Special Alert June 2026 - UPDATE Part 2 - Alert for 6.1 and 7.1 Coding and Reimbursement Policy Changes

REQUIREMENTS: **By June 1, 2026 (Anesthesia Physical Status Modifiers):** - Billing team must update claims processing system to exclude additional unit reimbursement for anesthesia modifiers P3, P4, and P5 on commercial plans only. - Notify anesthesia providers that these modifiers may continue to be documented but will not generate additional payment on commercial lines of business. - Configure billing rules to prevent claim rejections when P3, P4, P5 modifiers are submitted. - Consequence: Claims submitted with these modifiers will be reimbursed at base rate only; any appeals based on historical payment patterns will be denied. **By July 1, 2026 (Critical Care ED Denials and Anatomical Modifiers):** - Billing team must implement system edit to deny CPT 99291/99292 claims from facility emergency department settings when discharge disposition is "01" (home). - Educate ED providers and coders that critical care codes are inappropriate for ED-to-home discharges; instruct them to bill appropriate ED E/M codes (99281-99285) instead. - Billing team must update claim validation rules to flag and deny surgical procedure claims (CPT 10000-69999 bilateral-eligible procedures) when anatomical modifiers (RT, LT, E1-E4, F1-F9, T1-T9, LC, RC) are missing, incorrect, or replaced with non-specific modifiers (59, XS). - Create internal audit to identify historical claims billed with CPT 99291/99292 from ED with home discharge to address potential overpayments. - Communicate to providers: Modifier 59 and XS are not acceptable substitutes when specific anatomical modifiers are available; verify all surgical claims include proper laterality/site identification. - Consequence: Claims failing to meet these requirements will be denied at the line level; resubmission will require corrected coding and proper modifiers.