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Clinical & Payment Policies

 A-GH-QR-Z
 Acupuncture (PDF)
H Pylori Serology Testing (PDF) 
Radial Head Implant (PDF)
 ADHS Assessment and Treatment (PDF)
Effective Date: 1/1/18
Heart-Lung Transplant (PDF)Reduction Mammoplasty and Gynecomastia Surgery (PDF)
 ADHD Testing and Treatment (PDF)  Holter Monitors (PDF)Sacroiliac Joint Fusion (PDF)
 AHCT for Sickle Cell Anemia (PDF)Home Births (PDF)Sacroiliac Joint Interventions (PDF)
 Allergy Testing and Therapy (PDF)Home Phototherapy for Neonatal Hyperbilirubinemia (PDF)Sclerotherapy for Varicose Veins (PDF)
 Ambulatory EEG (PDF)Homocysteine Testing (PDF)  Effective:  1/1/21Selective Dorsal Rhizotomy for Spasticity in CP (PDF)
 Ambulatory Surgical Center (PDF)
Effective Date: 1/1/18
Hospice (PDF)SNF Leveling (PDF)
 Anesthesia Services for GI Endoscopy (PDF)Hospice Clinical Coverage (PDF)Sickle Cell Disease Observation (PDF)
 Antithrombin III (Atryn Thrombate) (PDF)Hyperemesis Gravidarum Treatment (PDF)Spinal Cord Stimulation (PDF)
 Applied Behavior Analysis (PDF)Hyperhidrosis Treatments (PDF)Stereotactic Body Radiation Therapy (PDF)
 Articular Cartilage Defect Repairs (PDF)Implantable Hypoglossal Nerve Stim (PDF)Tandem Transplant (PDF)
 ASC Optimization (PDF)Implantable Intrathecal Pain Pump (PDF)Testing Select Genitourinary conditions (PDF)
 Assisted Reproductive Technology (PDF)Implantable Wireless PAP Monitoring (PDF)Therapy Services (PDF)
 Balloon Sinus Ostial Dilation (PDF)In Network Referrals (PDF)
Effective Date: 1/1/18
Thymus Transplant (PDF)
 Bariatric Surgery (PDF)Inhaled Nitric Oxide (PDF)Thyroid Insulin Tests in Pediatrics (PDF)
 Biofeedback (PDF)Intensity-Modulated Radiotherapy (PDF)Thyroid Testing in Pediatrics (PDF)
 Bone-Anchored Hearing Aid (PDF)Intensity Modulated Radiation Therapy (PDF)Total Artificial Heart (PDF)
 Bronchial Thermoplasty (PDF)
Effective Date: 1/1/18
Intestinal & Multivisceral Transplant (PDF)TPN IDPN (PDF)
 Burn Surgery (PDF)Caudal or Interlaminar ESI (PDF)
Transcranial Magnetic Stimulation for MDD (PDF)
 Cardiac Biomarker Testing (PDF)Intradiscal Steroid Injections (PDF)Ultrasound in Pregnancy (PDF)
 Cardiac Biomarket Testing for Acute Myocardial Infarction (PDF)
Effective Date: 6/1/18
Laser Skin Treatment (PDF)
Effective Date: 1/1/18
Urinary Incontinence Devices and Treatments (PDF)
 Cardiac Rehabilitation (PDF)Laser Therapy for Skin Conditions (PDF)Urodynamic Testing (PDF)
 Caudal or Interlaminar ESI (PDF)Long Term Care PLacement Criteria (PDF)US in Pregnancy (PDF)
 Cell-Free Fetal DNA Testing (PDF)Low-frequency US and NNWT (PDF)Vagus Nerve Stimulation (PDF)
 Clinicial Policy Committee (PDF)

Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/18
Ventriculectomy Cardiomyoplasty (PDF)
 Clinical Trials (PDF)Lung Transplantation (PDF)Ventricular Assist Devices (PDF)
 Cochlear Implant Replacements (PDF)Lysis of Epidural Lesions (PDF)Video EEG Monitoring (PDF)
 Cosmetic and Reconstructive Procedures (PDF)Mechanical Stretch Devices (PDF)Vitamin D Testing in Children (PDF)
 CPG Grid (PDF)Medical Necessity Criteria (PDF)Wheelchair Seating (PDF)
 Cystic Fibrosis Carrier Screening (PDF)Measure Serum 1.25 Vitamin (PDF)Wireless Motility Capsule (PDF)
 Dental Anesthesia (PDF)Monitored Anesthesia Care (PDF)

