Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the Sunshine Health Clinical Policy Manual apply to Sunshine Health members. Policies in the Sunshine Health Clinical Policy Manual may have either a Sunshine Health or a “Centene” heading.  Sunshine Health utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Sunshine Health clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Sunshine Health. In addition, Sunshine Health may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by Sunshine Health.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the Sunshine Health Payment Policy Manual apply with respect to Sunshine Health members. Policies in the Sunshine Health Payment Policy Manual may have either a Sunshine Health or a “Centene” heading.  In addition, Sunshine Health may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by Sunshine Health.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-H I-Q R-Z
25-hydroxyvitamin D Testing in Children and Adolescents (PDF)
Effective Date: November 30, 2021
Laser Therapy for Skin Conditions (PDF)
Effective Date: March 31, 2022

Rehabilitative Therapy Site of Care Optimization (PDF)

Effective date: August 2019

Acupuncture Expanded Benefit (PDF)
Effective Date: July 2018
Low-Frequency Ultrasound 
Wound Therapy (PDF)

Effective Date: September 1, 2017

Rituximab (PDF)
Effective Date: 

Adalimumab (Humira), Adalimumab-afzb (Abrilada), Adalimumab-atto (Amjevita), Adalimumab-adbm (Cyltezo), Adalimumab-bwwd (Hadlima), Adalimumab-fkjp (Hulio), Adalimumab-adaz (Hyrimoz) (PDF)
Effective Date: August 2016
Measure Serum 1,25 Vitamin D (PDF)
Effective Date: October 31, 2021
Scanning Computerized Ophthalmic Diagnostic Imaging  (PDF)
Effective Date: January 1, 2022
ADHD Assessment and Treatment (PDF)
Effective Date: February 2, 2022
Mechanical Stretch Devices 
(PDF)

Effective Date: September 1, 2017
Testing for Rupture of Fetal Membranes (PDF)
Effective Date: Retired
Allergy Testing and Therapy (PDF)
Effective Date: May 31, 2022
Paclitaxel (PDF)
Effective Date: 
Testing of Select GU Conditions (PDF)
Effective Date: March 31, 2022
Ambulatory EEG (PDF)
Effective Until: September 14, 2020
PCR Respiratory Viral Panel  Testing - Prepayment Policy (PDF)
Effective Date: August 15, 2021
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
Effective Date: October 31, 2021
Ambulatory EEG (PDF)
Effective Date:  September 14, 2020
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
Effective Date: March 31, 2022
Ultrasound in Pregnancy (PDF)
Effective Date: March 31, 2022
Bevacizumab (PDF)
Effective Date: 
PROM Testing (PDF)
Effective Date: August 15, 2021
Urodynamic Testing (PDF)
Effective Date: March 31, 2022
Bronchial Thermoplasty (PDF)
Effective Date: January 15, 2017
Proton and Neutron 
Beam Therapy (PDF)

Effective Date: November 1, 2016

Visual Field Testing (PDF)
Effective Date: January 1, 2022

Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: June 1, 2018
  Vitamin D Testing 
in Children (PDF)

Effective Date: June 1, 2018
Diagnosis of Vaginitis (PDF)
Effective Date: January 15, 2017
  Wheelchair Seating (PDF)
Effective Date: March 31, 2022

Digital Analysis of EEGs (PDF)
Effective Date: 

 

  Wireless Motility Capsule 
(PDF)

Effective Date: September 1, 2017
EEG in Evaluation of Headache (PDF)
Effective Date: October 31, 2021

 

 

 
EEG in Evaluation of Headache (PDF)
Effective Date: October 31, 2021
   
Endometrial Ablation (PDF)
Effective Date: April 30, 2022
   
EpiFix Wound Treatment (PDF)
Effective Date: September 1, 2017

 

 
Evoked Potential Testing (PDF)
Effective Date: August 31, 2021
 

 

Extended Ophthalmoscopy (PDF)
Effective Date: August 15, 2021
 

 

External Ocular Photography (PDF)
Effective Date: January 1, 2022
   

Fecal Calprotectin Assay (PDF)
Effective Date: May 1, 2017

   
Fluorescein Angiography (PDF)
Effective Date: January 1, 2022
   
Fractional Exhaled Nitric Oxide (PDF)
Effective Date: Retired
   
Fundus Photography (PDF)
Effective Date: 
   
