Payment Policy Updates November 2022

November Policy Updates

The following policies received an annual review with no changes:

• Modifier 33 – Preventive Services
• Modifier 59 – Distinct Procedural Service
• Modifier 62 – Two Surgeons
• Modifier KX – Requirements Specified in the Medical Policy have been met
• Modifier NU – New Durable Medical Equipment (DME) and Modifier NR – New DME Equipment when Rented
• Modifier RR – Durable Medical Equipment (DME) Rental, Modifier KR – Rental Item-Partial Month and Modifier LL – Lease/Rental
• Modifiers XE, XS, XP and XU – Separate Encounter, Separate Structure, Separate Practitioner and Unusual Overlapping Service
• Preadmission Testing

The following November payment policies received their annual review with the noted changes:

Global Surgery

• Services included in the global surgery payment section: Revised the first bullet and added the second bullet.
• Modifier 54 section: Added second bullet on the use of modifier 54 by emergency room providers who perform minor or major surgery in the ER.
• Modifier 57 section: Added clarification on the need for documentation in medical records to support decision for surgery.
• Modifier 24 section: Created new section for modifier 24. Added bullet points of examples when modifier should not be appended.
• Modifier 25 section: Created new section for modifier 25. Added clarification on when modifier 25 is valid. Added a paragraph from the modifier 25 policy indicating appending modifier 25 does not automatically allow for payment unless documentation supports a separate and distinct service.
• Modifier 58 section: Added a paragraph indicating that documentation in the medical record indicates plans to return patient to the operating room.
• Modifier 76 section: Created new section for modifier 76. Added reference that documentation supports the need to repeat the procedure.
• Modifier 77 section: Created new section for modifier 77.
• Modifier 79 section: Added a statement on the need for the documentation to support that the procedure is unrelated to the original surgery.
• Multiple Procedure Reduction section: Added a link to the Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule.

Modifier RA – replacement of a DME, orthotic, or prosthetic item

• In the policy section, added two additional bullets for reasons for DME replacement.

Back to News