Medica Provider News: September 2025

REQUIREMENTS: By November 15, 2025: Billing team must review and implement three new reimbursement policies in billing software: 1. MPPR for Diagnostic Imaging (Commercial and IFB members only): - Audit ultrasound CPT codes currently billed to identify those without MPI indicator 4 - Configure billing system to apply MPPR reductions to ultrasound codes that are similar to codes with MPI indicator 4 when multiple procedures performed same date of service by same TIN - Distinguish between professional component (PC) and technical component (TC) reduction percentages - Medicare products will continue following CMS NPFS guidelines (no change needed) 2. Replacement Codes Policy (Commercial and IFB members only): - Update billing software to flag any CPT/HCPCS codes with CMS status code 'I' submitted on CMS-1500 forms - Configure system to require replacement code usage when CMS has assigned an RVU to replacement code - Train billing staff to verify replacement codes have assigned RVUs before claim submission 3. Device, Implant, and Skin Substitute Policy (Commercial, Medicare, IFB members): - Update billing system to require device/implant codes be submitted on SAME day and SAME UB-04 claim as procedure code - Configure system to automatically deny claims where device/implant submitted on different date or different claim - Program exception: Allow procedures without device/implant code only if appended with modifier 73 or 74 (discontinuation) - Apply Integrated Outpatient Claims Editor (OCE) validation rules 4. Discarded Drugs and Biologicals (All plans - currently in practice, clarification): - Ensure billing software requires modifier JW on second line for discarded/unused portion of single-use vials - Configure system to deny payment for lines with modifier JW (discarded amount not eligible for reimbursement) - Train staff: Multi-use vial discards are never reimbursable - Applies to commercial, Medicare, and IFB members Consequences of inaction: Claims will be denied if MPPR not applied to qualifying ultrasound codes, if status code 'I' codes without RVU replacement codes are submitted, if devices/implants submitted on different claims/dates than procedures, or if modifier JW rules not followed. Obtain updated reimbursement policy documents from Medica online or call Provider Literature Request Line at 1 (800) 458-5512, option 1, then option 8, ext. 2-2355.