Gonioscopy (PDF)
Effective Date: January 1, 2022
   
H Pylori Testing (PDF)
Effective Date: June 1, 2018
   
Holter Monitors (PDF)
Effective Date: December 31, 2021
   
Homocysteine Testing (PDF)
Effective Date: March 31, 2022
   
     
     
     

 

A-H I-Q R-Z
30 Day Readmission (PDF)
Effective Date: April 21, 2021
Incidental Diagnostic and Laboratory Tests Billed with Evaluation and Management Services (PDF)
Effective Date: January 1, 2013
Renal Hemodialysis (PDF)
Effective Date: September, 2022
3-Day Payment Window (PDF)

Inpatient Only Procedures (PDF)
Effective Date: November 30, 2021
Reporting Global Maternity Package (PDF)
Effective Date: January 1, 2013
Add-On Code Billed Without Primary Code (PDF)
Effective Date: November 30, 2021
Intravenous Hydration (PDF)
Effective Date: January 1, 2013
Robotic Surgery (PDF)
Effective Date: April 20, 2021
Assistant Surgeon (PDF)
Effective Date: November 30, 2021
Leveling of Care: Evaluation & Management Overcoding (PDF)
Effective Date: August 15, 2021
Sepsis Diagnosis (PDF)
Effective Date: March 1, 2016
Cerumen Removal (PDF) 
Effective Date: January 1, 2014
Leveling of Emergency Room Services  (PDF)
Effective Date: May 15, 2019
Sleep Studies Place of Services (PDF)
Effective Date: May 1, 2017
Clean Claim Reviews (PDF)
Effective Date: November 1, 2012
Maximum Units of Service (PDF)
Effective Date: January 1, 2013
Unbundling Adjustments on Clean Claim Reviews (PDF)
Effective Date: September 1, 2022
Clinical Validation of Modifier 25 (PDF)
Effective Date: January 1, 2013
Modifier to Procedure Code Validation (PDF)
Effective Date: January 1, 2013
Unlisted Procedure Codes (PDF)
Effective Date: January 1, 2013
Code Editing Overview (PDF)
Effective Date: November 30, 2021
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF)
Effective Date: March 1, 2019
Urine Specimen Validity Testing (PDF)
Effective Date: April 20, 2021
Cosmetic Procedures (PDF)
Effective Date: November 30, 2021
Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular Procedures (PDF)
Effective Date: February 6, 2021
Wheelchair Accessories (PDF)
Effective Date: August 15, 2021
Cost to Charge Adjustments on Clean Claim Reviews (PDF)
Effective Date: September 1, 2022
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective Date: August 23, 2021
 
Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF)
Effective Date: January 1, 2013
Multiple Procedure Reduction: Ophthalmology (PDF)
Effective Date: August 23, 2021
 
Distinct Procedural Service: Modifier 59 (PDF)
Effective Date: January 1, 2013
Never Paid Events (PDF)
Effective Date: January 1, 2013
 

Durable Medical Equipment, Medical Supplies, Prostheses and Orthoses-MMA (PDF)

Effective Date: March 10, 2021

Not Medically Necessary Inpatient Services (PDF)
Effective Date:
 

Durable Medical Equipment, Medical Supplies, Prostheses and Orthoses-LTC (PDF)

Effective Date: March 10, 2021

Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF)
Effective Date: May 1, 2021 
 

Facility Charges for  Hospital-Based Outpatient Clinics (PDF)
Effective: September 2022

Physician's Consultation Services (PDF)
Effective Date: May 15, 2019
 

High Complexity Medical Decision-Making (PDF)

Effective  Date: July, 31, 2017

Physician's Office Lab Testing (PDF)
Effective Date: August 1, 2022
 

Hospital Visit Codes Billed with Labs (PDF)
Effective Date: January 1, 2013

Place of Service Mismatch (PDF)
Effective Date: March 1, 2019 
 

 

Problem Oriented Visits Billed with Preventative Visits (PDF)
Effective Date: September 2, 2022
 

