Payment Policy Updates from December 2022

The following payment policies received their annual review with no changes:

• After Hours Services
• Facility Fees: Clinic Services, Professional Fees, and Specialty Services-Treatment Room
• Home Birth Kit Supplies 
• Modifier 79 – Unrelated Procedure/Service by Same Provider during Postoperative Period

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

• Blood Draw/Venipuncture:
  Added cross reference to policy “Contract Exclusions/Disallowed Charges – Inpatient and Outpatient Facility Services” where limit is also one unit/per provider/per day on facility claims.

• Claims Editing Exceptions: 
  Added an exception to the policy for self-funded groups that may opt-out of claims editing.

• Modifier 80, 81, 82 – Assistant Surgeons (Physician):
  In the policy section, clarified that the operative report must document the specific services that the physician assistant rendered rather than just mention a physician assistant was present. Added paragraph to indicate services with indicator flag “0” in the National Physician Fee Schedule must be accompanied by documentation for the need of a surgical assistant.

• Modifier AS – Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Services for Assistant at Surgery (Non-Physician):
  In the policy section, clarified that the operative report must document the specific services that the non-physician assistant rendered rather than just mention a physician assistant was present. Added paragraph to indicate services with indicator flag “0” in the National Physician Fee Schedule must be accompanied by documentation for the need of a surgical assistant.  Added a paragraph to indicate that the non-physician assistant must add their own identification number upon claims submitted.

• Modifier SL – State Supplied Vaccine:
  In the policy section, added the final paragraph noting that modifier SL is not appropriate to be appended to vaccine administration codes. Added a new section codes/coding guidelines and listed the applicable vaccine administration codes subject to the policy.

• New and Established Patient Guidelines:
  In the policy section, clarified the descriptions for “new” and “established” patients as set forth in the AMA CPT Codebook.

• Prolonged Services for Labor Management:
  In the codes/coding guidelines section, updated the codes to reflect revisions to code descriptions, new and terminated codes effective January 1, 2023.

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