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 7/2025) (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 7/2025) (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 7/2025) (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 7/2025) (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 7/2025) (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 7/2025) (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 7/2025) (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)
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