May 1, 2025
The following policies received their annual review with no changes:
The following policies received their annual review with the changes noted below:
Acupuncture
In the Policy section, at the end of the sixth paragraph, the last sentence was added to indicate that per NCCI criteria, bypass modifiers are not allowed to override the edit.
Contract Exclusions/Disallowed Charges-Inpatient and Outpatient Facility Services
Alphabetized all of the sub-bullets in each of the sub-sections in the Policy section.
Two Payment Policies added to the Cross Reference section.
Added or modified (BOLDED) the following bullets in the noted sections for additional clarification on non-reimbursable services:
Nursing Care Services
- Added: Bedside nursing care carried out by Nurses (RN/LPN), Certified Nursing Assistants
- Added: Tracheostomy care
- Modified: Point of care/bedside testing (such as blood count, arterial blood gas, clotting time, glucose monitoring/glucose monitoring device testing, glucometers, urine dipsticks, hemoglobin/hematocrit, etc.)
Equipment
- Added:
- Batteries for any equipment;
- Grounding Pads
- Robotic surgical systems and computer-aided navigation systems (e.g., DaVinci robotic system)
- Surgical Instruments
- Modified: Scopes (e.g., laparoscopes, bronchoscopes, endoscopes, fluoroscopy/C-Arm, etc.)
Operating Room/Surgical Suite:
- Added: Robotic surgical systems and computer-aided navigation systems (e.g., DaVinci robotic system)
Critical Care In Emergency Department when Patient is Discharged to Home (Facility)
In the policy section:
- Clarified the first paragraph content;
- In the third paragraph, removed the “may be reviewed” statement
- In the fourth paragraph, removed the example codes
In the coding section: removed the other non-critical care example codes.
Hospital or Hospital System Readmissions
In the Exceptions section, revised the bullet regarding an initial discharge against medical advice (AMA),
Laboratory and Pathology Billing Guidelines
In the Policy section, revised the subsection on Place of Service Codes (POS) and added examples.
Modifier 22 – Increased Procedural Services
In the Exception section, removed the payment reference to Oregon providers.
Modifier JW – Drug amount discarded/not administered to any patient and Modifier JZ – Zero drug amount discarded/not administered to any patient
In the Policy section:
- Under the Modifier JW subsection, removed the phrase: “…reimbursement for waste will be reduced to match the dose of the smallest vial available” that was added during the 11/12/24 policy annual review.
- Added a new section, “Suppliers of Drugs” at the end of the policy which describes how suppliers of drugs are to bill for the preparation and dispensing of drugs to patients, without actual administering the drug to a patient, when there is and is
not wastage of any portion of a single dose vial.
Modifier NU – New DME Equipment and Modifier NR – New DME Equipment When Rented
In the Policy section, under the subsection Replacement of DME, orthotic or prosthetic item, added the first paragraph referring to the Modifier RA Payment Policy for details on how to bill for replacement DME.
Modifier RA – Replacement of a DME, Orthotic or Prosthetic item
In the Policy section, the second paragraph was added to indicate that replacement DME needs two modifiers to identify whether a rental or purchase replacement piece of DME.
Modifier RR – Durable Medical Equipment (DME) Rental, Modifier KR – Rental item-partial month and Modifier LL – Lease/Rental
In the Policy section:
- Added the first paragraph which identifies the rental modifiers
- Under the subsection “Replacement of a DME, orthotic or prosthetic item”, added the first paragraph referring to the Modifier RA Payment Policy for details on how to bill for replacement DME.