Zika Virus Testing (PDF)

 Diabetes Prevention Program (PDF)Multiple Sleep Latency Testing (PDF) 
 Diagnosis of Vaginitis (PDF)
Effective Date: 1/1/18
Neonatal Abstinence Syndrome Guidelines (PDF) 
 Diaphragmatic Phernic Nerve Stimulation (PDF)Neonatal Sepsis Management Guidelines (PDF) 
 Digital Analysis of EEGS (PDF)Neurofeedback (PDF) 
  Neuromuscular Electrical Stimulation (PDF) 
 Disc Decompression Procedures (PDF)Nerve Blocks (PDF) 
 
Discography (PDF)
Nerve Blocks and Neurolysis for Pain Management (PDF) 
 DME (PDF)NICU Apnea Bradycardia Guidelines (PDF) 
 DNA Analysis of Stool (PDF)NICU Discharge Guidelines (PDF) 
 Donor Lymphocyte Infusion (PDF)Non-Invasive Home Ventilator (PDF) 
 EEG headache (PDF)OB Home Health Programs (PDF) 
 Electric Tumor Treating Fields (PDF)Oncology Algorithmic Testing (PDF) 
 Endometrial Ablation (EA) (PDF)Oncology Cancer Screening (PDF) 
 Epifix Wound Treatment (PDF)
Effective Date: 1/1/18
Oncology Circulating Tumor DNA and Circulating Tumor Cells (Lqd Biopsy) (PDF) 
 Essure Removal (PDF)Oncology Cytogenetic Testing (PDF) 
 Evoked Potentials (PDF)Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) 
 Experimental Policy (PDF)Optic nerve decompression surgery (PDF) 
 Experimental Technologies (PDF)Orthognathic Surgery (PDF) 
 Facet Joint Interventions (PDF)Outpatient Testing for DOA (PDF) 
 Fecal Calprotectin Assay (PDF)
Effective Date: 1/1/18
Oxygen Use and Concentrators (PDF) 
 Fecal Incontinence Treatments (PDF)  
 

Ferriscan R2 MRI (PDF)
Pancreas Transplantation (PDF) 
 Fertility Preservation (PDF)Panniculectomy (PDF) 
 Fetal Surgery in Utero (PDF)Pediatric Heart Transplant (PDF) 
 Fixed Wing Air Transportation (PDF)Pediatric Liver Transplant (PDF) 
 Functional MRI (PDF)Pediatric Oral Function Therapy (PDF) 
 Gastric Electrical Stimulation (PDF)Percutaneous LAAD Stroke Prevention (PDF) 
 Gastrointestinal Pathogen Nucleic Acid Detection Panel (PDF)PFO Closure Devices (PDF) 
  Post Acute Care (PDF) 
 Genetic and Pharmacogenetic Testing (PDF)Posterior Nerve Stimulation for Voiding Dysfunction (PDF) 
 Genetic Testing (PDF) Private Duty Nursing (PDF) 
 Genetic Testing Aortopathies and Connective Tissue Disorder (PDF)Presumptive Testing for Drugs of Abuse (PDF) 
 Genetic Testing Cardiac Disorders (PDF)Preventative Health and CPG Policy (PDF) 
 Genetic Testing Dermatologic Conditions (PDF)PROM Testing (PDF)
Effective Date: 1/1/18
 
 Genetic Testing Epilepsy NeurodegenerativeNeuromuscular Disorder (PDF)Proton and Neautron Beam Therapy (PDF)
Effective Date: 1/1/18
 
 Genetic Testing Exome and Genome Sequencing (PDF)PT OT ST (PDF) 
 Genetic Testing Eye Disorders (PDF)Pulmonary Function Testing (PDF) 
 Genetic Testing Gastroenterologic Disorders (Non-Cancerous) (PDF)  
 Genetic Testing General Approach to Genetic Testing (PDF)  
 Genetic Testing Hearing Loss (PDF)  
 Genetic Testing Hematologic Conditions (non-cancerous) (PDF)  
 Genetic Testing Hereditary Cancer Susceptibility (PDF)  
 Genetic Testing Immune Autoimmune and Rheumatoid Disorders (PDF)  
 Genetic Testing Kidney Disorders (PDF)  
 Genetic Testing Lung Disorders (PDF)  
 Genetic Testing Metabolic Endocrine and Mitochondrial Disorders (PDF)  
 Genetic Testing for  Multisystem Inherited Disorders, ID & DD (PDF)  
 Genetic Testing Non-Invasive Prenatal Screening (NIPS) (PDF)  
 Genetic Testing Pharmacogenetics (PDF)  
 Genetic Testing Preimplantation Genetic Testing (PDF)  
 Genetic Testing Prenatal and Precon Carrier Screening (PDF)  
 Prenatal Diagnosis (Via Amniocentesis CVS or PUBS) & Pregnancy Loss (PDF)  
 Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (PDF)  
 GI Pathogen Nucleic Acid Detection Panel Testing (PDF)  
 Grid (PDF)  
    
    

 

A-J

H-T

U-Z

Acupuncture (PDF)H Pylori Serology Testing (PDF) Ultrasound in Pregnancy (PDF)
ADHD Testing and Treatment (PDF)Holter Monitors (PDF)Urinary Incontinence Devices and Treatments (PDF)
AHCT for Sickle Cell Anemia (PDF)Home Births (PDF)Urodynamic Testing (PDF)
Allergy Testing and Therapy (PDF)Home Phototherapy for Neonatal Hyperbilirubinemia (PDF)US in Pregnancy (PDF)
Ambulatory EEG (PDF)
Effective Date: 1/1/18
Homosysteine Testing (PDF)
Effective Date: 1/1/21
Ventriculectomy Cardiomyoplasty (PDF)
Antithrombin III (Atryn Thrombate) (PDF)Hospice (PDF)Ventricular Assist Devices (PDF)
Applied Behavior Analysis (PDF)Hyperemesis Gravidarum Treatment (PDF)Video EEG Monitoring (PDF)
Articular Cartilage Defect Repairs (PDF)Hyperhidrosis Treatments (PDF)Vitamin D Testing in Children (PDF)
ASC Optimization (PDF)Implantable Hypoglossal Nerve Stim (PDF)Wheelchair Seating (PDF)
Assisted Reproductive Technology (PDF)Inhaled Nitric Oxide (PDF)Wireless Motility Capsule (PDF)
Balloon Sinus Ostial Dilation (PDF)Intensity-Modulated Radiotherapy (PDF) 
Bevacizumab (PDF)
Effective Date: 1/1/18
Laser Skin Treatment (PDF)
Effective Date: 1/1/18
 
Biofeedback (PDF)Low-frequency US and NNWT (PDF) 
Burn Surgery (PDF)Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/18
 
Bronchial Thermoplasty (PDF)
Effective Date: 1/1/18
Lung Transplantation (PDF) 
Cardiac Biomarker Testing (PDF)Lysis of Epidural Lesions (PDF) 

Caudal or Interlaminar ESI (PDF)Measure Serum 1.25 Vitamin (PDF) 
Cell-Free Fetal DNA Testing (PDF)  
Clinicial Policy Committee (PDF)Mechanical Stretch Devices (PDF) 
Clinical Trials (PDF)Neonatal Abstinence Syndrome Guidelines (PDF) 
Cochlear Implant Replacements (PDF)Neonatal Sepsis Management Guidelines (PDF) 
Cosmetic and Reconstructive Procedures (PDF)Neurofeedback (PDF) 
CPG Grid (PDF)Neuromuscular Electrical Stimulation (PDF) 
Dental Anesthesia (PDF)Nerve Blocks and Neurolysis for Pain Management (PDF) 
Diagnosis of Vaginitis (PDF)
Effective Date: 1/1/18
NICU Apnea Bradycardia Guidelines (PDF) 
Diaphragmatic Phernic Nerve Stimulation (PDF)Non-Invasive Home Ventilator (PDF) 
Digital Analysis of EEGS (PDF)Oncology Algorithmic Testing (PDF) 
Disc Decompression Procedures (PDF)Oncology Cancer Screening (PDF) 
Discography (PDF)Oncology Circulating Tumor DNA and Circulating Tumor Cells (Lqd Biopsy) (PDF) 
DME (PDF)Oncology Cytogenetic Testing (PDF) 
DNA Analysis of Stool (PDF)Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF) 
Donor Lymphocyte Infusion (PDF)Optic nerve decompression surgery (PDF) 
EEG headache (PDF)Orthognathic Surgery (PDF) 
Electric Tumor Treating Fields (PDF)Outpatient Testing for DOA (PDF) 
Endometrial Ablation EA (PDF)
Effective Date: 1/1/18
Oxygen Use and Concentrators (PDF) 
EpiFix Wound Treatment (PDF)
Effective Date: 1/1/18
Paclitaxel (PDF) 
Essure Removal (PDF)Pancreas Transplantation (PDF) 
Evoked Potentials (PDF)Panniculectomy (PDF) 
Facet Joint Interventions (PDF)Pediatric Heart Transplant (PDF) 
Fecal Calprotectin Assay (PDF)
Effective Date: 1/1/18
Pediatric Liver Transplant (PDF) 
Fecal Incontinence Treatments (PDF)Pediatric Oral Function Therapy (PDF) 
Ferriscan R2 MRI (PDF)Percutaneous LAAD Stroke Prevention (PDF) 
Fetal Surgery in Utero (PDF)  
Fertility Preservation (PDF)PFO Closure Devices (PDF) 
Functional MRI (PDF)Post Acute Care (PDF) 
Gastric Electrical Stimulation (PDF)Presumptive Testing for Drugs of Abuse (PDF) 
Gastrointestinal Pathogen Nucleic Acid Detection Panel (PDF)Preventative Health and CPG Policy (PDF) 
Gender Affirming Procedures (PDF)Private Duty Nursing (PDF) 
Genetic and Pharmacogenetic Testing (PDF)

