Payment Policy Updates

June 5, 2025

The following policies received their annual review with no changes:

• Modifier 33
• Modifier 51
• Modifier 59
• Modifier 90
• Modifier SU
• Multiple Modifiers
• Place of Service Codes

The following policies received their annual review with the changes noted below:

Modifier 26 & TC

Incorporated information from the “Modifier TC” Payment Policy into this policy as follows:

• Added modifier TC to title of policy.
• Added technical component to the purpose
• Added multiple diagnostic imaging, cardiovascular, and ophthalmology policies to the cross-reference section.
• In the policy section:
  • Added TC modifier recognition details in second paragraph
  • Added modifier TC status indicator details

Archived the Modifier TC policy effective May 5, 2025

Modifier TC

• This policy is archived effective May 5, 2025. Please refer to the modifier 26 & TC policy.

Modifier 52

• In the policy section, adjusted the reimbursement for modifier 52 from 75% of the providers applicable fee schedule to 50% effective on dates of service November 1st, 2025 and after.
• Added in the exceptions section: “Alaska Providers: Reimbursement of modifier 52 will continue to be 75% of the provider’s applicable Fee Schedule allowed amount.”

Modifier 80, 81, 82

• In the coding section, adjusted the reimbursement rate under the modifier table for modifiers 80 and 82 from 20% of the providers applicable fee schedule to 16% effective November 1st, 2025.
• In the exceptions section added: “Alaska Providers: Reimbursement of modifiers 80 and 82 will continue to be 20% of the provider’s applicable Fee Schedule allowed amount for the primary surgery.”
• In the exceptions section removed: “Oregon providers: Reimbursement of modifier 81 will be 15% of the provider’s applicable Fee Schedule allowed amount for the primary surgery.”

DME/HME

• New codes added to the embedded code list effective April 1, 2025:
  • A4593, E1032, E1033, E1034, E1832, E3200 - Capped Rental (RR) or Outright Purchase (NU)
  • E0201 - Rental Only – RR or Outright Purchase – NU
• Removed the following codes from the embedded code list effective April 1, 2025 (codes were not terminated but just removed from the list): A4614, E0785
• Correction made to the status of code E0743 effective April 1, 2025: changed to Capped Rental (RR) or Outright Purchase (NU)

Unlisted non-specific codes

Removed purpose statement: To define the Plan’s limitations on the use of “unlisted”, “not otherwise specified” or “miscellaneous” CPT or HCPCS codes submitted on provider claims that are submitted on a CMS 1500 paper claim or 837P electronic claim form.

• Added new purpose statement: This policy applies to all providers and facilities