 

Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: May 15, 2019
 

 

Professional Services (Visit Codes) Billed With Labs (PDF)
Effective Date: January 1, 2013
 

A-H I-Q R-Z
30 Day Readmission (PDF)
Effective Date: April 21, 2021
Incidental Diagnostic and Laboratory Tests Billed with Evaluation and Management Services (PDF)
Effective Date: January 1, 2013
Renal Hemodialysis (PDF)
Effective Date: September, 2022
3-Day Payment Window (PDF)
Effective Date: 
Inpatient Consultation (PDF) 
Effective Date: October 1, 2017
Reporting Global Maternity Package (PDF)
Effective Date: January 1, 2013
Add-On Code Billed Without Primary Code (PDF)
Effective Date: November 30, 2021
Inpatient Only Procedures (PDF) 
Effective Date: November 30, 2021
Same Day Visits (PDF)
Effective Date: July 15, 2021
ADHD Assessment and Treatment (PDF)
Effective Date: January 1, 2022
Intravenous Hydration (PDF)
Effective Date: January 1, 2013
Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)
Effective Date: January 1, 2022
Allergy Testing and Therapy (PDF)
Effective Date: January 1, 2022
Laser Skin Treatment  (PDF)
Effective Date: March 31, 2022
Sepsis Diagnosis (PDF)
Effective Date: March 1, 2016
Ambulatory EEG (PDF)
Effective Date: September 14, 2020

Leveling of Care Evaluation and Management Overcoding (PDF)

Effective Date: May 15, 2021

Short Inpatient Hospital Stay (PDF)

Effective Date: October 1, 2020

Assistant Surgeon (PDF)
Effective Date: November 30, 2021

 

Leveling of ER Services (PDF)
Effective Date: January 1, 2018

Sleep Studies Place of Services (PDF)
Effective Date: May 1, 2017

Bevacizumab (Avastin) (PDF)
Effective Date: August 12, 2016

Maximum Units of Service (PDF)
Effective Date: January 1, 2013

Status "B" Bundled Services (PDF)
Effective Date: January 1, 2014
Bilateral Procedures (PDF)
Effective Date: January 1, 2014
Mechanical Stretch Devices (PDF)
Effective Date:  September 1, 2017
Status "P" Bundled Services (PDF)
Effective Date: April 1, 2017
Bronchial Thermoplasty (PDF)
Effective Date: January 15, 2017
Moderate Conscious Sedation (PDF)
Effective Date:
Supplies Same Day as Surgery (PDF)
Effective Date: January 1, 2013

Cerumen Removal (PDF) 
Effective Date: January 1, 2014

Modifier DOS Validation (PDF)
Effective Date: January 1, 2013
Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) (PDF)
Effective Date: January 1, 2022

Clean Claims (PDF)
Effective Date: 

Modifier to Procedure Code Validation (PDF)
Effective Date: January 1, 2013
Transgender Related Services (PDF)
Effective Date: 
Clean Claim Reviews (PDF)
Effective Date: November 1, 2012
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) Effective Date: March 1, 2019 Ultrasound in Pregnancy (PDF)
Effective Date: March 31, 2022
Clinical Validation of Modifier 25 (PDF)
Effective Date: January 1, 2013
Multiple CPT Code (PDF)
Effective Date: January 1, 2014
Unbundled Professional Services (PDF)
Effective Date: January 1, 2014
Code Editing Overview (PDF)
Effective Date: January 1, 2013

Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF)

Effective Date: February 6, 2021

Unbundled Surgical Procedures (PDF)
Effective Date: 
Cosmetic Procedures (PDF)
Effective Date: November 30, 2022
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective Date: August 23, 2021
Unbundling Adjustments on Clean Claim Reviews (PDF)
Effective Date: September 1, 2022
Cost to Charge Adjustments on Clean Claim Reviews (PDF)
Effective Date: September 1, 2022
Multiple Procedure Reduction: Ophthalmology (PDF)
Effective Date: August 23, 2021
Unlisted Procedure Codes (PDF)
Effective Date: January 1, 2013
Diagnosis of Vaginitis (PDF) 
Effective Date: January 15, 2017 - September 30, 2017

