January 3, 2019
In early January 2019, two new Payment Policies are being published. One policy announces new edits coming for drugs administered in a provider office and the other policy clarifies how to identify procedures subject to multiple procedure reductions.
Modifier 51 – Multiple Procedures (Effective 01/01/2019)
The policy identifies the criteria used to determine which procedure codes are subject to “multiple procedure reductions” based on the Center for Medicare and Medicaid Services (CMS) National Physician Fee Schedule. It identifies which codes are not subject to multiple procedure reductions in reimbursement. This policy was created in response to provider inquiries.
Drugs Administered in a Physician Office (Effective 04/14/2019 Process Dates on And After)
Upcoming claims edits will be implemented effective for claims processed on and after 04/14/2019 for drugs that are administered in a physician’s office. These drugs are submitted under a member’s medical benefits utilizing either a J-series or Q-series HCPCS code. The edits being implemented are based on criteria that are listed in the Federal Drug Administration package inserts for the drugs such as but not limited to age limits, treatment contraindications, and dosage maximums/minimums. The specific drugs and the exact criteria to be implemented for each drug will be defined in either a Medical or Pharmacy policy.