Reimbursement Policy Manual
- Manual Overview/Introduction
- Moda Health Reimbursement Policy Overview (last updated 3/2025) (RPM001)
- Administrative
- Add-on Codes (last updated 4/2025) (RPM025)
- After Hours and Other Special Circumstances (last updated 1/2025) (RPM004)
- Clinical Editing (last updated 3/2025) (RPM002)
- Diagnosis Code Requirements - Invalid as Primary Diagnosis (last updated 8/2024) (RPM054)
- Diagnosis Code Requirements - Level Of Detail, Number of Characters, Laterality, and Site (last updated 9/2024) (RPM053)
- Incident-To Services (last updated 9/2024) (RPM040)
- Medical, Surgical, and Routine Supplies (including but not limited to 99070) (last updated 5/2025) (RPM021)
- Medically Unlikely Edits (MUEs) (last updated 9/2024) (RPM056)
- Never Events, Adverse Events, Hospital-Acquired Conditions (HAC), and Serious Reportable Events (SRE) (last updated 7/2024) (RPM071)
- Procedures Designated as "Separate Procedure" (last updated 9/2024) (RPM051)
- Records Fees, Copying Fees (last updated 4/2025) (RPM005)
- Risk Adjustment/HCC Coding and Documentation (last updated 8/2024) (RPM050)
- Anesthesia
- Anesthesia Physical Status Modifiers (P1 - P6) (last updated 8/2024) (RPM032)
- Modifiers AA, AD, GC, QK, QX, QY, QZ - Anesthesia Payment Modifiers (last updated 9/2024) (RPM034)
- Qualifying Circumstances for Anesthesia (last updated 4/2025) (RPM033)
- Behavioral Health
- Behavioral Health Case Management & Care Coordination (last updated 2/2025) (RPM058)
- Evaluation and Management (E/M) Services With Psychotherapy Services (last updated 5/2025) (RPM081)
- Supervised Behavioral Health Provider Program Requirements (last updated 3/2025) (RPM079)
- Documentation
- E0486 Oral Sleep Apnea Device/Appliance Documentation & Bundled Services (last updated 1/2025) (RPM055)
- Medical Records Documentation Standards (last updated 3/2025) (RPM039)
- Evaluation & Management
- 2021 & 2023 Updates to Evaluation and Management (E/M) Visits and Prolonged Services (last updated 2/2025) (RPM076)
- Clinic Services In the Hospital Outpatient Setting - Commercial (last updated 10/2024) (RPM061)
- Critical Care, Evaluation and Management Services (99291, 99292) (last updated 9/2024) (RPM041)
- Emergency Department Visit Leveling (last updated 2/2025) (RPM075)
- Gynecologic or Annual Women's Exam Visit & Use of Q0091 (Pap, Pelvic, & Breast Visit) (last updated 2/2025) (RPM044)
- Preventive Medicine & Problem-Oriented E/M Visits, Same Day (last updated 1/2025) (RPM078)
- Scope Of License For Evaluation & Management Codes (last updated 3/2025) (RPM080)
- Facility-Specific
- DRG Payment With Patient Transfers (last updated 6/2025) (RPM066)
- Facility DRG Validation & Outlier Review (last updated 6/2025) (RPM069)
- Facility Guidelines, General Overview (last updated 6/2025) (RPM065)
- Facility Reimbursement of Respiratory Therapy Services (last updated 7/2024) (RPM047)
- Hospital Routine Supplies and Services (last updated 7/2024) (RPM043)
- Level of Care Review (last updated 6/2025) (RPM067)
- Modifiers 73 & 74 - Discontinued Procedures For Facilities (last updated 5/2025) (RPM049)
- Readmissions (last updated 1/2024) (RPM068)
- Revenue Codes Ending in "9" ("Other" Categories) (last updated 7/2024) (RPM042)
- Laboratory & Pathology
- Clinical Drug Screening and/or Drug Testing (last updated 8/2024) (RPM016)
- Routine Venipuncture and/or Collection of Specimens (last updated 1/2025) (RPM012)
- Medicine
- Additional Practice Expense Items During a Public Health Emergency (PHE) - CPT 99072 (last updated 2/2025) (RPM074)
- Moderate (Conscious) Sedation (last updated 4/2025) (RPM048)
- Supply Limits For Ongoing Medical Supplies (last updated 2/2025) (RPM072)