PROM (PDF)

Effective Date:  1/15/20

 
Genetic Testing Aortopathies and Connective Tissue Disorder (PDF)Proton and Neutron Beam Therapy (PDF)
Effective Date: 1/1/18
 
Genetic Testing Cardiac Disorders (PDF)Pulmonary Function Testing (PDF) 
Genetic Testing Dermatologic Conditions (PDF)Radial Head Implant (PDF) 
Genetic Testing Epilepsy NeurodegenerativeNeuromuscular Disorder (PDF)Reduction Mammoplasty and Gynecomastia Surgery (PDF) 
Genetic Testing Exome and Genome Sequencing (PDF)Rituximab (PDF)
Effective Date: 1/1/18
 
Genetic Testing Eye Disorders (PDF)Sacroiliac Joint Interventions (PDF) 
Genetic Testing Gastroenterologic Disorders (Non-Cancerous) (PDF)Selective Dorsal Rhizotomy for Spasticity in CP (PDF) 
Genetic Testing General Approach to Genetic Testing (PDF)Short Inpatient Hospital Stay (PDF) 
Genetic Testing Hearing Loss (PDF)SNF Leveling (PDF) 


Genetic Testing Hematologic Conditions (non-cancerous) (PDF)

Spinal Cord Stimulation (PDF) 
Genetic Testing Hereditary Cancer Susceptibility (PDF)Stereotactic Body Radiation Therapy (PDF) 
Genetic Testing Immune Autoimmune and Rheumatoid Disorders (PDF)Testing Select Genitourinary conditions (PDF) 
Genetic Testing Kidney Disorders (PDF)Thymus Transplant (PDF) 
Genetic Testing Lung Disorders (PDF)Thyroid Testing in Pediatrics (PDF) 
Genetic Testing Metabolic Endocrine and Mitochondrial Disorders (PDF)Thyroid Insulin Tests in Pediatrics (PDF) 
Genetic Testing for  Multisystem Inherited Disorders, ID & DD (PDF)Total Artificial Heart (PDF) 
Genetic Testing Non-Invasive Prenatal Screening (NIPS) (PDF)  
Genetic Testing Pharmacogenetics (PDF)  
Genetic Testing Preimplantation Genetic Testing (PDF)  
Genetic Testing Prenatal and Precon Carrier Screening (PDF)  
Prenatal Diagnosis (Via Amniocentesis CVS or PUBS) & Pregnancy Loss (PDF)  
Genetic Testing Skeletal Dysplasia and Rare Bone Disorders (PDF)  
GI Pathogen Nucleic Acid Detection Panel Testing (PDF)  

For Medicare information, please visit our Medicare Prior Authorization website.

