May 2025 billing policy updates

We publish billing policies to offer transparency and help providers bill claims more accurately to reduce delays in processing claims, as well as avoid rebilling and additional requests for information.

The following billing policies were recently published to or updated in our Provider Manual.

Note: If the effective date is listed as N/A, the policy represents our current system set up and/or expectations for transparency. There are either no changes for you as the policy is already in effect or the policy was recently shared with the network and we’re implementing a clinical edit in alignment with the policy’s language.

Billing policy	New or updated	Description	Effective date
Add-on codes	New	This new policy is complementary to our General Coding policy, providing additional detail for add-on code billing.	N/A
Concierge medicine	New	This new policy outlines our current rules for concierge medicine / concierge care, for transparency.	N/A
Condition codes	Updated	Added “Related denial language” section to include prism denial explanation code “y04 – Invalid condition code.” You’ll soon start to see this clinical edit applied to claims when an invalid condition code is used. Note: You can see exactly why a claim denied in prism – including the explanation code, details and rationale. Here’s how.	N/A
General coding	Updated	Added “Related denial language” section to include prism denial explanation code “pf9 – Add-on procedure submitted w/o appropriate primary procedure.” You’ll soon start to see this clinical edit applied to claims.	N/A
Genetic testing, counseling and screening	Updated	Updated the title to match the associated medical policy (#91540) and added information specific to the new CPT code 96041 (medical genetics and genetic counseling services).	N/A
Infusion services and supplies	Updated	Added “Frequencies” section.	July 15, 2025
Lab and pathology	Updated	Added billing guidance for P9603 or P9604 (Travel allowance one way in connection with medically necessary laboratory specimen) – these should be coded with a specimen collection code. When coded without a specimen collection, code P9603 and P9604 will be denied.	July 15, 2025
Medicare Annual Wellness Visits	Updated	Added “Related denial language” section to include prism denial explanation code “pf1 – Code previously billed / paid on fac claim.” You’ll soon start to see this clinical edit applied to claims.	N/A
Miscellaneous DME supplies	Updated	Updated with additional information found in CMS LCD / LCAs including a chart with billing frequency limits that are based on MDHHS guidelines.	July 15, 2025
Partial Hospitalization Program (PHP)	Updated	Updated to include a frequency of one per day for revenue code 0912, to support transparency for a clinical edit that’s been in place since 2019.	N/A
Professional status indicators	Updated	Added “Exceptions” section with exception information for status indicator B and information specific to new CPT code 96041 (medical genetics and genetic counseling services).	N/A