June 2025 billing policy updates

This policy was created primarily using content previously available on the Provider Manual. The following additions were made:

• Allergy studies for percutaneous and intradermal tests (reported with CPT codes 95004, 95024, and 95027) should not exceed 120 units per year regardless of rendering/administering provider.

• CPT 95115 and/or 95117 are payable one to three injections per week.  Any combination of these codes exceeding three injections per week will be denied.

A maximum of three units of CGM supplies per 90 day will be allowed at a time. A denial will occur if more than three units are billed within 90-day timeframe.

• Bill one unit with the same date of service in the “to” and “from” date on the claim line.

• If billing for supplies for two or three months, use more than one unit and use a date span in the “to” and “from” date on the claim line.

Added “Related denial language” section, including prism denial code:

• pf0 – Mod 77 required; code was billed in hx by different provider

Additions:

• To “Global surgical packages” section: In addition, services that have a global surgery indicator of “XXX” have inherent pre-procedure, intra-procedure and post-procedure work.  This inherent work should NOT be reported with a separate E&M code.

• New “Online Digital Management Services” section

Added “Related denial language” section, including prism denial codes:

• pf6 – ESRD modifier V5, V6, or V7 required with Rev Code 0821

• x82 – Units > 1 for bilateral procedure with modifier 50

• pg0 – Modifier GZ indicates this is not eligible for payment

Added prism denial code to the “Related denial language” section:

• t24 – Add-on procedure code has been submitted without an appropriate primary procedure code

• Clarifications added to support coding to the highest degree of specificity: The lab requisition must include the diagnostic reason for the testing. Additionally, final reports for lab results must include final diagnostic findings.

• Added “Related denial language” section and prism denial code for applicable clinical edits: u84 - Sign or Symptoms Reported as primary Dx; E5N - Price of Lab Panel Components Exceed Lab

• Updated to include new code E1032 in the unbundle table to match updates to LCAs (A52504 and A52505)

• Added clarifying information in the “Frequency” section

• Updated the “Wheelchair seating” section to indicate that a manual swingaway (E1028) should not be reported in addition to E0955 or E0956 mounting hardware

• Removed frequency for general supplies A4450, A4452 and A4455, as they’re being added to our to Miscellaneous DME Supplies billing policy with a limit of 240 per month set by MDHHS

• Added clarifying information under the “Ostomy supply maximum quantities” section

• Clarification: Capped rental devices should be billed with a date span that encompass the month being billed for the DME rental.  The “from” date will identify the date the item was furnished to the member and the “to” date should reflect the last date of the date span for the item or supply. Accurately defining this date span will allow for accurate processing of the claim

• Claims with dates of service that overlap will result in a denial.

• Supplies that are billed for a date span should also follow the “From” / “To” date guidelines.

• Addition: RR Rental (use the RR modifier when DME is to be rented)

Added the following clarification to the “Billing requirements” section:

Unless otherwise stated in the facility contract, our policy is to deny readmissions within 30 days of discharge and consider them a part of the original admission.

• Medicaid and the Healthy Michigan Plan define readmissions as within 15 days of discharge.

• Same-day readmissions are considered a continuation of care, and one claim should be submitted.

• All authorized claims may be subject to post pay reimbursement review.  Authorization is not a guarantee for payment.

Added “Related denial language” section, including prism denial code:

• pf7 – Occurrence Code 50 required on SNF claims w/ Rev Code 0022

• Removed frequency for general supplies A4450 and A4452, as they’re being added to our to Miscellaneous DME Supplies billing policy with a limit of 240 per month set by MDHHS

• Added clarifying information under the “Quantity of surgical dressings” section