New and updated billing policies are now available

In alignment with industry standards, we’ve posted several new billing policies to the Provider Manual.

Policies going into effect Nov. 11, 2024

The following policies and policy updates will go into effect on Nov. 11, 2024. Below are links and a high-level overview of each policy. Please see each policy for specific billing, coding and reimbursement details.

  • Advance care planning (ACP) billing policy: Modifier 33 is required for ACP to be considered a preventive service for all products. For Medicare plans, we’re aligning with CMS to pay as preventive once per year when billed with an annual wellness visit (AWV). For commercial plans, we’ll pay as preventive visit once per quarter. More frequent billings will still be considered, but cost share will apply. This is a new policy.
  • Advanced Practice Professionals (APP) billing policy: We’re better aligning with CMS requirements for mid-level billing. Mid-level providers are paid differently when billing directly for versus “incident to” services (those billed under the NPI of a supervising physician). This is a new policy.
  • E/M services billed with treatment room revenue codes policy: In alignment with industry standard, we’ll deny claims billed with treatment room revenue codes (760, 761 and 769) when billed with an E/M service. This is a new policy.
  • Lab and pathology billing policy: We’ll require providers to append panel codes (87800 or 87801) when billing three or more infectious agent lab tests. Impacted lab tests include 87468-87799. This update is in alignment with CMS guidelines associated with the panel code verses individual code reporting. This is a policy revision.
  • Positive Airway Pressure (PAP) devices for treatment of sleep apnea billing policy: We’re aligning to CMS standards for limits on supplies. This is a new policy.
  • Professional and technical components status indicator payment policy: We’re aligning with CMS’s professional and technical status indicator requirements. This is a new policy.
  • Wound care and debridement billing policy: We’re aligning with CMS policy on the proper use of modifiers 59, XE, XP, XS, XU. These separate and distinct modifiers will only be appropriate when performed at a separate location – they’ll no longer be appropriate when performed in a separate session. This is a policy revision.

Additional policy updates

Additionally, the following policies were recently posted to or updated in the billing / coding policies page in our Provider Manual. The new policies and revisions outline our current requirements for transparency. Please see the individual policies for details: