New and updated billing policies are now available

We’ve posted several new and updated billing policies, which align to industry standards, to the Provider Manual.

Policies going into effect Jan. 20, 2025

The following policies will go into effect on Jan. 20, 2025. Below are links and a high-level overview of each policy. Please see each policy for specific billing, coding and reimbursement details.

• Prosthetic orthotics and footwear: This new policy sets billing and coding standards – in alignment Centers for Medicare and Medicaid Services (CMS) local coverage determinations (LCDs) and local coverage articles (LCAs) – for orthopedic footwear, ankle-foot orthosis (AFO) and knee-ankle-foot orthosis (KAFO).
• Fundus photography: Using a retinal camera to photograph regions of the vitreous, retina, choroid and optic nerve – fundus photography documents abnormalities of disease processes affecting the eye or follows the progression of a disease. In alignment with HEDIS and CMS LCDs and LCAs, this new policy identifies how this service will be reimbursed (generally no more than two times per year) and for which specific conditions.

Additional policies, new and updated

Additionally, the following policies were recently posted to or updated this Provider Manual's billing / coding policies page. They put our current policies and requirements into writing for transparency. Please see the individual policies for details:

• Behavioral health
• Condition codes
• Continuous Glucose Monitor (CGM) supplies
• Facility modifiers
• General coding
• Miscellaneous durable medical equipment (DME)
• Ophthalmology and vision
• Pelvic and transvaginal ultrasounds
• Portable radiology services