Payment Policy Updates

September 5, 2024

The following policies received their annual review with no changes:

• After Hours Services
• Blood Draw/Venipuncture – 36415
• Claim Editing
• Home Birth Kit Supplies – S8415
• Modifier 52 – Reduced Services
• Modifier SG - Ambulatory Surgery Center (ASC) facility services
• New and Established Patient Guidelines

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

Modifier 79 – Unrelated Procedure/Service by Same Provider during Postoperative Period

In the Policy section:

• added the third paragraph to indicate that modifier 79 is not valid following an initial procedure with 0-day global period and is valid  following an initial procedure with 10-days or 90-days global periods as noted in the CMS National Physician Fee Schedule.

Modifier 80, 81, 82 – Assistant Surgeons (Physician)

In the Cross Reference section, added Modifier 62-Two Surgeons.

In the Policy section:

• Added the third paragraph to indicate that the assistant surgeon must bill the same procedure code, appended with a surgical assist modifier, as the primary surgeon.
• Added the sixth paragraph to indicate that when two surgeons are acting as primary surgeons performing distinct or simultaneous parts of a procedure, they are not acting as assistants-at-surgery but co-surgeons whose services must be appended with modifier 62.
• In the second to the last paragraph, indicated that the NPI number of the assistant surgeon must be on the assistant surgeon’s claim

In the Codes/Coding Guidelines sections:

• added a bullet to each modifier section indicating that the provider reports their services using their own NPI number.

Modifier AS – Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Services for Assistant at Surgery (Non-Physician)

In the Cross Reference section, added Modifier 62-Two Surgeons.

In the Policy section:

• Added the third paragraph to indicate that the assistant surgeon must bill the same procedure code, appended with a surgical assist modifier, as the primary surgeon.
• Added the tenth paragraph to indicate that when two surgeons are acting as primary surgeons performing distinct or simultaneous parts of a procedure, they are not acting as assistants-at-surgery but co-surgeons whose services must be appended with modifier 62.
• In the second to the last paragraph, indicated that the NPI provider identification number of the assistant surgeon must be on the assistant surgeon’s claim.

Prolonged Services for Labor Management

In the Codes/ Coding Guidelines section, removed codes 99354-99357 that were deleted on January 1, 2023.