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Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the Home State Health Clinical Policy Manual apply to Home State Health members. Policies in the Home State Health Clinical Policy Manual may have either a Home State Health or a “Centene” heading.  Home State Health utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Home State Health clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Home State Health. In addition, Home State Health may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual®criteria 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-G H-Q R-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:  1/1/21 Selective 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 for Rupture of Fetal Membranes (PDF)
  Assisted Reproductive Technology (PDF) Implantable Wireless PAP Monitoring (PDF) Testing Select Genitourinary conditions (PDF)
  Balloon Sinus Ostial Dilation (PDF) In Network Referrals (PDF)
Effective Date: 1/1/18
Therapy Services (PDF)
  Bariatric Surgery (PDF) Inhaled Nitric Oxide (PDF) Thymus Transplant (PDF)
  Biofeedback (PDF) Intensity-Modulated Radiotherapy (PDF) Thyroid Insulin Tests in Pediatrics (PDF)
  Bone-Anchored Hearing Aid (PDF) Intensity Modulated Radiation Therapy (PDF) Thyroid Testing in Pediatrics (PDF)
  Bronchial Thermoplasty (PDF)
Effective Date: 1/1/18
Intestinal & Multivisceral Transplant (PDF) Total Artificial Heart (PDF)
  Burn Surgery (PDF) Caudal or Interlaminar ESI (PDF)
TPN IDPN (PDF)
  Cardiac Biomarker Testing (PDF) Intradiscal Steroid Injections (PDF) Transcranial Magnetic Stimulation for MDD (PDF)
  Cardiac Biomarket Testing for Acute Myocardial Infarction (PDF)
Effective Date: 6/1/18
Laser Skin Treatment (PDF)
Effective Date: 1/1/18
Ultrasound in Pregnancy (PDF)
  Cardiac Rehabilitation (PDF) Laser Therapy for Skin Conditions (PDF) Urinary Incontinence Devices and Treatments (PDF)
  Caudal or Interlaminar ESI (PDF) Long Term Care PLacement Criteria (PDF) Urodynamic Testing (PDF)
  Cell-Free Fetal DNA Testing (PDF) Low-frequency US and NNWT (PDF) US in Pregnancy (PDF)
  Clinicial Policy Committee (PDF)

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

Wireless Motility Capsule (PDF)

  Diabetes Prevention Program (PDF) Multiple Sleep Latency Testing (PDF) Zika Virus 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)  
  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)  
 

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)  
  Gender Affirming Procedures (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)    
  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

ADHD Testing and Treatment (PDF) H Pylori Serology Testing (PDF)  Ultrasound in Pregnancy (PDF)
AHCT for Sickle Cell Anemia (PDF) Holter Monitors (PDF) Urinary Incontinence Devices and Treatments (PDF)
Allergy Testing and Therapy (PDF) Home Births (PDF) Urodynamic Testing (PDF)
Ambulatory EEG (PDF)
Effective Date: 1/1/18
Home Phototherapy for Neonatal Hyperbilirubinemia (PDF) US in Pregnancy (PDF)
Antithrombin III (Atryn Thrombate) (PDF) Homosysteine Testing (PDF)
Effective Date: 1/1/21
Ventriculectomy Cardiomyoplasty (PDF)
Applied Behavior Analysis (PDF) Hospice (PDF) Ventricular Assist Devices (PDF)
Articular Cartilage Defect Repairs (PDF) Hyperemesis Gravidarum Treatment (PDF) Video EEG Monitoring (PDF)
ASC Optimization (PDF) Hyperhidrosis Treatments (PDF) Vitamin D Testing in Children (PDF)
Assisted Reproductive Technology (PDF) Implantable Hypoglossal Nerve Stim (PDF) Wheelchair Seating (PDF)
Balloon Sinus Ostial Dilation (PDF) Inhaled Nitric Oxide (PDF) Wireless Motility Capsule (PDF)
Bariatric Surgery (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)  

