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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-HI-QR-Z
25-hydroxyvitamin D Testing in Children and Adolescents (PDF)
Effective Date: November 30, 2021
Individual and Family Outpatient Therapy Expanded Benefit (PDF)
Effective date: November 2018
Rehabilitative Therapy Site of Care Optimization (PDF)
Effective date: August 2019
Acupuncture Expanded Benefit (PDF)
Effective Date: November 1, 2018
Infant Mental Health Pre and Post Testing In Lieu of Service (PDF)
Effective date: October 1, 2021
Review for Nutritional Products Requests (PDF)
Effective date: June 2015
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
Involuntary Admissions (PDF)
Effective date: April 20, 2021
Review for Personal Care Services Requests (PDF)
Effective date: June 2015
ADHD Assessment and Treatment (PDF)
Effective Date: February 2, 2022
Laser Therapy for Skin Conditions (PDF)
Effective Date: March 31, 2022
Review of External Insulin Pumps (PDF)
Effective date: June 2015
Adult Pneumonia and Shingles Vaccine  Expanded Benefit (PDF)
Effective date: May 1, 2014
Leveling of Care Evaluation and Management Overcoding (PDF)
Effective Date: February 5, 2021
Review of Private Duty Nursing  Requests (PDF)
Effective date: June 2015
Allergy Testing and Therapy (PDF)
Effective Date: May 31, 2022
Life Skills Development Expanded Benefit (PDF)
Effective date: November 2018
Rituximab (PDF)
Effective Date: 
Ambulatory EEG (PDF)
Effective Until: September 14, 2020
Long Term Care Skilled Therapy Clinical Policy (PDF)
Effective date: May 1, 2014
Scanning Computerized Ophthalmic Diagnostic Imaging  (PDF)
Effective Date: January 1, 2022
Ambulatory EEG (PDF)
Effective Date:  September 14, 2020
Low-Frequency Ultrasound 
Wound Therapy (PDF)

Effective Date: September 1, 2017
Self Help/Peer Support In Lieu of Service (PDF)
Effective date: November 1, 2018
Ambulatory Detoxification In Lieu of Service (PDF)
Effective date: November 1, 2018
Massage Therapy Expanded Benefit (PDF)
Effective date: November 1, 2018
Skilled Nursing Clinical Policy (PDF)
Effective date: 
Ambulatory Infusion Pump Expanded Benefit (PDF)
Effective date: November 2018
Meals: Non-Emergency Transportation Day-Trips Expanded Benefit (PDF)
Effective date: October 1, 2021
Specialized Therapeutic Foster Care Services (PDF)
Effective date: October 1, 2021
Behavioral Health Expanded Benefits (PDF)
Effective date: October 1, 2021
Measure Serum 1,25 Vitamin D (PDF)
Effective Date: October 31, 2021
Substance Abuse Short-Term Residential Treatment Program In Lieu of Service (PDF)
Effective date: November 2018
Bevacizumab (PDF)
Effective Date: 
Mechanical Stretch Devices 
(PDF)

