Reimbursement Policy Manual
- Administrative
- Add-on Codes (last updated 4/2018)
- After Hours and Other Special Circumstances (last updated 12/2020)
- Clinical Editing (last updated 1/2021)
- Diagnosis Code Requirements - Level Of Detail and Number of Characters (last updated 10/2019)
- Diagnosis Code Requirements - Invalid As Primary (last updated 2/2020)
- Global Surgery Package for Professional Claims (last updated 1/2021)
- Incident-To Services (last updated 9/2019)
- Medical Records Documentation Standards (last updated 9/2019)
- Medical, Surgical, and Routine Supplies (including but not limited to 99070) (last updated 5/2018)
- Medically Unlikely Edits (MUEs) (last updated 11/2020)
- Moda Health Reimbursement Policy Overview (last updated 12/2020)
- Never Events, Adverse Events, Hospital-Acquired Conditions (HAC), and Serious Reportable Events (SRE) (last updated 7/2020)
- Preventive Services versus Diagnostic and/or Medical Services (last updated 10/2020)
- Procedures Designated as "Separate Procedure" (last updated 10/2019)
- Records Fees, Copying Fees (last updated 4/2019)
- Revenue Codes Ending in "9" ("Other" Categories) (last updated 4/2019)
- Risk Adjustment/HCC Coding and Documentation (last updated 8/2018)
- Behavioral Health
- Behavioral Health Case Management & Care Coordination (last updated 2/2021)
- Anesthesia
- Anesthesia Physical Status Modifiers (P1 - P6) (last updated 3/2019)
- Modifiers AA, AD, GC, QK, QX, QY, QZ - Anesthesia Payment Modifiers (last updated 9/2019)
- Qualifying Circumstances for Anesthesia (last updated 7/2020)
- Documentation
- E0486 Oral Sleep Apnea Device/Appliance Documentation (last updated 11/2020)
- Evaluation & Management
- Clinic Services In the Hospital Outpatient Setting - Commercial (last updated 3/2019)
- Critical Care, Evaluation and Management Services (99291, 99292) (last updated 9/2019)
- Emergency Department Visit Leveling (last updated 12/2020)
- Gynecologic or Annual Women's Exam Visit & Use of Q0091 (Pap, Pelvic, & Breast Visit) (last updated 12/2020)
- Office or Other Outpatient Evaluation and Management (E/M) Visits and Prolonged Services (last updated 1/2021)
- Facility-Specific
- DRG Payment With Patient Transfers (last updated 6/2019)
- Hospital Routine Supplies and Services (last updated 8/2020)
- Level of Care Review (last updated 4/2019)
- Facility DRG Validation (last updated 8/2020)
- Facility Reimbursement of Respiratory Therapy Services (last updated 8/2020)
- Facility Guidelines, General Overview (last updated 5/2020)
- Readmissions (last updated 8/2020)
- Laboratory & Pathology
- Clinical Drug Screening and/or Drug Testing (last updated 4/2019)
- Molecular Pathology Procedure (MPP) Codes (a.k.a. Genetic Testing) (last updated 2/2017)
- Routine Venipuncture and/or Collection of Specimens (last updated 2/2021)
- Medicine
- Additional Practice Expense Items During a Public Health Emergency (PHE) – CPT 99072 (last updated 11/2020)
- Drugs and Biologicals, Wastage and/or Discarded Amounts (Modifier JW) (last updated 7/2020)
- Moderate (Conscious) Sedation (last updated 7/2018)
- Telehealth And Telemedicine (last updated 8/2020)
- Telehealth and Telemedicine Expanded Services for COVID-19 (last updated 12/2020)
- Modifiers
- Modifier 22 - Increased Procedural Services (last updated 9/2019)
- Modifier 25 - Significant, Separately Identifiable E/M Service (last updated 8/2018)
- Modifier 47 - Modifier 47 - Anesthesia By Surgeon (last updated 7/2018)
- Modifier 50 - Bilateral Procedure (last updated 1/2021)
- Modifier 51 - Multiple Procedure Fee Reductions (last updated 11/2018)
- Modifier 52 - Reduced Services (last updated 4/2019)
- Modifier 53 - Discontinued Procedure (last updated 2/2019)
- Modifiers 54, 55, and 56 - Split Surgical Care (last updated 7/2020)
- Modifier 57 - Decision For Surgery (last updated 9/2019)
- Modifiers 58, 78, and 79 - Staged, Related, and Unrelated Procedures (last updated 1/2021)
- Modifier PO - G0463 Clinic Visit Services at Excepted Off-Campus Provider-Based Outpatient Department - Medicare Advantage (last updated 11/2020)
- Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service (last updated 12/2020)
- Modifiers 62 & 66 - Co-surgery (Two Surgeons) and Team Surgery (More Than Two Surgeons) (last updated 7/2019)
- Modifier 63 - Procedure Performed on Infants Less Than 4 kg (last updated 11/2020)
- Modifiers 73 & 74 - Discontinued Procedures For Facilities (last updated 4/2019)
- Modifiers 80, 81, 82, and AS - Assistant At Surgery (last updated 8/2020)
- Modifiers GA, GX, GY, and GZ (last updated 11/2020)
- Modifier SL - State Supplied Vaccine (last updated 4/2019)
- Modifier SU - Procedure Performed in Physician's Office (Facility and equipment) (last updated 4/2019)
- Reference (Outside) Laboratory -- Modifier 90 (last updated 2/2021)
- Technical Component (TC), Professional Component (PC/26), and Global Service Billing (last updated 1/2021)
- Valid Modifier to Procedure Code Combinations (last updated 10/2020)
- Radiology Reductions for Technology Type - Modifiers FX and FY (last updated 7/2019)
- Transportation of Portable X-ray Equipment, Multiple Portable X-rays - Modifiers UN, UP, UQ, UR, US (last updated 2/2021)
- 340B Drug Discount Program-Acquired Drugs and Biologicals (Modifiers JG & TB) (last updated 1/2021)
- Preventive Services
- Colorectal Cancer Screening And Related Ancillary Services (last updated 1/2021)
- Surgery
- Computer Assisted Navigation (last updated 7/2019)
- Intra-joint and Surgical Site Postoperative Pain Relief Drug Delivery System (Pain Pump) (last updated 2/2020)
- Maternity Care (last updated 8/2020)
- Operating Microscope (CPT Code 69990) (last updated 4/2019)
- Postoperative Sinus Endoscopy and/or Debridement Procedures (last updated 3/2020)
- Procedure Codes Assigned to Surgical Benefit Categories (last updated 4/2019)
- Robotic Assisted Surgery (last updated 1/2021)
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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.
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