Clinical Policies
A-FG-OP-Z
Adjacent-Tissue-Transfer-Grafts-involving-Eyelid (PDF)Glaucoma (PDF)Pediatric-Eye-Examinations (PDF)
Age-Related-Macular-Degeneration (PDF)Glaucoma-Screening (PDF)Photodynamic-and-Intravitreal-Therapies-and-Pharmaceuticals (PDF)
Amblyopia (PDF)Gonioscopy (PDF)Probing-and-Closure-of-the-Lacrimal-Duct-System (PDF)
Amniotic-Membrane-Placement-on-Ocular-Surface (PDF)Guidelines-for-Dilation-Protocol-during-Examination-of-the-Eye (PDF)Prophylaxis-of-Retinal-Detachment (PDF)
Anterior-Segment-Photography-with-Fluorescein-Angiography (PDF)Indocyanine-Green-(ICG)-Angiography (PDF)Refractive-Surgery (PDF)
Aqueous-Shunt (PDF)Infracture-of-the-Inferior-Turbinate (PDF)Refraction (PDF)
Blepharoplasty-Ptosis-Repair-and-Canthoplasty (PDF)Iris-Coloboma (PDF)Repair-of-Retinal-Detachment (PDF)
Canthotomy (PDF)Keratoplasty (PDF)Scanning-Computerized-Ophthalmic-Diagnostic-Imaging (PDF)
Cataract-Extraction (PDF)Laser-Iridotomy-and-Iridectomy for Glaucoma (PDF)Secondary-Intraocular-Lens-(IOL) (PDF)
Chemodenervation (PDF)Laser-Trabeculoplasty (PDF)Sensorimotor-Examination (PDF)
Complex-Cataract-Extraction (PDF)Low-Vision-Evaluations-and-Aids (PDF)Serial-Tonometry (PDF)
Corneal-Erosion-and-Photo-Keratectomy (PDF)Ocular-Prosthesis (PDF)Specular-Microscopy (PDF)
Corneal-Hysteresis (PDF)Ocular-Surface-Reconstruction (PDF)Surgical-Excision-of-Eyelid-Lesions (PDF)
Corneal-Pachymetry (PDF)Ophthalmic-Biometry (PDF)Surgical-Strabismus-Repair (PDF)
Corneal-Topography (PDF)Ophthalmic-B-scans (PDF)Teleretinal-Screening-for-Diabetic-Retinopathy (PDF)
Dark-Adaption-and-Color-Vision-Examinations (PDF) Trabeculectomy-Ab-Externo (PDF)
Destruction-of-Localized-Lesion-of-Choroid (PDF) Visual-Field-Testing (PDF)
Destruction-of-Localized-Lesion-of-the-Retina (PDF) Visual-Therapy (PDF)
Destruction-of-Retinopathy (PDF) Vitrectomy (PDF)
Ectropion-Entropion-Repair (PDF) Yttrium-Aluminium-Garnet-(YAG)-Laser-Capsulotomy (PDF)
Electroretinography (PDF)  
Eyelid-Reanimation (PDF)  
Examination-Guidelines-for-Diabetic-Patients (PDF)  
Extended-Ophthalmoscopy (PDF)  
External-Ocular-Photography (PDF)  
Fluorescein-Angiography (PDF)  
Fundus-Photography (PDF)  

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Home State Health Payment Policy Manual apply with respect to Home State Health members. Policies in the Home State Health Payment Policy Manual may have either a Home State Health or a “Centene” heading.  In addition, Home State Health may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Home State Health.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-HI-QR-Z
30-Day Readmission (PDF)
Effective Date: 1/1/18
Inpatient Consultation (PDF)

Renal Hemodialysis (PDF)

Effective:  1/1/21

Assistant Surgeon (PDF)Inpatient Only Procedures (PDF)Robotic Surgery (PDF)
Effective Date: 1/1/18
BH Services for Children with Severe Trauma (PDF)IV Hydration (PDF)Same Day Visits (PDF)


Bilateral Procedures (PDF)
Leveling of Care: Evaluation and Management Overcoding (PDF)Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)
Effective Date: 1/1/18
Biopsychosocial Treatment of Obesity (PDF)Leveling of ER Services (PDF)
Effective Date: 1/1/19
Sleep Studies Place of Service (PDF)
Effective Date: 1/1/18
Cerumen Removal (PDF)Leveling of ER Services (Hospitals) (PDF)Status "B" Bundled Services (PDF)

Clean Claims (PDF)

Maximum Units (PDF)Status "P" Bundled Services (PDF)
Effective Date: 1/1/18
Cosmetic Procedures (PDF)Moderate Conscious Sedation (PDF)Supplies Billed on Same Day As Surgery (PDF)
Cost to Charge Adjustments on Clean Claim Reviews (PDF)

Modifer 59 Clinical Validation (PDF)
Transcranial Magnetic Stimulation for MDD (PDF)

Coding Overview (PDF)





Modifer DOS Validation (PDF)
Transgender Related Services (PDF)
Distinct Procedural Modifiers (PDF)Modifer to Procedure Code Validation (PDF)Unbundling Adjustments on Clean Claim Reviews (PDF)

Duplicate Primary Code Billing (PDF)



MPPR for Ophthalmology (PDF)
Effective 01/01/2021
Unbundled Professional Services (PDF)
EM Bundling Edits (PDF)

Multiple CPT Code Replacement (PDF)
Unbundled Surgical Procedures (PDF)
E&M Medical Decision-Making (PDF)Multiple Diagnosis Cardiovascular (PDF)Unlisted Procedure Codes (PDF)
Extended Ophthalmoscopy (PDF)
Effective Date: 1/1/18
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)Urine Specimen Validity Testing (PDF)
External Ocular Photography (PDF)
Effective Date: 1/1/18
NCCI Unbundling (PDF)Visual Field Testing (PDF)
Effective Date: 1/1/18
Fluorescein Angiography (PDF)
Effective Date: 1/1/18
Never Paid Events (PDF)

Wheelchair Seating (PDF)

Effective Date: 10/1/2018 

Fundus Photography (PDF)
Effective Date: 1/1/18
New Patient (PDF)

 


Global Maternity Billing (PDF)
Non-Obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF)
Effective 01/01/2021
 
Gonioscopy (PDF)
Effective Date: 1/1/18
Optum Comprehensive Payment Integrity (CPI) (PDF) 
Hospital Visit Codes Billed with Labs (PDF)Outpatient Consultation (PDF) 
 
Physician's Office Lab Testing (PDF)

 
 Physician Visit Codes Billed with Labs (PDF) 
 Post-Operative Visits (PDF)s 
 
Pre-Operative Visits (PDF)
 
 

Professional Component (PDF)
 
 

Problem Oriented Visits with Preventative Visits (PDF)
 
 Pulse Oximetry (PDF)

 
 Place of Service Mismatch (PDF)
Effective Date: 11/1/18
 

A-JK-TU-Z
3 Day Payment Window (PDF)
Effective Date: 1/1/18
Maximum Units (PDF)
Effective Date: 1/1/18
Unbundling Adjustments on Clean Claim Reviews (PDF)
30-Day Readmission (PDF)
Effective Date: 1/1/18
Moderate Conscious Sedation (PDF)
Effective Date: 1/1/18
Unbundled Professional Services (PDF)
Effective Date: 1/1/18
Assistant Surgeon (PDF)
Effective Date: 1/1/18
Modifier-59 Clinical Validation (PDF)
Effective Date: 1/1/18
Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/18
Add on Code Billed Without Primary Code
Effective Date: 1/1/18
Modifier DOS Validation (PDF)
Effective Date: 1/1/18
Unlisted Procedure Codes (PDF)
Effective Date: 1/1/18
Bilateral Procedures (PDF)
Effective Date: 1/1/18
Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/18

Wheelchair Seating (PDF)

Effective Date: 10/1/2018 

MPPR for Ophthalmology (PDF)
Effective 01/01/2021
MPPR for Ophthalmology (PDF)
Effective 01/01/2021
NCCI Unbundling (PDF)
Effective Date: 1/1/18
Cerumen Removal (PDF)
Effective Date: 1/1/18
Multiple CPT Code Replacement (PDF)
Effective Date: 1/1/18
 
Clean Claims (PDF)Multiple Diagnosis Cardiovascular (PDF) 
Coding Overview (PDF)
Effective Date: 1/1/18
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective 01/01/2021
 
Cosmetic Procedures (PDF)
Effective Date: 1/1/18
Never Paid Events (PDF)
Effective Date: 1/1/18
 
Cost to Charge Adjustments on Clean Claim Reviews (PDF)New Patient (PDF)
Effective Date: 1/1/18
 
Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/18
Non-Obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF)
Effective 01/01/2021
 
Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/18
Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 11/1/18
 