Effective Date: September 1, 2017
Sunshine Health Medically Related Lodging and Food (PDF)
Effective date: May 1, 2014
Bronchial Thermoplasty (PDF)
Effective Date: January 15, 2017
Medically Fragile Children (PDF)
Effective date: October 1, 2021
Swimming Lessons Expanded Benefit (PDF)
Effective date: October 1, 2021
Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: June 1, 2018
Mental Health Assessments Expanded Benefit/Behavioral Health Assessment/Evaluation Services (PDF)
Effective date: November 2018
Targeted Case Management for Substance Use Disorder Expanded Benefit (PDF)
Effective date: November 2018
Care Grant Expanded Benefit (PDF)
Effective date: November 2018
Mobile Crisis Assessment and Intervention – In Lieu of Service (PDF)
Effective date: November 2018
Testing for Rupture of Fetal Membranes (PDF)
Effective Date: Retired
Chiropractic Manipulative Therapy Expanded Benefit (PDF)
Effective date: November 2018
Moderate Conscious Sedation (PDF)
Date of Last Revision: June 26, 2023
Testing of Select GU Conditions (PDF)
Effective Date: March 31, 2022
Clinical Criteria for Hospice Services (PDF)
Effective date: July 1, 2017
Negative Pressure Wound Therapy (NPWT) Pump Criteria (PDF)
Effective date: June 2015
Therapeutic Behavioral On-site Services (PDF)
Effective date: August 2019
Community Wrap Around Services In Lieu of Service (PDF)
Effective date: October 1, 2021
Newborn Circumcision Expanded Benefit (PDF)
Effective date: October 1, 2021
Thyroid Hormones and Insulin Testing in Pediatrics (PDF)
Effective Date: October 31, 2021
Crisis Stabilization Unit In Lieu of Service (PDF)
Effective date: October 1, 2021
Non-Emergency Transportation Services (PDF)
Effective date: July 11, 2022
Transition Assistance  Expanded Benefit (PDF)
Effective date: November 2018
Detoxification or Addiction Receiving Facility In Lieu of Service (PDF)
Effective date: October 1, 2021
Nutritional Counseling Expanded Benefit (PDF)
Effective date: November 2018
Ultrasound in Pregnancy (PDF)
Effective Date: March 31, 2022
Diagnosis of Vaginitis (PDF)
Effective Date: January 15, 2017
Paclitaxel (PDF)
Effective Date: 
Urodynamic Testing (PDF)
Effective Date: March 31, 2022
Digital Analysis of EEGs (PDF)
Effective Date: 
Partial Hospitalization Program In Lieu of Service (PDF)
Effective date: November 1, 2018
Visual Field Testing (PDF)
Effective Date: January 1, 2022
DME Orthotics Prosthetics Clincial Criteria Policy (PDF)
Effective date: May 1, 2014
PCR Respiratory Viral Panel  Testing - Prepayment Policy (PDF)
Effective Date: August 15, 2021
Vitamin D Testing 
in Children (PDF)

Effective Date: June 1, 2018
Doula Services  Expanded Benefit (PDF)
Effective date: November 2018
Peristeen Anal Irrigation System (Coloplast)  (PDF)
Effective date: June 1, 2022
Wheelchair Seating (PDF)
Effective Date: March 31, 2022
Drop-In Services In Lieu of Service (PDF)
Effective date: November 1, 2018
Physical, Occupational, and Speech Therapy Expanded Benefit (PDF)
Effective date: November 1, 2018
Wireless Motility Capsule (PDF)
Effective Date: September 1, 2017
Early Intervention Services Program (PDF)
Effective date: December 1, 2018
Physical, Occupational, Speech, and Medical Massage Therapy Services (PDF)
Effective date: May 2018
 
EEG in Evaluation of Headache (PDF)
Effective Date: October 31, 2021
Planned Out of Hospital Births (Home Birth or Birth Center) (PDF)
Effective date: November 9, 2020
 
EEG in Evaluation of Headache (PDF)
Effective Date: October 31, 2021
Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
Effective Date: March 31, 2022
 
Elective Deliveries Before 39 Weeks Gestational Age (PDF)
Effective date: September 2015
Powered Pressure Reducing Air Mattress Expanded Benefit (PDF)
Effective date: November 2018
 
Endometrial Ablation (PDF)
Effective Date: April 30, 2022
Process for Managing Requests for Non-Classified or Miscellaneous Codes (PDF)
Effective date: June 10, 2015
 
EpiFix Wound Treatment (PDF)
Effective Date: September 1, 2017
PROM Testing (PDF)
Effective Date: August 15, 2021
 
Evoked Potential Testing (PDF)
Effective Date: August 31, 2021
Proton and Neutron 
Beam Therapy (PDF)

Effective Date: November 1, 2016
 
Experimental and Investigational Review Process (PDF)
Effective date: December 1, 2018

 

 

 
Expressive Therapy Benefit for children under 21 (PDF)
Effective date: October 1, 2021
  
Expressive Therapy Expanded Benefit (PDF)
Effective date: November 2018
  
Extended Ophthalmoscopy (PDF)
Effective Date: August 15, 2021
 

 

