Coding and Payment Guidelines Modifiers
Effective 1 de setembro, 2023, payments for subsequent services under multiple radiology services/diagnostic imaging section will be paid at 60%. Prior to this change, these services were paid at 60.4%. For additional information, please refer to the policy here.
COVID-19 Diagnostic Testing After PHE End Date
This new policy extends the waiver of cost share for COVID-19 testing for fully insured and municipal self-funded accounts. Cost share waiver applies to Medicare Advantage plans for dates of service through 30 de junho, 2023. For dates of service after this date, cost share will apply for Medicare Advantage plans. For all commercial products and Medicare Advantage plans, all tests including OTC tests will require a provider order. For additional information, please refer to the policy here.
COVID-19 Monoclonal Antibody Treatment and Antiviral IV Medications
For dates of service on or after 12 de maio, 2023, monoclonal antibody treatment and antiviral medications will be covered and reimbursed according to provider contracts, medical policy, Evidence of Coverage, and/or Subscriber Agreements. Member cost share will no longer be in effect for dates of service on or after 12 de maio, 2023 for commercial and 1 de julho, 2023 for Medicare Advantage. For additional information, please refer to the policy here.
COVID-19 Vaccinations
For dates of service on or after 12 de maio, 2023 this policy is no longer in effect. Please see the Immunizations and Vaccinations policy for information on COVID-19 vaccinations.
Epidural Injections for Pain Management
Effective 1 de setembro, 2023, for commercial products only, thoracic epidural injections for pain management will change from being considered not medically necessary to medically necessary when the medical criteria in the policy is met. This change will also be reflected in the online authorization tool for participating providers. There will be no changes for Medicare Advantage plans. For additional information, please refer to the policy here.
Functional Neuromuscular Electrical Stimulation
Effective 1 de setembro, 2023, the medical necessity criteria in the online authorization tool, MHK, will be utilized for Medicare Advantage plans. As a result, all guidance related to Medicare Advantage plans will be removed from this policy, which will now apply to commercial products only. These services will continue to be considered not medically necessary for commercial products. For additional information, please refer to the policy here.
Hydrogel Spacer Use During Radiotherapy for Prostate Cancer
Effective 1 de setembro, 2023, hydrogel spacer use during radiotherapy for prostate cancer will require prior authorization and be considered medically necessary for commercial products when the criteria found in the policy has been met. The service will remain covered for Medicare Advantage plans. For additional information, please refer to the policy here.
Immunizations Adult and Pediatric
Effective 12 de maio, 2023, COVID-19 bivalent vaccination and administration codes have been added to this policy. Cost share will be waived on COVID-19 vaccines for fully insured, municipal self-funded, and Medicare Advantage plans. For additional information, please refer to the policy here.
Non-Reimbursable Health Service Codes
Effective 1 de abril, 2023, the following codes were added to this policy: A2019, A2020, A2021, A4341, A4342, E0677, E0711, J2403, K1024, K1025, K1031, K1032, K1033, and L8678. In addition, the indicator for certain DME codes was updated to reflect which codes are reimbursable for DME providers. For additional information, please refer to the policy here.
Preventive Services for Medicare Advantage Plans
Effective 1 de janeiro, 2023, the following codes were added to this policy: 0353U (Sexually Transmitted Infection Screening) and 0359U (Prostate Cancer Screening). For additional information, please refer to the policy here.
Preventive Services for Commercial Members
The preventive service grid was updated to refer to recommendation from the USPSTF for screening for anxiety for children and adolescents for code 96127. This code is also covered under other preventive service categories.
Effective 1 de setembro, 2023, codes A4281, A4283, A4284, A4285, and A4286 will have a two unit maximum per 12 months; A4282 will have a one unit maximum per 12 months and K1005 will have a 100 unit maximum per month (up to two months billed at one time).
For additional information related to these two updates, please refer to the policy here.
