K74.5 Insurance Policy Changes

ICD-10 K74.5 is officially defined as "Biliary cirrhosis, unspecified." code K74.5 is referenced in 4 tracked payer policy changes from Horizon BCBS NJ, Blue Cross & Blue Shield of Mississippi, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code K74.5 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Horizon BCBS NJ · Effective Jan 1, 2026High impact
Statin Use in Persons with Diabetes (SUPD)
This is a new Medicare Part D Star Ratings measure (SUPD) effective for 2026 that evaluates whether patients ages 40-75 with diabetes on antidiabetic medications are also receiving statin therapy. Billing teams must ensure proper documentation and ICD-10 coding of exclusionary diagnoses to accurately track eligible patients and avoid measure performance penalties. Claims must include appropriate exclusion codes when patients have contraindications to statin therapy.
Blue Cross & Blue Shield of Mississippi · Effective Oct 1, 2026Medium impact
Vitamin D Testing
Serum measurement of vitamin D (25-hydroxyvitamin D [25(OH)D], CPT 82306) is considered medically necessary up to four times per calendar year for the following conditions, among others: biliary cirrhosis, celiac disease, hypercalcemia or hypocalcemia, hyperparathyroidism or hypoparathyroidism, intestinal malabsorption, liver cirrhosis, long-term use of anticonvulsants, glucocorticoids or other medications known to lower vitamin D levels, malnutrition, osteomalacia, osteoporosis, rickets, sarcoidosis, stage III-V chronic kidney disease and end stage renal disease, and vitamin D deficiency on replacement therapy to monitor treatment efficacy. Routine serum vitamin D testing performed for screening purposes in asymptomatic patients is considered not medically necessary. Intestinal failure-associated liver disease (ICD-10 K76.83) is listed as a new diagnosis code effective 10/01/2026.
Capital Blue Cross · Effective Apr 1, 2026Medium impact
AB2026-04-002 Medicare only
Capital Blue Cross updated Medicare Part D Star measures for 2026, adding new exclusions for Statin Use in Persons with Diabetes (SUPD) that recognize PCSK9 inhibitors and bempedoic acid as alternatives for patients who cannot tolerate statins. Providers must submit specific ICD-10-CM codes annually during in-person or audio/video visits to qualify patients for exclusions from the SUPD measure.
Presbyterian Health Plan · Identified Jul 31, 2026Medium impact
2026 July Network Connection
CPT 90785 (interactive complexity) may be billed only as an add-on code that accompanies an eligible primary psychiatric service, and only when its specific criteria and requirements are met. Medical records must clearly support CPT 90785 by describing specific communication challenges, challenges affecting clinical interaction, the interactive methods used, and why standard communication approaches were insufficient, and claims submitted without adequate documentation may be subject to audit or review with payment adjusted if billing requirements are not met. Nail pathogen panel claims should be supported by clear clinical indication and medical necessity, prior testing and treatment history, a valid signed provider order specifying test type, and accurate diagnosis coding, and the Presbyterian Program Integrity Department performs random claims validation audits.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code K74.5?

There are 4 tracked policy changes affecting code K74.5, including updates from Horizon BCBS NJ, Blue Cross & Blue Shield of Mississippi, Capital Blue Cross. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code K74.5?

Payers that have issued tracked updates for code K74.5 include: Horizon BCBS NJ, Blue Cross & Blue Shield of Mississippi, Capital Blue Cross, Presbyterian Health Plan.

How do I get notified when code K74.5 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code K74.5. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for code K74.5?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

All billing codes J3590 C9399 J3490 99215 99213 99202

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Statin Use in Persons with Diabetes (SUPD)

Vitamin D Testing

AB2026-04-002 Medicare only

2026 July Network Connection

What insurance policy changes affect code K74.5?

Which payers have updated policy for code K74.5?

How do I get notified when code K74.5 policy changes?

Why do payers change policies for code K74.5?