External Ocular Photography (PDF)
Effective Date: January 1, 2022
  
Family Training and Counseling for Child Development In Lieu of Service (PDF)
Effective date: October 1, 2021
  
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
  
Group Outpatient Therapy Expanded Benefit (PDF)
Effective date: November 2018
  
Hearing and Vision Services (PDF)
Effective date: October 1, 2021
  
Hepatitis Vaccine Coverage Policy (PDF)
Effective date: October 30, 2019
  
Holter Monitors (PDF)
Effective Date: December 31, 2021
  
Home Delivered Meals-Post Facility Discharge Expanded Benefit (PDF)
Effective date: October 1, 2021
  
Home Health Nursing/Aide Services Expanded Benefit (PDF)
Effective date: October 1, 2021
  
Home Visit by a Clinical Social Worker Expanded Benefit (PDF)
Effective date: December 1, 2018
  
Homocysteine Testing (PDF)
Effective Date: March 31, 2022
  
H Pylori Testing (PDF)
Effective Date: June 1, 2018
  
Housing Supportive Services – Pilot Diversion Program (PDF)
Effective date: October 1, 2021
  

 

A-HI-QR-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 Consultation (PDF) 
Effective Date: January 1, 2014
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
Robotic Surgery (PDF)
Effective Date: April 20, 2021
Assistant Surgeon (PDF)
Effective Date: November 30, 2021
Intravenous Hydration (PDF)
Effective Date: January 1, 2013
Sepsis Diagnosis (PDF)
Effective Date: October 1, 2020
Bilateral Procedures (PDF)
Effective Date: January 1, 2014
Leveling of Care: Evaluation & Management Overcoding (PDF)
Effective Date: August 15, 2021
Sleep Studies Place of Services (PDF)
Effective Date: May 1, 2017
Billing Requirements for Transgender Services (PDF)
Last Review Date: April 17, 2023
  
Cerumen Removal (PDF) 
Effective Date: January 1, 2014
Leveling of Emergency Room Services  (PDF)
Effective Date: May 15, 2019
Supplies Billed On Same Day as Surgery (PDF)
Effective Date: January 1, 2013
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 DOS Validation (PDF)
Effective Date: January 1, 2013
Unlisted Procedure Codes (PDF)
Effective Date: January 1, 2013
CMS Correct Coding Initiative Unbundling Edits (PDF)
Effective Date:
Modifier to Procedure Code Validation (PDF)
Effective Date: January 1, 2013
Urine Specimen Validity Testing (PDF)
Effective Date: April 20, 2021
Code Editing Overview (PDF)
Effective Date: November 30, 2021
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF)
Effective Date: March 1, 2019
Wheelchair Accessories (PDF)
Effective Date: August 15, 2021
Cosmetic Procedures (PDF)
Effective Date: January 1, 2014
Multiple CPT Code Replacement  (PDF)
Effective Date: January 1, 2014
 
Cost to Charge Adjustments on Clean Claim Reviews (PDF)
Effective Date: September 1, 2022
Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular Procedures (PDF)
Effective Date: February 6, 2021
 
Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF)
Effective Date: January 1, 2013
Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services (PDF)
Effective Date: August 23, 2021
 
Distinct Procedural Service: Modifier 59 (PDF)
Effective Date: January 1, 2013
Multiple Procedure Reduction: Ophthalmology (PDF)
Effective Date: August 23, 2021
 

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

Effective Date: March 10, 2021

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

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

Effective Date: March 10, 2021

New Patient (PDF)
Effective Date: January 1, 2014
 
Facility Charges for  Hospital-Based Outpatient Clinics (PDF)
Effective: September 2022
Not Medically Necessary Inpatient Services (PDF)
Effective Date:
 

High Complexity Medical Decision-Making (PDF)

Effective  Date: July, 31, 2017

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

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

Outpatient Consultation (PDF)
Effective Date: January 1, 2014
 
 Physician's Consultation Services (PDF)
Effective Date: May 15, 2019
 

 

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

 

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

 

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

 

Pulse Oximetry with Evaluation & Management Services (PDF)
Effective Date: January 1, 2014
 

