April 6, 2023
The following policies received their annual review with no changes:
- Modifier 73 - Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to Administration of Anesthesia
- Modifier 74 - Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure after Administration of Anesthesia
- Modifier 78 - Unplanned Return to the Operating Room by the Same Physician for a Related Procedure During Post-operative Period
The following policies received their annual review with the following changes:
- In the policy section, added the following clarifications:
- Clarified in the fourth and fifth paragraphs the name of the “Global Days” indicator flag used from the CMS National Physician Fee Schedule.
- Under the “010-minor surgery” section, added the fourth bullet similar to the fourth bullet under the “090-major surgical procedures” section.
- In the Modifier 24 section, deleted duplicate bullet points.
Laboratory and Pathology Billing Guidelines
- In the cross-reference section, added two policies referencing Modifiers 76 and 77
- In the policy section, added the following:
- In the first paragraph, created sub-bullets of the types of procedure codes subject to the policy.
- In the surgical pathology section, added a paragraph which references Modifiers 76 and 77 usages.
- In the place of service code section, added place of service code 21-Inpatient Hospital which was missing.
Medicare Indicator Status B and Status T Services Reimbursement – 90-day notice
- Modified the policy title to include Status T codes.
- In the definitions section, added a definition for Status Indicator T codes.
- Revised the policy section to include references to Status Indicator T codes which will no longer be reimbursed effective with claim dates of service on and after July 8, 2023.
- In the codes/coding guidelines section, for code 99072, added the first bullet indicating that the code will return to being a non-reimbursable Status Indicator B code effective with claim dates of service on or after July 8, 2023, due to the termination of the PHE as declared by the federal government.
Modifier 52 – Reduced Services
- In the policy section, removed the examples for how to determine units on time-based codes.
Modifier 53 – Discontinued Procedure
- Clarified the policy statement that the use of modifier 53 is valid for professional services only and that modifiers 73 and 74 are appropriate for discontinued ASC and outpatient facility services.
Modifier JW – Drug Amount Discarded/not Administered to any Patient
- In the policy section, added the fifth paragraph indicating that when multiple sized, single-dose drug vials are available, one or more of the smaller sized vials should be used in order to eliminate or minimize drug wastage.
National Drug Code (NDC) Billing Guidelines-Outpatient Facility Claims
- In the policy section, created a new section titled Discarded, Wasted and Non-Administered Drugs and added instructions on how to correctly bill/code for single-use vial/package drug wastage by billing on two separate lines with modifier JW appended to the code line representing the wasted portion of the drug.
National Drug Code (NDC) Billing Guidelines-Professional Claims
- In the policy section, created a new section titled Discarded, Wasted and Non-Administered Drugs and added instructions on how to correctly code for single-use vial/package drug wastage by coding the administered and wasted portions of the drugs on the shaded portion of field 24 on the CMS-1500 claim form, appending modifier JW to the wasted drug HCPCS code.
Physical Medicine and Rehabilitation Services
- Title of policy changed to be more reflective of the actual category of procedure codes as defined in the CPT Codebook. Title changed from Physical, Occupational and Speech Therapy Services to Physical Medicine and Rehabilitation Services.
- Purpose statement changed to reflect the new policy title.
- Policy section was divided into the same categories of codes as defined in the CPT Codebook:
- Modalities: Supervised and Constant Attendance
- Therapeutic Procedure
- Physical Therapy, Occupational Therapy Evaluation and Re-evaluations
- Plan of care modifier section introductory paragraph changed to reflect the type of services subject to the requirement for modifiers.
Unlisted, Non-Specific and Miscellaneous Procedure Codes
- In the cross-reference section, added policy Modifier 22 - Increased Procedural Services.
- At the end of the supporting documentation requirements section, revised the wording of the last paragraph.
- In each code category, indicated that a description of the service rendered is required on the claim line.
In response to the federal government declaration of the end of the public health emergency (PHE), the following policies have been updated:
Personal Protective Equipment (PPE) – 90-day notice
- In the codes/coding guidelines section, under the code exception section, for code 99072, added the first bullet indicating that the code would return to being a non-reimbursable Status Indicator B code effective with claim dates of service on and after July 8, 2023, due to the termination of the public health emergency (PHE) as declared by the federal government. This statement was also included in the exceptions section of the policy.
- In the second bullet under code 99072, clarified that for claims with dates of service on and after April 16, 2021, through July 7, 2023, code 99072 would continue as a code exception and be reimbursed.
COVID-19 Testing: Diagnostic Surveillance and Over-the-Counter
- At the beginning of the section Over-the-Counter (OTC) COVID-19 Tests of the policy, added a paragraph indicating that OTC tests purchased on and after May 11, 2023, will no longer be reimbursed as member-submitted claims due to the federal government declaration that the PHE is ending May 11, 2023. Member submitted claims will be reimbursed for purchase dates prior to May 11, 2023, only.
Facility Fees: Clinic Services, Professional Fees and Specialty Services-Treatment Room - 90-day notice
In the exception section of the policy, added a paragraph indicating that effective with dates of service on and after July 8, 2023, COVID-19 vaccines and their administration procedure codes would no longer be reimbursed when submitted with the revenue codes in this policy in response to the federal government declaration that the PHE is over.