EM Bundling Edits (PDF)
Effective Date: 1/1/18
Optum Comprehensive Payment Integrity (CPI) (PDF) 
E&M Medical Decision-Making (PDF)
Effective Date: 1/1/18
Outpatient Consultation (PDF)
Effective Date: 1/1/18
 

Evaluation and Management Services Billed with Treatment Rooms (PDF)

Effective 6/18/2022

Physician Consultative Services (PDF)

Effective Date:  1/15/20

 

Global Maternity Billing (PDF)
Effective Date: 1/1/18

Physician's Office Lab Testing (PDF)

 
Hospital Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18

Physician Visit Codes Billed with Labs (PDF)
Effective Date: 1/1/18

 
Inpatient Consultation (PDF)
Effective Date: 1/1/18
Place of Service Mismatch (PDF)
Effective Date: 11/1/18
 
IV Hydration (PDF)

 

 
Inpatient Only Procedures (PDF)
Effective Date: 1/1/18

Post-Operative Visits (PDF)
Effective Date: 1/1/18

 

Leveling of ER Services (PDF)

Effective Date:  1/15/20

Pre-Operative Visits (PDF)
Effective Date: 1/1/18
 

Leveling of ER Services (Hospitals) (PDF)

Problem Oriented Visits with Preventive Visits (PDF)

Effective Date:  1/15/20

 
Leveling of Care: Evaluation and Management Overcoding (PDF)

Problem Oriented Visits with Surgical Procedures (PDF)

Effective Date:  1/15/20

 
 Professional Component (PDF)
Effective Date: 1/1/18
 
 Pulse Oximetry (PDF)
Effective Date: 1/1/18
 
 

Renal Hemodialysis (PDF)

Effective:  1/1/21

 
 Robotic Surgery (PDF)
Effective Date: 1/1/18
 

 

Same Day Visits (PDF)
Effective Date: 1/1/18
 
 Sepsis Diagnosis (PDF) 
 Status "B" Bundled Services (PDF)
Effective Date: 1/1/18
 
 Status "P" Bundled Services (PDF)
Effective Date: 1/1/18
 
 Supplies Billed on Same Day As Surgery (PDF)
Effective Date: 1/1/18
 
 Transgender Related Services (PDF)
Effective Date: 1/1/18
 

 

A-HI-QR-Z
30 Day Readmission (PDF)IV Hydration  (PDF)

Renal Hemodialysis (PDF)

Effective:  1/1/21

Bevacizumab (PDF)
Effective Date: 1/1/18
Leveling of Care: Evaluation and Management Overcoding (PDF)Robotic Surgery (PDF)
Effective Date: 1/1/18
Bilateral Procedures (PDF)Leveling of ER Services (PDF)
Effective Date: 1/1/18
Same Day Visits (PDF)
Clean Claims (PDF)Leveling of ER Services (Hospitals) (PDF)Sepsis Diagnosis (PDF)
Clinical Validation (PDF)Modifer DOS Validation (PDF)Status "B" Bundled Services (PDF)
Effective Date: 1/1/18
Cosmetic Procedures (PDF)MPPR for Ophthalmology (PDF)
Effective 01/01/2021
Status "P" Bundled Services (PDF)
Effective Date: 1/1/18
Cost to Charge Adjustments on Clean Claim Reviews (PDF)Multiple Diagnosis Cardiovascular (PDF)Unbundling Adjustments on Clean Claim Reviews (PDF)
E&M Medical Decision-Making (PDF)Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective 01/01/2021
Unbundled Professional Services (PDF)

Evaluation and Management Services Billed with Treatment Rooms (PDF)

Effective 6/18/2022

Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 11/1/18
Urine Specimen Visits with Surgical Procedures (PDF)
Effective Date: 1/1/18

 

Non-Obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF)
Effective 01/01/2021
Skilled Nursing Facility Leveling (CC.PP.206) (PDF) Effective Date: January 1, 2024
 NCCI Unbundling (PDF) 
 Optum Comprehensive Payment Integrity (CPI) (PDF) 
 Physician's Office Lab Testing (PDF) 
 Professional Component (PDF) 
 Problem Orriented Visits with Preventative Visits (PDF)
Effective: 1/1/18
 
 

Problem Oriented Visits with Surgical Procedures (PDF)

Effective Date:  1/1/19

 
 Place of Service Mismatch (PDF)
Effective Date: 11/1/18