 

A-HI-QR-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: January 1, 2014
Reporting Global Maternity Package (PDF)
Effective Date: January 1, 2013
Billing Requirements for Transgender Services (PDF)
Last Review Date: April 17, 2023
 Robotic Surgery (PDF)
Effective Date: April 20, 2021
Add-On Code Billed Without Primary Code (PDF)
Effective Date: January 1, 2013
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: October 1, 2020
Ambulatory EEG (PDF)
Effective Date: September 14, 2020

Leveling of Care Evaluation and Management Overcoding (PDF)

Effective Date: February 5, 2021

Short Inpatient Hospital Stay (PDF)

Effective Date: October 1, 2020

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

 

Leveling of Emergency Room Services (PDF)
Effective Date: May 15, 2019

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
Billing Requirements for Transgender Services (PDF)
Last Review Date: April 17, 2023
  
Bronchial Thermoplasty (PDF)
Effective Date: January 15, 2017
Moderate Conscious Sedation (PDF)
Date of Last Revision: June 26, 2023
Supplies Billed On 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
 
Clean Claim Reviews (PDF)
Effective Date: November 1, 2012
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) Effective Date: March 1, 2019Ultrasound in Pregnancy (PDF)
Effective Date: March 31, 2022
Clinical Validation of Modifier 25 (PDF)
Effective Date: January 1, 2013
Multiple CPT Code Replacement  (PDF)
Effective Date: January 1, 2014
Unbundled Professional Services (PDF)
Effective Date: January 1, 2014
CMS Correct Coding Initiative Unbundling Edits (PDF)
Effective Date: 

Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular Procedures (PDF)
Effective Date: February 6, 2021

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

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
Cosmetic Procedures (PDF)
Effective Date: January 1, 2014
Multiple Procedure Reduction: Ophthalmology (PDF)
Effective Date: August 23, 2021
Unlisted Procedure Codes (PDF)
Effective Date: January 1, 2013
Cost to Charge Adjustments on Clean Claim Reviews (PDF)
Effective Date: September 1, 2022
NCCI Unbundling (PDF)
Effective Date: 
Urine Specimen Validity Testing (PDF)
Effective Date: April 20, 2021
Diagnosis of Vaginitis (PDF) 
Effective Date: January 15, 2017 - September 30, 2017

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

Urodynamic Testing (PDF)
Effective Date: March 31, 2022
Diagnosis of Vaginitis (PDF) Effective Date: October 1, 2017 - December 31, 2017

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

Visual Field Testing (PDF)
Effective Date: January 1, 2022
Digital Analysis of EEGs (PDF)
Effective Date: October 31, 2021

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

Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)

Effective Date: March 31, 2022

 
Evoked Potentials (PDF)
Effective Date: January 1, 2022

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

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

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

 
External Ocular Photography (PDF) 
Effective Date: January 1, 2022
Problem Oriented Visits Billed with Preventative Visits (PDF)
Effective Date: September 2, 2022
 
Facility Charges for  Hospital-Based Outpatient Clinics (PDF)
Effective: September 2022
Problem Oriented Visits with Surgical Procedures (PDF)
Effective Date: December 1, 2017
 
Fecal Calprotectin Assay (PDF)
Effective Date: May 1, 2017
Professional Component Modifier 26 (PDF)
Effective Date: January 1, 2013
 

Fluorescein Angiography (PDF)

Effective Date: January 1, 2022

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

Gonioscopy (PDF)

Effective Date: January 1, 2022

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

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

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

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

Pulse Oximetry with Evaluation & Management Services (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

  

 

 

A-HI-QR-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 Emergency Room Services (PDF)
Effective Date: May 15, 2019
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
Sleep Studies Place of Services (PDF)
Effective Date: May 1, 2017
Billing Requirements for Transgender Services (PDF)
Last Review Date: April 17, 2023
  

Bronchial Thermoplasty (PDF)
Effective Date: January 15, 2017

Measurement of Serum 1,25-dihydroxyvitamin D (PDF)
Effective Date: January 1, 2022

