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

HISTORICAL MATERIAL REQUIRING CURRENT APPLICABILITY VERIFICATION: 1. ALREADY EFFECTIVE (6/1/2026 – past deadline): Verify whether Providence Health Plan's elimination of additional reimbursement units for anesthesia physical status modifiers P3, P4, P5 on commercial plans has been implemented in billing system claims logic. Confirm current policy status with Providence Health Plan, as this change predates the analysis date. 2. ALREADY EFFECTIVE (7/1/2026 – past deadline): Verify implementation of two July 2026 edits in billing software: - Critical care services denial logic: Confirm that claims with CPT 99291/99292 billed in the emergency department with discharge to home (status code 01) are flagged for denial or manual review. Verify this applies to facility claims only and excludes ED-to-inpatient admissions. - Surgical procedure anatomical modifier requirement: Confirm that claims with CPT codes 10000–69999 that are bilateral-eligible under the Medicare Physician Fee Schedule are validated for required anatomical modifiers (RT, LT, E1–E4, F1–F9, T1–T9, LC, RC). Verify that missing, incorrect, or non-specific modifiers (59, XS) trigger line-level denials when a more specific anatomical modifier is available. 3. Billing team should contact Providence Health Plan to confirm the current status of all three active policies and document verification in compliance records. Do not assume these edits are active in your billing system without confirmation.