Prior Authorization via Web-Based Tool for Durable Medical Equipment (DME)
Effective 1 de setembro, 2023, the following services will continue to require prior authorization, however, may be covered when the criteria in the medical necessity policy is met:
- Commercial products: E0183, E0983, E0984, E1802, K0812, L2006
- Medicare Advantage plans: E0183
For additional information, please refer to the policy here.
Proprietary Laboratory Analyses Codes
Effective 1 de setembro, 2023, CPT codes 0353U and 0359U will no longer require prior authorization for Medicare Advantage plans. These tests will be covered as they are considered to be preventive services for Medicare Advantage plans. For commercial products, CPT code 0353U will remain not medically necessary and CPT code 0359U will continue to require prior authorization using the criteria found in the medical necessity policy. For additional information, please refer to the policy here.
Prostate Cancer Detection with IsoPSA
Effective 1 de setembro, 2023, this policy will be archived, as requests for CPT code 0359U will require prior authorization for commercial products using the criteria found in the medical necessity policy. CPT code 0359U will be changed from prior authorization required to covered for Medicare Advantage plans, as this test is considered a preventive service by the Centers for Medicare and Medicaid Services (CMS). For additional information, please refer to the policy here.
Serologic Genetic and Molecular Screening for Colorectal Cancer
Effective 1 de setembro, 2023, for Medicare Advantage plans, CPT codes 81327 and 0163U will be not covered as the evidence is insufficient to determine that the technology results in an improvement in the net health outcomes. Commercial products statements will remain the same. For additional information, please refer to the policy here.
Telemedicine Services for Commercial Products
Effective 12 de maio, 2023, coverage of Prevention Medicine Evaluation and Management codes under Telemedicine (99381-99397) including “split visits" is removed. In addition, the cost share waiver for CPT codes 99211 and 99212 no longer is in effective for dates of service on or after 12 de maio, 2023. For additional information, please refer to the policy here.
Telemedicine/Telephone Services for Medicare Advantage Plans During the Covid_19 Public Health Emergency
For dates of service after on or after 12 de maio, 2023, please refer to Telemedicine Services for Medicare Advantage Products policy. This policy will stay on the website for one year.
Telemedicine Services for Medicare Advantage Plans
Effective 12 de maio, 2023, the list of codes covered was edited to remove the Prevention Medicine Evaluation and Management codes (99381-99397). Deleted codes 99217-99220 and 99224-99226 were also removed from the list. Cost share waivers for specific providers and codes will continue to be in place through dates of service 31 de dezembro, 2023. For additional information, please refer to the policy here.
TEMPORARY COVID-19 Diagnostic Testing
This policy is no longer in effect for dates of service on or after 12 de maio, 2023. Please see COVID-19 Diagnostic Testing After PHE end date. This policy will stay on the website for one year.
TEMPORARY COVID-19 Pediatric Vaccination Preventative Medicine Counseling Services for Commercial Members
For dates of service on or after 10 de julho, 2023, this policy is no longer in effect. This policy will stay on the website for one year.
TEMPORARY Cost Share Waiver for Treatment of Confirmed Cases of
COVID-19
This policy is no longer in effect for dates of service on or after 12 de maio, 2023 for commercial products and 1 de julho, 2023 for Medicare Advantage. This policy will stay on the website for one year.
TEMPORARY Encounter for Determination of Need for COVID-19
Diagnostic Testing
This policy is no longer in effect for dates of service on or after 12 de maio, 2023 for commercial products and 1 de julho, 2023 for Medicare Advantage. This policy will stay on the website for one year.
Transcutaneous Electrical Nerve Stimulation (TEN)
Effective 1 de setembro, 2023, HCPCS codes K1017 and K1019, supplies associated with HCPCS codes K1016 (transcutaneous electrical nerve stimulator for electrical stimulation of the trigeminal nerve) and K1018 (external upper limb tremor stimulator of the peripheral nerves of the wrist), will be not covered for Medicare Advantage plans and not medically necessary for commercial products. HCPCS codes K1016 and K1018 will continue to be considered not covered for Medicare Advantage plans and not medically necessary for commercial products. For additional information, please refer to the policy here.