Cell-Free Fetal DNA Testing (PDF) Measure Serum 1.25 Vitamin (PDF)  
Clinicial Policy Committee (PDF) Mechanical Stretch Devices (PDF)  
Clinical Trials (PDF) Neonatal Abstinence Syndrome Guidelines (PDF)  
Cosmetic and Reconstructive Procedures (PDF) Neurofeedback (PDF)  
CPG Grid (PDF) Nerve Blocks and Neurolysis for Pain Management (PDF)  
Dental Anesthesia (PDF) NICU Apnea Bradycardia Guidelines (PDF)  
Diagnosis of Vaginitis (PDF)
Effective Date: 1/1/18
Non-Invasive Home Ventilator (PDF)  
Diaphragmatic Phernic Nerve Stimulation (PDF) Oncology Algorithmic Testing (PDF)  
Digital Analysis of EEGS (PDF) Oncology Cancer Screening (PDF)  
Disc Decompression Procedures (PDF) Oncology Circulating Tumor DNA and Circulating Tumor Cells (Lqd Biopsy) (PDF)  
Discography (PDF) Oncology Cytogenetic Testing (PDF)  
DME (PDF) Oncology Molecular Analysis of Solid Tumors and Hematologic Malignancies (PDF)  
DNA Analysis of Stool (PDF) Orthognathic Surgery (PDF)  
Donor Lymphocyte Infusion (PDF) Outpatient Testing for DOA (PDF)  
EEG headache (PDF) Oxygen Use and Concentrators (PDF)  
Electric Tumor Treating Fields (PDF) Paclitaxel (PDF)  
Endometrial Ablation EA (PDF)
Effective Date: 1/1/18
Pancreas Transplantation (PDF)  
EpiFix Wound Treatment (PDF)
Effective Date: 1/1/18
Panniculectomy (PDF)  
Essure Removal (PDF) Pediatric Heart Transplant (PDF)  
Evoked Potentials (PDF) Pediatric Liver Transplant (PDF)  
Fecal Calprotectin Assay (PDF)
Effective Date: 1/1/18
Pediatric Oral Function Therapy (PDF)  
Ferriscan R2 MRI (PDF) Percutaneous LAAD Stroke Prevention (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) Radial Head Implant (PDF)  
Genetic Testing Dermatologic Conditions (PDF) Rituximab (PDF)
Effective Date: 1/1/18
 
Genetic Testing Epilepsy NeurodegenerativeNeuromuscular Disorder (PDF) Sacroiliac Joint Interventions (PDF)  
Genetic Testing Exome and Genome Sequencing (PDF) Selective Dorsal Rhizotomy for Spasticity in CP (PDF)  
Genetic Testing Eye Disorders (PDF) Short Inpatient Hospital Stay (PDF)  
Genetic Testing Gastroenterologic Disorders (Non-Cancerous) (PDF) SNF Leveling (PDF)  



Genetic Testing General Approach to Genetic Testing (PDF)
Spinal Cord Stimulation (PDF)  
Genetic Testing Hearing Loss (PDF) Stereotactic Body Radiation Therapy (PDF)  
Genetic Testing Hematologic Conditions (non-cancerous) (PDF) Testing for Rupture of Fetal Membranes (PDF)  
Genetic Testing Hereditary Cancer Susceptibility (PDF) Testing Select Genitourinary conditions (PDF)  
Genetic Testing Immune Autoimmune and Rheumatoid Disorders (PDF) Thymus Transplant (PDF)  
Genetic Testing Kidney Disorders (PDF) Thyroid Testing in Pediatrics (PDF)  
Genetic Testing Lung Disorders (PDF) Thyroid Insulin Tests in Pediatrics (PDF)  
Genetic Testing Metabolic Endocrine and Mitochondrial Disorders (PDF) Total Artificial Heart (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)    
Clinical Policies
A-F G-O P-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-H I-Q R-Z
3-Day Payment Window (PDF)
Effective Date: 1/1/18
Inpatient Consultation (PDF)

Renal Hemodialysis (PDF)

Effective:  1/1/21

30-Day Readmission (PDF)
Effective Date: 1/1/18
Inpatient Only Procedures (PDF) Robotic Surgery (PDF)
Effective Date: 1/1/18
Assistant Surgeon (PDF) IV Hydration (PDF) Same Day Visits (PDF)


BH Services for Children with Severe Trauma (PDF)
Leveling of Care: Evaluation and Management Overcoding (PDF) Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)
Effective Date: 1/1/18
Bilateral Procedures (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)

Clinic Facility Charge (PDF)
Maximum Units (PDF) Status "P" Bundled Services (PDF)
Effective Date: 1/1/18
Clean Claims (PDF) Moderate Conscious Sedation (PDF) Supplies Billed on Same Day As Surgery (PDF)
Cosmetic Procedures (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)
Unbundled Professional Services (PDF)
Duplicate Primary Code Billing (PDF)

