May 2, 2024
The following policies received their annual review with no changes:
The following policies received their annual review with the changes noted:
Consultation Code Services
- Clarified the Policy statement to indicate that consultation codes, both inpatient and outpatient, are eligible for reimbursement only when billed by providers contracted on a 2009 or earlier Resource Based Relative Value System (RBRVS) fee agreement.
- Clarified the Exception section for contracted Alaska providers to indicate that consult codes with dates of service prior to December 11, 2023, will be reimbursed and on or after this date will be subject to the policy criteria. All other providers are subject to the policy.
Contract Exclusions/Disallowed Charges-Inpatient and Outpatient Facility Services
Modified the following sections (BOLDED) to clarify non-reimbursable services:
- Nursing services: Removed the bullet : Incremental therapy charges (PT, OT, ST)
- Radiology: Fluoroscopy/Ultrasound/Vascular access guidance for procedures
- Pharmacy services: Anesthetic related drugs administered as part of or during the time of a procedure (e.g. Propofol)
Modifier 66 – Surgical Team
In the Policy section:
- Revised and clarified the first paragraph that the surgeons may have same or different specialties performing surgical procedures on distinct parts.
- In the fifth paragraph, clarified correct coding when the provider acts as a surgical assistant, modifier 66 should not be appended to the procedure.
- Added the seventh paragraph on correct coding when only two surgeons are involved in a surgical procedure.
Modifier 76 – Repeat Procedure by the Same Provider
In the Policy section:
- Added the second paragraph to indicate that if the repeated procedure is performed on the same date of service as the original service, both procedures should be billed on the same claim with modifier 76 appended to the second claim line procedure.
- Added the sixth paragraph to indicate that modifier 76 is not appropriate to append to a surgical procedure if the procedure was previously planned or staged to be repeated at a later time.
Modifier 77 – Repeat Procedure by Another Provider
In the Policy section:
- In the first and second paragraphs, indicated that repeat procedure performed by another provider must be identical to the original procedure performed.
- added the fourth paragraph to indicate that modifier 77 is not appropriate to append to a surgical procedure if the procedure was previously planned or staged to be repeated at a later time.
Modifier CQ-Physical Therapy Assistant and Modifier CO-Occupational Therapy Assistant
Added the seventh and eighth paragraphs which discusses the “de minimis” or 10% requirement of time for services rendered by the Physical Therapy Assistant (PTA) or the Occupational Therapy Assistant (OTA) and provides a link to the CMS criteria on how to count minutes for timed codes.
Modifier JW – Drug amount discarded/not administered to any patient and Modifier JZ – Zero drub amount discarded/not administered to any patient
- In the Purpose section, expanded to include facility claims to support Outpatient Facility NDC billing guidelines policy.
- In the Policy section, added the first two paragraphs introducing Modifier JW and JZ.
- In the Modifier JW section, in the fourth and fifth paragraphs, indicated that fractional unit billing is not valid.
Modifier TH – Obstetrical treatment/services
- In the Policy section, in the second paragraph, added that an appropriate global maternity care procedure code could be billed when more than three antepartum visits are rendered as part of complete maternity care rendered.
- In the Codes/Coding Guidelines section, updated the code descriptions for New and Established Office Visits. Deleted code 99343 which terminated January 1, 2023.
Multiple Deliveries/Births
In the Policy section:
- Revised the fourth and fifth paragraphs on the correct usage of modifier 59 and correct diagnosis code usage for the outcome of delivery of multiple births.
- Added a new expanded section on Maternity Complications/High-Risk Pregnancies that addresses when to correctly append modifier 22 to the delivery code to represent increased procedural services rendered for a high-risk pregnancy.