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

Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: June 1, 2018
Mechanical Stretch Devices (PDF)
Effective Date:  September 1, 2017
Status "P" Bundled Services (PDF)
Effective Date: April 1, 2017
Cerumen Removal (PDF) 
Effective Date: January 1, 2014
Moderate Conscious Sedation (PDF)
Date of Last Revision: June 26, 2023
Supplies Billed On Same Day as Surgery (PDF)
Effective Date: January 1, 2013

Clean Claims (PDF)
Effective Date: 

Modifier DOS Validation (PDF)
Effective Date: January 1, 2013
Testing for Rupture of Fetal Membranes (PDF)
Effective Date: Retired
Clean Claim Reviews (PDF)
Effective Date: November 1, 2012
Modifier to Procedure Code Validation (PDF)
Effective Date: January 1, 2013
Testing for Select Genitourinary Conditions (formerly Diagnosis of Vaginitis) (PDF)
Effective Date: January 1, 2022
Clinical Validation of Modifier 25 (PDF)
Effective Date: January 1, 2013
Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF) Effective Date: March 1, 2019

Testing of Select GU Conditions  (PDF)

Effective Date: March 31, 2022

CMS Correct Coding Initiative Unbundling Edits (PDF)
Effective Date: 
 

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

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

Multiple CPT Code Replacement  (PDF)
Effective Date: January 1, 2014

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

Multiple Procedure Payment Reduction (MPPR) for Diagnostic Cardiovascular Procedures (PDF)

Effective Date: February 6, 2021

Ultrasound in Pregnancy (PDF)
Effective Date: March 31, 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

Unbundled Professional Services (PDF)
Effective Date: January 1, 2014
Diagnosis of Vaginitis (PDF) 
Effective Date: January 15, 2017 - September 30, 2017

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

Unbundled Surgical Procedures (PDF)
Effective Date: 
Diagnosis of Vaginitis (PDF) Effective Date: October 1, 2017 - December 31, 2017NCCI Unbundling (PDF)
Effective Date: 
Unbundling Adjustments on Clean Claim Reviews (PDF)
Effective Date: September 1, 2022
Digital Analysis of EEGs (PDF)
Effective Date: October 31, 2021

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

Unlisted Procedure Codes (PDF)
Effective Date: January 1, 2013
Digital Breast Tomosynthesis (PDF)
Effective Date: December 1, 2016 - December 31, 2017
New Patient (PDF)
Effective Date: January 1, 2014
Urine Specimen Validity Testing (PDF)
Effective Date: April 20, 2021
Distinct Procedural Modifiers: XE, XS, XP, & XU (PDF)
Effective Date: January 1, 2013

Non-obstetrical Pelvic and Transvaginal Ultrasounds (PDF) Effective Date: March 1, 2019

Urodynamic Testing (PDF)
Effective Date: March 31, 2022
Distinct Procedural Service: Modifier 59 (PDF)
Effective Date: January 1, 2013
Outpatient Consultation (PDF)
Effective Date: January 1, 2014
Visual Field Testing (PDF)
Effective Date: January 1, 2022
Duplicate Primary Code Billing (PDF)
Effective Date: January 1, 2014
Paclitaxel Protein Bound (PDF)
Effective Date: January 1, 2022
Vitamin D Testing in Children and Adolescents (PDF)
Effective Date: June 1, 2018
EEG in the Evaluation of Headache (PDF)
Effective Date: January 1, 2022
Physician Visit Codes Billed with Labs (PDF)
Effective Date: 
Wheelchair and Accessories (PDF)
Effective Date: August 12, 2016
Endometrial Ablation (PDF)
Effective Date: April 30, 2022
Physician's Consultation Services (PDF)
Effective Date: December 1, 2017
Wheelchair Seating (PDF)
Effective Date: March 31, 2022
EpiFix Wound Treatment (PDF)
Effective Date: September 1, 2017
Physician's Office Lab Testing (PDF)
Effective Date: January 1, 2022
Wireless Motility Capsule (PDF)
Effective Date: September 1, 2017
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 26 (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 Evaluation & Management Services (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