blood Draw (Venipuncture) – 36415
• Claims Editing System (CES) – Exceptions
• Facility Fees: Clinic Services, Professional Fees and Specialty Services-Treatment Room
• Home Birth Kit (S8415)
• New and Established Patient Guidelines
• Prolonged Services for Labor Management (99354-99357)

The following policies received their annual review and had revisions as noted:

• Anesthesia Guidelines
  In the MODIFIERS subsection of the policy statement, reference to the Anesthesia Modifiers Payment Policy was added. In the codes/coding guidelines section, code 01967 was added to the list of applicable codes.
• Anesthesia Modifiers
  The second paragraph in the policy section was added to indicate that anesthesia services submitted without a modifier will be denied reimbursement.
• Hospital or Hospital System Readmissions
  Two additional bullets were added to the list of policy exceptions: Pediatric Oncology and Behavioral Health readmissions.
• Modifier 79 – Unrelated Procedure/Service by Same Provider during Postoperative Period
  A statement was added at the end of the first paragraph stating that documentation in the patient’s medical record must identify that the subsequent procedure is unrelated to the original surgery.
• Modifier SL-State Supplied Vaccine
  Minor revisions to the wording of the second paragraph in the policy statement.
• Physical and Occupational Therapy Services
  The wording under the “Physical/Occupational Therapy Evaluation and Re-evaluation Procedures” section (5th sub-bullet) has been revised since the original bullet timeframe had been exceeded.

A new section was created at the end of the policy statement titled “Unit billing for Timed Codes.” It references the CPT guidelines used for this policy to determine when a unit of time has been reached and therefore billable.

March 7, 2019

The following is a NEW Payment Policy effective with claim process date of June 9, 2019 and after.

Routine blood draws/venipunctures (CPT code 36415) will no longer be separately reimbursable when the service is billed on the same date of service as an E&M office visit service (CPT codes 99201-99215) by the same provider or provider group. Modifier 59, XS, XP, XE or XU will not override/bypass the denial of the blood draw/venipuncture code when billed with an E&M office visit on the same date of service.

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