CPT 99354 is referenced in 4 tracked payer policy changes from Blue Cross of Idaho, Oregon Health Plan, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 99354 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Blue Cross of Idaho added a new Part 2 Substance Use Disorder (SUD) section to policy PAP229 effective October 2025. Providers treating or referring SUD patients must obtain documented patient consent before submitting claims containing Part 2 Records to the insurer, and must include specific notice that records are subject to the Part 2 Rule (42 C.F.R. Part 2). Claims submitted without proper consent will be denied.
Blue Cross of Idaho updated PAP229 to add Part 2 Substance Use Disorder (SUD) record handling requirements and clarified that medical records must be submitted with claims for specific prolonged service codes (99417, 99418, 99354-99357, 99358-99359, 99415-99416), modifier 22/63 claims, and observation stays exceeding 48 hours. Providers must now obtain and certify patient consent before submitting any SUD-related claims to Blue Cross.
Oregon Health Authority is increasing Medicaid fee-for-service primary care rates by 2%, raising the conversion factor from $27.82 to $28.50. This affects evaluation and management codes, immunization administration codes, and health/behavior assessment codes.
CPT code 99354 with modifier TH is currently being denied when billed with E/M services due to NCCI edit conflicts. IHCP is seeking CMS approval to deactivate this edit, and claims will be mass reprocessed within 60 days of approval.
Watch 99354
Get one email when a payer policy names 99354, a payer adds or drops it from a prior auth list, or Medicare changes its NCCI pairs, unit limit, payment or coverage articles.
Get alerts for changes like this
Save a search and get email alerts when a new policy change matches your filters: daily or weekly, your choice, on every plan.