MPPR for Ophthalmology (PDF)
Effective 01/01/2021
Unbundled Surgical Procedures (PDF)
EM Bundling Edits (PDF) Multiple CPT Code Replacement (PDF) Unlisted Procedure Codes (PDF)
E&M Medical Decision-Making (PDF) Multiple Diagnosis Cardiovascular (PDF) Urine Specimen Validity Testing (PDF)
Extended Ophthalmoscopy (PDF)
Effective Date: 1/1/18
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF) Visual Field Testing (PDF)
Effective Date: 1/1/18
External Ocular Photography (PDF)
Effective Date: 1/1/18
NCCI Unbundling (PDF)

Wheelchair Seating (PDF)

Effective Date: 10/1/2018 


Fluorescein Angiography (PDF)
Effective Date: 1/1/18
Never Paid Events (PDF)

 
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
Outpatient Consultation (PDF)  
Hospital Visit Codes Billed with Labs (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)
 
  Problem Oriented Visits with Surgical Procedures (PDF)

 
  Pulse Oximetry (PDF)

 
  Place of Service Mismatch (PDF)
Effective Date: 11/1/18
 
A-J K-T U-Z
3 Day Payment Window (PDF)
Effective Date: 1/1/18
Maximum Units (PDF)
Effective Date: 1/1/18
Unbundled Professional Services (PDF)
Effective Date: 1/1/18
30-Day Readmission (PDF)
Effective Date: 1/1/18
Moderate Conscious Sedation (PDF)
Effective Date: 1/1/18
Unbundled Surgical Procedures (PDF)
Effective Date: 1/1/18

340B Drug Payment Reduction (PDF)

Effective date:  2/1/2022

Modifier-59 Clinical Validation (PDF)
Effective Date: 1/1/18
Unlisted Procedure Codes (PDF)
Effective Date: 1/1/18
Assistant Surgeon (PDF)
Effective Date: 1/1/18
Modifier DOS Validation (PDF)
Effective Date: 1/1/18

Wheelchair Seating (PDF)

Effective Date: 10/1/2018 

Add on Code Billed Without Primary Code
Effective Date: 1/1/18
Modifier to Procedure Code Validation (PDF)
Effective Date: 1/1/18
NCCI Unbundling (PDF)
Effective Date: 1/1/18
Bilateral Procedures (PDF)
Effective Date: 1/1/18
MPPR for Ophthalmology (PDF)
Effective 01/01/2021
 
Cerumen Removal (PDF)
Effective Date: 1/1/18
Multiple CPT Code Replacement (PDF)
Effective Date: 1/1/18
 
Clean Claims (PDF)
Effective Date: 1/1/18
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
 
Distinct Procedural Modifiers (PDF)
Effective Date: 1/1/18
New Patient (PDF)
Effective Date: 1/1/18
 
Duplicate Primary Code Billing (PDF)
Effective Date: 1/1/18
Non-Obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF)
Effective 01/01/2021
 
EM Bundling Edits (PDF)
Effective Date: 1/1/18
Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 11/1/18
 
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
 
  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-H I-Q R-Z
30 Day Readmission (PDF) IV Hydration  (PDF)

Renal Hemodialysis (PDF)

Effective:  1/1/21

340B Drug Payment Reduction (PDF) Leveling of Care: Evaluation and Management Overcoding (PDF) Robotic Surgery (PDF)
Effective Date: 1/1/18
Bevacizumab (PDF)
Effective Date: 1/1/18
Leveling of ER Services (PDF)
Effective Date: 1/1/18
Same Day Visits (PDF)
Bilateral Procedures (PDF) Leveling of ER Services (Hospitals) (PDF) Status "B" Bundled Services (PDF)
Effective Date: 1/1/18
Clinical Validation (PDF) Modifer DOS Validation (PDF) Status "P" Bundled Services (PDF)
Effective Date: 1/1/18
Cosmetic Procedures (PDF) MPPR for Ophthalmology (PDF)
Effective 01/01/2021
Unbundled Professional Services (PDF)
E&M Medical Decision-Making (PDF) Multiple Diagnosis Cardiovascular (PDF) Urine Specimen Visits with Surgical Procedures (PDF)
Effective Date: 1/1/18

Evaluation and Management Services Billed with Treatment Rooms (PDF)

Effective 6/18/2022

Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective 01/01/2021
 
  Non-Obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: 11/1/18
 
  Non-Obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds (PDF)
Effective 01/01/2021
 
  NCCI Unbundling (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