Reimbursement Policy Manual
- Manual Overview/Introduction
- Moda Health Reimbursement Policy Overview (last updated 6/2022)
- Administrative
- Add-on Codes (last updated 3/2022)
- After Hours and Other Special Circumstances (last updated 6/2022)
- Clinical Editing (last updated 1/2022)
- Diagnosis Code Requirements - Level Of Detail, Number of Characters, and Laterality (last updated 2/2022)
- Diagnosis Code Requirements - Invalid As Primary (last updated 11/2021)
- Global Surgery Package for Professional Claims (last updated 1/2022)
- Incident-To Services (last updated 11/2021)
- Medical, Surgical, and Routine Supplies (including but not limited to 99070) (last updated 3/2022)
- Medically Unlikely Edits (MUEs) (last updated 8/2021)
- Never Events, Adverse Events, Hospital-Acquired Conditions (HAC), and Serious Reportable Events (SRE) (last updated 6/2022)
- Preventive Services versus Diagnostic and/or Medical Services (last updated 10/2021)
- Procedures Designated as "Separate Procedure" (last updated 12/2021)
- Records Fees, Copying Fees (last updated 2/2022)
- Revenue Codes Ending in "9" ("Other" Categories) (last updated 7/2021)
- Risk Adjustment/HCC Coding and Documentation (last updated 5/2021)
- Anesthesia
- Anesthesia Physical Status Modifiers (P1 - P6) (last updated 11/2021)
- Modifiers AA, AD, GC, QK, QX, QY, QZ – Anesthesia Payment Modifiers (last updated 6/2022)
- Qualifying Circumstances for Anesthesia (last updated 7/2021)
- Behavioral Health
- Behavioral Health Case Management & Care Coordination (last updated 5/2022)
- Documentation
- E0486 Oral Sleep Apnea Device/Appliance Documentation (last updated 12/2021)
- Medical Records Documentation Standards (last updated 6/2022)
- Evaluation & Management
- Clinic Services In the Hospital Outpatient Setting - Commercial (last updated 12/2021)
- Critical Care, Evaluation and Management Services (99291, 99292) (last updated 11/2021)
- Emergency Department Visit Leveling (last updated 6/2022)
- Gynecologic or Annual Women's Exam Visit & Use of Q0091 (Pap, Pelvic, & Breast Visit) (last updated 6/2022)
- Office or Other Outpatient Evaluation and Management (E/M) Visits and Prolonged Services (last updated 6/2022)
- Facility-Specific
- DRG Payment With Patient Transfers (last updated 6/2022)
- Hospital Routine Supplies and Services (last updated 7/2021)
- Level of Care Review (last updated 5/2022)
- Facility DRG Validation (last updated 6/2022)
- Facility Reimbursement of Respiratory Therapy Services (last updated 7/2021)
- Facility Guidelines, General Overview (last updated 5/2022)
- Readmissions (last updated 6/2022)
- Laboratory & Pathology
- Clinical Drug Screening and/or Drug Testing (last updated 2/2022)
- Routine Venipuncture and/or Collection of Specimens (last updated 1/2022)
- Medicine
- Additional Practice Expense Items During a Public Health Emergency (PHE) - CPT 99072 (last updated 10/2021)
- Drugs and Biologicals, Wastage and/or Discarded Amounts (Modifier JW) (last updated 2/2022)
- Moderate (Conscious) Sedation (last updated 3/2022)
- Supply Limits For Ongoing Medical Supplies (last updated 4/2021)
- Telehealth and Telemedicine Expanded Services for COVID-19 (last updated 4/2022)
- Telehealth and Telemedicine Services (last updated 4/2022)
- Modifiers
- Modifier 22 - Increased Procedural Services (last updated 6/2022)
- Modifier 25 - Significant, Separately Identifiable E/M Service (last updated 7/2021)
- Modifier 47 - Anesthesia By Surgeon (last updated 7/2021)
- Modifier 50 - Bilateral Procedure (last updated 2/2022)
- Modifier 51 - Multiple Procedure Fee Reductions (last updated 3/2022)
- Modifier 52 - Reduced Services (last updated 5/2022)
- Modifier 53 - Discontinued Procedure (last updated 5/2022)
- Modifiers 54, 55, and 56 - Split Surgical Care (last updated 7/2021)
- Modifier 57 - Decision For Surgery (last updated 11/2021)
- Modifiers 58, 78, and 79 – Staged, Related, and Unrelated Procedures (last updated 1/2022)
- Modifiers PO & PN - G0463 Clinic Visit Services at Excepted Off-Campus Provider-Based Outpatient Department - Medicare Advantage (last updated 6/2021)
- Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service (last updated 11/2021)
- Modifiers 62 & 66 - Co-surgery (Two Surgeons) and Team Surgery (More Than Two Surgeons) (last updated 7/2021)
- Modifier 63 - Procedure Performed on Infants Less Than 4 kg (last updated 11/2020)
- Modifiers 73 & 74 - Discontinued Procedures For Facilities (last updated 5/2022)
- Modifiers 80, 81, 82, and AS - Assistant At Surgery (last updated 6/2022)
- Modifiers GA, GX, GY, and GZ (last updated 7/2021)
- Modifier SL - State Supplied Vaccine (last updated 2/2022)
- Modifier SU - Procedure Performed in Physician's Office (Facility and equipment) (last updated 6/2021)
- Reference (Outside) Laboratory -- Modifier 90 (last updated 2/2022)
- Technical Component (TC), Professional Component (PC/26), and Global Service Billing (last updated 10/2021)
- Valid Modifier to Procedure Code Combinations (last updated 2/2022)
- Radiology Reductions for Technology Type - Modifiers FX and FY (last updated 6/2022)
- Therapy Assistant Modifiers CO & CQ (last updated 12/2021)
- Transportation of Portable X-ray Equipment, Multiple Portable X-rays - Modifiers UN, UP, UQ, UR, US (last updated 6/2022)
- 340B Drug Discount Program-Acquired Drugs and Biologicals (Modifiers JG & TB) (last updated 2/2022)
- Preventive Services
- Colorectal Cancer Screening And Related Ancillary Services (last updated 11/2021)
- Surgery
- Computer Assisted Navigation (last updated 7/2021)
- Intra-joint and Surgical Site Postoperative Pain Relief Drug Delivery System (Pain Pump) (last updated 1/2022)
- Maternity Care (last updated 2/2022)
- Operating Microscope (CPT Code 69990) (last updated 3/2022)
- Postoperative Sinus Debridement Procedures (last updated 7/2021)
- Procedure Codes Assigned to Surgical Benefit Categories (last updated 12/2021)
- Robotic Assisted Surgery (last updated 5/2022)
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