NCCI Unbundling (PDF)
Effective Date: 

Urine Specimen Validity Testing (PDF)
Effective Date: April 20, 2021
Diagnosis of Vaginitis (PDF) Effective Date: October 1, 2017 - December 31, 2017

Never Paid Events (PDF)
Effective Date: January 1, 2013

Urodynamic Testing (PDF)
Effective Date: March 31, 2022
Digital Analysis of EEGs (PDF)
Effective Date: October 31, 2021

New Patient (PDF)
Effective Date: January 1, 2014

Visual Field Testing (PDF)
Effective Date: January 1, 2022
Digital Breast Tomosynthesis (PDF)
Effective Date: December 1, 2016 - December 31, 2017
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) Effective Date: May 1, 2021 Vitamin D Testing in Children and Adolescents (PDF)
Effective Date: June 1, 2018
Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF)
Effective Date: January 1, 2013
Outpatient Consultation (PDF)
Effective Date: January 1, 2014
Wheelchair and Accessories (PDF)
Effective Date: August 12, 2016
Distinct Procedural Service: Modifier 59 (PDF)
Effective Date: January 1, 2013
Paclitaxel Protein Bound (PDF)
Effective Date: January 1, 2022
Wheelchair Seating (PDF)
Effective Date: March 31, 2022
Duplicate Primary Code Billing (PDF)
Effective Date: January 1, 2014
Paclitaxel, protein bound (PDF)
Effective Date: August 12, 2016 - October 31, 2017
Wireless Motility Capsule (PDF)
Effective Date: September 1, 2017
EEG in the Evaluation of Headache (PDF)
Effective Date: January 1, 2022
Physician Visit Codes Billed with Labs (PDF)
Effective Date:
 
Endometrial Ablation (PDF)
Effective Date: April 30, 2022
Physician's Office Lab Testing (PDF)
Effective Date: August 1, 2022
 
EpiFix Wound Treatment (PDF)
Effective Date: September 1, 2017
Place of Service Mismatch (PDF) Effective Date: March 1, 2019   
Evoked Potentials (PDF)
Effective Date: January 1, 2022

Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)

Effective Date: March 31, 2022

 
Extended Ophthalmoscopy (PDF) 
Effective Date: May 15, 2021 

Post-Operative Visits (PDF)
Effective Date: January 1, 2014

 
External Ocular Photography (PDF) 
Effective Date: January 1, 2022
Pre-Operative Visits (PDF)
Effective Date: January 1, 2014
 
Facility Charges for  Hospital-Based Outpatient Clinics (PDF)
Effective: September 2022
Problem Oriented Visits Billed with Preventative Visits (PDF)
Effective Date: September 2, 2022
 
Fecal Calprotectin Assay (PDF)
Effective Date: May 1, 2017
Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: December 1, 2017
 

Fluorescein Angiography (PDF)

Effective Date: January 1, 2022

Professional Component Modifier 26 (PDF)
Effective Date: January 1, 2013
 

Gonioscopy (PDF)

Effective Date: January 1, 2022

Professional Services (Visit Codes) Billed With Labs (PDF)
Effective Date: January 1, 2013
 

Helicobacter Pylori (H. pylori) Serology Testing (PDF)
Effective Date: JUne 1, 2018

PROM Testing (PDF)
Effective Date: December 1, 2017
 

High Complexity Medical Decision-Making (PDF)
Effective Date: June 2017

Proton and Neutron Beam Therapy (PDF)
Effective Date: December 1, 2016

 

Holter Monitors (PDF)
Effective Date: December 31, 2021

Pulse Oximetry with Office Visits (PDF)
Effective Date: January 1, 2014
 
Homocysteine Testing (PDF)
Effective Date: March 31, 2022
   

Hospital Visit Codes Billed with Labs (PDF)
Effective Date: January 1, 2013

   

 

 

