Coding policies going into effect Sept. 23, 2024

In alignment with industry standards, we’ve posted the following policies to our Provider Manual, to go into effect on Sept. 23, 2024.

Below are links and a high-level overview of each policy. Please see each policy for specific billing, coding and reimbursement details.

• Care management services policy: We’re clarifying existing criteria and establishing more specific criteria, including aligning documentation requirements with CMS.
• Distinct modifier unbundling policy: In alignment with CMS National Correct Coding Initiative (NCCI) standards, we’ll no longer allow separate and distinct modifiers (59, XE, XS, XP and XU) to automatically override our clinical edits for unbundling for the codes listed in the policy. The claim lines will deny, and the provider will have the option to appeal with medical records to support the modifier use and payment.
• Drug testing policy: We’re defining limits on the number of drug tests (definitive and presumptive tests) that can be billed / reimbursed, including moving from yearly limit of 12 tests (combined definitive and presumptive) to a daily limit of 1 test per date of service.
• Radiation oncology policy: We’re sharing our expectations for radiation oncology billing, which are in alignment with industry standards, including CMS and National Imaging Associates (NIA).