New and recently updated billing / coding policies

The following billing / coding policies were recently updated or newly posted to our Provider Manual. 

Policy LOBs impacted Effective date Notes
Delivery & postpartum care policy All plans, except self-funded plans with a maternity exclusion for dependents 4/2/2024 Addition: For both professional and facility claims, claims will be denied when a delivery procedure code is billed, and an outcome of delivery diagnosis isn't also reported on the claim. This is in accordance with Chapter 15 of the ICD-10 official coding and reporting guidelines.
Urological supplies policy Commercial 8/1/2024 These new policies establish reimbursable limits / frequency guidelines for commercial plans. These limits / guidelines are pulled directly from the Centers for Medicare and Medicaid Services (CMS) local coverage determination (LCD) guidelines. Providers may appeal denials for units exceeding the defined limits – appeals must be supported with medical record documentation.
Ostomy supplies policy
Allergy injections / immunotherapy policy All plans 5/1/2024 Addition: Billing and coding guidelines that align with CMS.
Evaluation and management (E/M) policy All plans N/A - standard billing practices that are already effective This new policy offers a high-level overview of existing industry standard coding guidelines for evaluation and management (E/M) services. It gives documentation to help providers avoid overcoding and points to existing Provider Manual pages for relevant education.

Additional medical claims billing / coding policies are available online. The information they contain may help providers bill claims more accurately to reduce delays in processing, as well as avoid rebilling and additional requests for information.