Payment Policy Updates

REQUIREMENTS: By July 1, 2026: Billing team must update billing software and staff training to reflect clarifications in PP CO 500.01 (Status Codes), PP CO 012.01 (Hair Removal Services Gender Dysphoria), PP CO 016.01 (Critical Care), and PP CO 080.02 (Doula Services). Review History Section of each policy for specific clarifications. No logic changes apply, but staff must understand new details to avoid unnecessary denials. Update internal reference materials and EMR templates where applicable. By September 1, 2026: Billing team and providers must prepare for October 1, 2026 expansion of three policies to Government Programs: PP CC 002.04 (Claims During Inpatient Admission), PP CC 400.05 (MPPR Well Problem Visit E/M Pay Percent), and PP CC 017.02 (Outpatient Services Prior to Admission). Obtain complete policy text and conduct staff training. Ensure billing system rules are configured to apply these policies to Government Programs claims effective October 1, 2026. By September 1, 2026: Billing team and coding staff must review new policy PP GP 002.01 (Diagnosis Guidelines) which becomes effective October 1, 2026 for Government Programs. Policy will be publicly available by July 1, 2026. Review requirements for diagnosis, manifestation, and etiology coding. Update EMR templates, superbills, and billing rules to reflect new requirements. Claims submitted without compliance will be denied. Immediately: Billing team and providers must implement denial prevention measures for ALL plan types: - STOP billing multiple units or using modifier 59 for codes with inclusive descriptors (e.g., CPT 11901 'Inject skin lesions >7' = 1 unit only). Review codes with 'Initial', 'up to', 'up to and including', or plural descriptors in the code set. - REVIEW modifier 91 usage immediately. Reference PP CO 600.01, PP CO 600.02, PP CO 600.05, PP CO 600.06, and PP CO 090.01. Consult CareFirst's Modifier 91 Fact Sheet before billing. Modifier 91 denials are increasing. - STOP billing ICD-10 codes that violate Excludes 1 notes and coding conventions (e.g., DO NOT bill M54.50 + M54.41 together). Implement coding compliance audits in billing system. - ELIMINATE laterality (RT/LT) modifier conflicts with diagnosis codes. If procedure is billed with RT modifier, diagnosis must specify right side, not left. Add validation rules to billing software. - NEVER use secondary-only diagnosis codes as primary diagnosis. Codes marked 'Use additional code' must follow the primary diagnosis (e.g., Z3A.01 'Less than 8 weeks gestation' cannot be primary; obstetric condition must be coded first). Update coding guidelines in EMR and billing software. Consequences: Non-compliance will result in claim line denials across all affected services and diagnoses.