Reimbursement Policy Manual
- Administrative
- Add-on Codes (last updated 06/2019)
- After Hours and Other Special Circumstances (last updated 01/2019)
- Clinical Editing (last updated 06/2019)
- Diagnosis Code Requirements - Level Of Detail and Number of Characters (last updated 11/2017)
- Diagnosis Code Requirements - Invalid As Primary (last updated 11/2017)
- Hospital Routine Supplies and Services (last updated 5/2018)
- Incident-To Services (last updated 10/2017)
- Medical Records Documentation Standards (last updated 06/2019)
- Medical, Surgical, and Routine Supplies (last updated 05/2018)
- Medically Unlikely Edits (MUEs) (last updated 11/2018)
- Moda Health Reimbursement Policy Overview (last updated 01/2019)
- Never Events, Adverse Events, Hospital-Acquired Conditions (HAC), and Serious Reportable Events (SRE) (last updated 04/2019)
- Preventive Services versus Diagnostic and/or Medical Services (last updated 11/2018)
- Procedures Designated as "Separate Procedure" (last updated 10/2017)
- Records Fees, Copying Fees (last updated 04/2019)
- Revenue Codes Ending in "9" ("Other" Categories) (last updated 04/2019)
- Risk Adjustment/HCC Coding and Documentation (last updated 08/2018)
- Behavioral Health
- Behavioral Health Case Management & Care Coordination (last updated 07/2018)
- Anesthesia
- Anesthesia Physical Status Modifiers (P1 - P6) (last updated 03/2019)
- Modifiers AA, AD, GC, QK, QX, QY, QZ - Anesthesia Payment Modifiers (last updated 07/2018)
- Qualifying Circumstances for Anesthesia (last updated 07/2018)
- Documentation
- E0486 Oral Sleep Apnea Device/Appliance Documentation (last updated 06/2019)
- Evaluation & Management
- Clinic Services In the Hospital Outpatient Setting (last updated 3/2019)
- Critical Care, Evaluation and Management Services (99291, 99292) (last updated 10/2017)
- Gynecologic or Annual Women's Exam Visit & Use of Q0091 (Pap, Pelvic, & Breast Visit) (last updated 10/2017)
- Facility-Specific
- DRG Payment With Patient Transfers (last updated 04/2019)
- Level of Care Review (last updated 04/2019)
- Facility DRG Validation (last updated 04/2019)
- Facility Reimbursement of Respiratory Therapy Services (last updated 06/2017)
- Facility Guidelines, General Overview (last updated 03/2019)
- Readmissions (last updated 04/2019)
- Laboratory & Pathology
- Clinical Drug Screening and/or Drug Testing (last updated 06/2019)
- Molecular Pathology Procedure (MPP) Codes (a.k.a. Genetic Testing) (last updated 02/2017)
- Routine Venipuncture and/or Collection of Specimens (last updated 01/2019)
- Medicine
- Drugs and Biologicals, Wastage and/or Discarded Amounts (Modifier JW) (last updated 06/2019)
- Moderate (Conscious) Sedation (last updated 6/2019)
- Telehealth And Telemedicine (last updated 02/2019)
- Modifiers
- Modifier 22 - Increased Procedural Services (last updated 03/2018)
- Modifier 25 - Significant, Separately Identifiable E/M Service (last updated 08/2018)
- Modifier 47 - Modifier 47 - Anesthesia By Surgeon (last updated 07/2018)
- Modifier 50 - Bilateral Procedure (last updated 04/2018)
- Modifier 51 - Multiple Procedure Fee Reductions (last updated 11/2018)
- Modifier 52 - Reduced Services (last updated 04/2019)
- Modifier 53 – Discontinued Procedure (last updated 02/2019)
- Modifiers 54, 55, and 56 - Split Surgical Care (last updated 07/2018)
- Modifier 57 -- Decision For Surgery (last updated 10/2017)
- Modifiers 58, 78, and 79 - Staged, Related, and Unrelated Procedures (last updated 01/2019)
- Modifier PO - G0463 Clinic Visit Services at Excepted Off-Campus Provider-Based Outpatient Department (last updated 02/2019)
- Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service (last updated 10/2017)
- Modifiers 62 & 66 - Co-surgery (Two Surgeons) and Team Surgery (More Than Two Surgeons) (last updated 03/2018)
- Modifier 63 - Procedure Performed on Infants Less Than 4 kg (last updated 11/2018)
- Modifiers 73 & 74 - Discontinued Procedures For Facilities (last updated 04/2019)
- Modifiers 80, 81, 82, and AS - Assistant At Surgery (last updated 07/2018)
- Modifiers GA, GX, GY, and GZ (last updated 11/2017)
- Modifier SL - State Supplied Vaccine (last updated 06/2019)
- Modifier SU - Procedure Performed in Physician’s Office (Facility and equipment) (last updated 04/2019)
- Reference (Outside) Laboratory -- Modifier 90 (last updated 10/2017)
- Technical Component (TC), Professional Component (PC/26), and Global Service Billing (last updated 06/2019)
- Valid Modifier to Procedure Code Combinations (last updated 04/2019)
- Radiology Reductions for Technology Type - Modifiers FX and FY (last updated 07/2018)
- Transportation of Portable X-ray Equipment, Multiple Portable X-rays - Modifiers UN, UP, UQ, UR, US (last updated 08/2018)
- 340B Drug Discount Program-Acquired Drugs and Biologicals (Modifiers JG & TB) (last updated 02/2019)
- Preventive Services
- Colorectal Cancer Screening And Related Ancillary Services (last updated 01/2019)
- Surgery
- Computer Assisted Navigation (last updated 07/2018)
- Global Surgery Package for Professional Claims (last updated 04/2019)
- Intra-joint and Surgical Site Postoperative Pain Relief Drug Delivery System (Pain Pump) (last updated 01/2019)
- Maternity Care (last updated 04/2019)
- Operating Microscope (CPT Code 69990) (last updated 06/2019)
- Postoperative Sinus Endoscopy and/or Debridement Procedures (last updated 01/2019)
- Procedure Codes Assigned to Surgical Benefit Categories (last updated 06/2019)
- Robotic Assisted Surgery (last updated 01/2019)
The Moda Health Reimbursement Policy Manual is intended only for physicians, facilities, and other healthcare professionals, except where otherwise indicated. By using the Moda Health Reimbursement Policy Manual you acknowledge your understanding of, and agreement with the Moda Health Reimbursement Policy Disclaimer.
Questions?
If you can't find an answer, please feel free to contact our Customer Service Customer Service Customer Service
Questions?
If you can't find an answer, please feel free to contact our Customer Service
Employer web tools
Benefit Tracker
Check benefits, eligibility, incentive and utilization
Producer web tools
Hello.
We have exciting news to share. ODS is changing its name to Moda Health.
Moda comes from the latin term "modus" and means "a way". We picked it because that's what we are here to do: help our communities find a way to better health.
Together, we can be more, be better.
Please select the state you live in, or the state where your employer is headquartered, so we can tailor your experience:
Hello.
Please select the state you live in, or the state where your employer is headquartered, so we can tailor your experience:
Changing your location to Oregon
You can return to your previous location in the site header.