A-H I-Q R-Z
30-Day Readmission (PDF)
Effective Date: February 5, 2021
Incidental Diagnostic and Laboratory Tests Billed with Evaluation and Management Services (PDF)
Effective Date: January 1, 2013
Renal Hemodialysis (PDF)
Effective Date: September, 2022
3-Day Payment Window (PDF)
Effective Date: 
Inpatient Consultation (PDF) 
Effective Date: October 1, 2017
Reporting Global Maternity Package (PDF)
Effective Date: January 1, 2013
Add on Code Billed Without Primary Code (PDF)
Effective Date: January 1, 2013
Inpatient Only Procedures (PDF) 
Effective Date: November 30, 2021
Rituximab (PDF)
Effective Date: November 1, 2017
ADHD Assessment and Treatment (PDF)
Effective Date: January 1, 2022
Intravenous Hydration (PDF)
Effective Date: January 1, 2013
Robotic Surgery (PDF)
Effective Date: April 20, 2021
Allergy Testing and Therapy (PDF)
Effective Date: January 1, 2022
Laser Skin Treatment  (PDF)
Effective Date: March 31, 2022
Same Day Visits (PDF)
Effective Date: December 1, 2022

Ambulatory EEG (PDF)
Effective Until: September 14, 2020

Ambulatory EEG (PDF)
Effective Date: September 14, 2020

Leveling of Care: Evaluation and Management Overcoding (PDF)
Effective Date: February 5, 2021
Scanning Computerized Ophthalmic Diagnostic Imaging (PDF)
Effective Date: January 1, 2022

Assistant Surgeon (PDF)
Effective Date: January 1, 2014

Leveling of ER (PDF)
Effective Date: August 1, 2018
Sepsis Diagnosis (PDF)
Effective Date: October 1, 2020
Bevacizumab (Avastin) (PDF)
Effective Date: August 12, 2016
Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: September 1, 2017

Short Inpatient Hospital Stay (PDF)

Effective Date: October 1, 2020

Bilateral Procedures (PDF)
Effective Date: January 1, 2014

Maximum Units of Service (PDF)
Effective Date: January 1, 2013

Status "B" Bundled Services (PDF)
Effective Date: January 1, 2014

Bronchial Thermoplasty (PDF)
Effective Date: January 15, 2017
Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
Effective Date: January 1, 2022
Status "P" Bundled Services (PDF)
Effective Date: April 1, 2017
Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: June 1, 2018
Mechanical Stretch Devices (PDF)
Effective Date:  September 1, 2017
Supplies Same Day as Surgery (PDF)
Effective Date: January 1, 2013

Cerumen Removal (PDF) 
Effective Date: January 1, 2014

Moderate Conscious Sedation (PDF)
Effective Date: 
Testing for Rupture of Fetal Membranes (PDF)
Effective Date: Retired
Clean Claims (PDF)
Effective Date: 
Modifier DOS Validation (PDF)
Effective Date: January 1, 2013
Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) (PDF)
Effective Date: January 1, 2022
Clean Claim Reviews (PDF)
Effective Date: November 1, 2012
Modifier to Procedure Code Validation (PDF)
Effective Date: January 1, 2013

Testing of Select GU Conditions  (PDF)

Effective Date: March 31, 2022

Clinical Validation of Modifier 25 (PDF)
Effective Date: January 1, 2013
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) Effective Date: March 1, 2019 

Thryoid Hormones and Insulin Testing in Pediatrics (PDF)
Effective Date: October 31, 2021

Code Editing Overview (PDF)
Effective Date: January 1, 2013

Multiple Diagnostic Cardiovascular Procedure (PDF)

Effective Date:

Transgender Related Services (PDF)
Effective Date: 
Cosmetic Procedures (PDF) 
Effective Date: January 1, 2014
Multiple CPT Code (PDF)
Effective Date: January 1, 2014
Ultrasound in Pregnancy (PDF)
Effective Date: March 31, 2022
Cost to Charge Adjustments on Clean Claim Reviews (PDF)
Effective Date: September 1, 2022

Multiple Diagnostic Cardiovascular Procedure Payment Reduction (PDF)

Effective Date: February 6, 2021

Unbundled Professional Services (PDF)
Effective Date: January 1, 2014
Diagnosis of Vaginitis (PDF) 
Effective Date: January 15, 2017 - September 30, 2017
Multiple Procedure Reduction: Ophthalmology (PDF)
Effective Date: August 23, 2021
Unbundled Surgical Procedures (PDF)
Effective Date: 
Diagnosis of Vaginitis (PDF) Effective Date: October 1, 2017 - December 31, 2017

Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective Date: August 23, 2021

Unbundling Adjustments on Clean Claim Reviews (PDF)
Effective Date: September 1, 2022
Digital Analysis of EEGs (PDF)
Effective Date: October 31, 2021
NCCI Unbundling (PDF)
Effective Date: 
Unlisted Procedure Codes (PDF)
Effective Date: January 1, 2013
Digital Breast Tomosynthesis (PDF)
Effective Date: December 1, 2016 - December 31, 2017

Never Paid Events (PDF)
Effective Date: January 1, 2013

Urine Specimen Validity Testing (PDF)
Effective Date: April 20, 2021
Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF)
Effective Date: January 1, 2013
New Patient (PDF)
Effective Date: January 1, 2014
Urodynamic Testing (PDF)
Effective Date: March 31, 2022
Distinct Procedural Service: Modifier 59 (PDF)
Effective Date: January 1, 2013
Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) Effective Date: March 1, 2019 Visual Field Testing (PDF)
Effective Date: January 1, 2022
Duplicate Primary Code Billing (PDF)
Effective Date: January 1, 2014
Outpatient Consultation (PDF)
Effective Date: January 1, 2014
Vitamin D Testing in Children and Adolescents (PDF)
Effective Date: June 1, 2018
  Paclitaxel Protein Bound (PDF)
Effective Date: January 1, 2022
Wheelchair and Accessories (PDF)
Effective Date: August 12, 2016
EEG in the Evaluation of Headache (PDF)
Effective Date: January 1, 2022
Physician Visit Codes Billed with Labs (PDF)
Effective Date: 
Wheelchair Seating (PDF)
Effective Date: March 31, 2022
Endometrial Ablation (PDF)
Effective Date: April 30, 2022
Physician's Consultation Services (PDF)
Effective Date: December 1, 2017
Wireless Motility Capsule (PDF)
Effective Date: September 1, 2017
EpiFix Wound Treatment (PDF)
Effective Date: September 1, 2017
Physician's Office Lab Testing (PDF)
Effective Date: January 1, 2022
 
Evaluation and Management Services Billed with Treatment Rooms (PDF)
Effective Date: January 1, 2022
Place of Service Mismatch (PDF) Effective Date: March 1, 2019   
Evoked Potentials (PDF)
Effective Date: January 1, 2022

Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)

Effective Date: March 31, 2022

 

Extended Ophthalmoscopy (PDF)

Effective Date: May 15, 2021 

Post-Operative Visits (PDF)
Effective Date: January 1, 2014

 
External Ocular Photography (PDF) 
Effective Date: January 1, 2022
Pre-Operative Visits (PDF)
Effective Date: January 1, 2014
 

Facility Charges for  Hospital-Based Outpatient Clinics (PDF)
Effective: September 2022

Problem Oriented Visits Billed with Preventative Visits (PDF)
Effective Date: September 2, 2022
 
Fecal Calprotectin Assay (PDF)
Effective Date: May 1, 2017
Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: Decmeber 1, 2017
 

Fluorescein Angiography (PDF)

Effective Date: January 1, 2022

Professional Component Modifier (PDF)
Effective Date: January 1, 2013
 
Fundus Photography (PDF)
Effective Date: February 5, 2021
Professional Services (Visit Codes) Billed With Labs (PDF)
Effective Date: January 1, 2013
 
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)
Effective Date: January 1, 2022
PROM Testing (PDF)
Effective Date: December 1, 2017
 

Gonioscopy (PDF)

Effective Date: January 1, 2022

Proton and Neutron Beam Therapy (PDF)
Effective Date: December 1, 2016
 

High Complexity Medical Decision-Making (PDF)
Effective Date: June 2017

Pulse Oximetry with Office Visits (PDF)
Effective Date: January 1, 2014
 
Holter Monitors (PDF)
Effective Date: December 31, 2021
   

Homocysteine Testing (PDF)
Effective Date: March 31, 2022

   

Hospital Visit Codes Billed with Labs (PDF)
Effective Date: January 1, 2013