- Modifiers
- Modifier 22 - Increased Procedural Services (last updated 8/2024) (RPM007)
- Modifier 25 - Significant, Separately Identifiable E/M Service (last updated 5/2024) (RPM028)
- Modifier 47 - Anesthesia By Surgeon (last updated 4/2025) (RPM031)
- Modifier 50 - Bilateral Procedure (last updated 3/2025) (RPM057)
- Modifier 51 - Multiple Procedure Fee Reductions (last updated 5/2025) (RPM022)
- Modifier 52 - Reduced Services (last updated 4/2025) (RPM003)
- Modifier 53 - Discontinued Procedure (last updated 4/2025) (RPM018)
- Modifiers 54, 55, and 56 - Split Surgical Care (last updated 1/2025) (RPM030)
- Modifier 57 - Decision For Surgery (last updated 8/2024) (RPM029)
- Modifiers 58, 78, and 79 - Staged, Related, and Unrelated Procedures (last updated 3/2025) (RPM010)
- Modifiers 62 & 66 - Co-surgery (Two Surgeons) and Team Surgery (More Than Two Surgeons) (last updated 8/2024) (RPM035)
- Modifier 63 - Procedure Performed on Infants Less Than 4 kg (last updated 10/2024) (RPM062)
- Modifiers 80, 81, 82, and AS - Assistant At Surgery (last updated 9/2024) (RPM013)
- Modifier 90 - Reference (Outside) Laboratory (last updated 2/2025) (RPM045)
- Modifiers CO & CQ - Therapy Assistant Services (last updated 2/2025) (RPM077)
- Modifiers GA, GX, GY, and GZ (last updated 9/2024) (RPM036)
- Modifiers JG & TB - 340B Drug Discount Program, Acquired Drugs and Biologicals last updated 2/2025 (RPM063)
- Modifiers JW & JZ - Drugs and Biologicals, Wastage and/or Discarded Amounts (last updated 5/2025) (RPM015)
- Modifiers PO & PN - G0463 Clinic Visit Services at Excepted Off-Campus Provider-Based Outpatient Department - Medicare Advantage (last updated 5/2025) (RPM064)
- Modifier SL - State Supplied Vaccine (last updated 4/2025) (RPM024)
- Modifier SU - Procedure Performed in Physician's Office (Facility and equipment) (last updated 5/2025) (RPM070)
- Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service (last updated 8/2024) (RPM027)
- Technical Component (TC), Professional Component (PC/26), and Global Service Billing (last updated 6/2024) (RPM008)
- Radiology Reductions for Technology Type - Modifiers FX and FY (last updated 5/2025) (RPM059)
- Transportation of Portable X-ray Equipment, Multiple Portable X-rays - Modifiers UN, UP, UQ, UR, US (last updated 10/2024) (RPM060)
- Valid Modifier to Procedure Code Combinations (last updated 3/2025)(RPM019)
- Preventive Services
- Colorectal Cancer Screening and Related Ancillary Services (last updated 3/2025) (RPM046)
- Preventive Services versus Diagnostic and/or Medical Services (last updated 11/2024) (RPM037)
- Surgery
- Computer Assisted Navigation (last updated 7/2024) (RPM038)
- Global Surgery Package for Professional Providers (last updated 3/2025) (RPM011)
- Intra-joint and Surgical Site Postoperative Pain Relief Drug Delivery System (Pain Pump) (last updated 1/2025) (RPM014)
- Maternity Care (last updated 8/2024) (RPM020)
- Operating Microscope (CPT Code 69990) (last updated 4/2025) (RPM026)
- Postoperative Sinus Debridement Procedures (last updated 7/2024) (RPM009)
- Procedure Codes Assigned to Surgical Benefit Categories (last updated 2/2025) (RPM023)
- Robotic Assisted Surgery (last updated 2/2025) (RPM006)
- Telemedicine
- Telehealth and Telemedicine Expanded Services for COVID-19 - Updated for Public Health Emergency Ending (last updated 4/2025) (RPM073)
- Telehealth And Telemedicine Services (last updated 11/2024) (RPM052)
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
Rate finder is now in the Producer Dashboard
Log in with your current username and password to create quotes for groups up to 50.
Producer DashboardLog in
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.