Reimbursement Policies

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Reimbursement Policies

Title Download (PDF)
After Hours and Weekend Care Download (PDF)
Allergy Testing Immunotherapy Download (PDF)
Ambulatory Surgical Groupers Download (PDF)
Anesthesia Reimbursement Policy Download (PDF)
Assistant at Surgery – Modifiers 80/81/82 and AS (Commercial) Download (PDF)
Billing for Habilitative and Rehabilitative Services Download (PDF)
Biomarkers Testing for Autoimmune Rheumatic Disease (LBM) Download (PDF)
Bundled Services (Commercial and Medicare) Download (PDF)
Coding Edits Policy (Commercial, Medicare, and Medicaid)  Download (PDF)
Colorectal Cancer (LBM) Download (PDF)
Compression Garments Download (PDF)
Computer Assisted Surgical Navigation Download (PDF)
Coronavirus Testing in the Outpatient Setting (LBM) Download (PDF)
Corrected Claim Submission Download (PDF)
Co-Surgeon/Team Surgeon-Modifiers 62/66 Download (PDF)
CPT and HCPCS Billing Guidelines Download (PDF)
Daily Maximum Units (Commercial/Medicare) Download (PDF)
Diagnosis Code Guidelines: Manifestation/Secondary Diagnosis Codes Download (PDF)
Discarded Drugs/Biologicals – Modifier JW (Commercial) Download (PDF)
Discontinued Procedures – Modifiers 53, 73 & 74 (Commercial) Download (PDF)
DME In-Office/Non-Facility Download (PDF)
DME Rental vs. Purchase Download (PDF)
Drug Alcohol Testing (Commercial/Medicaid) Download (PDF)
Drugs and Biologicals Download (PDF)
Emergency Department Facility E&M Coding’ Download (PDF)
Evaluation and Management (E&M) Services Download (PDF)
Facility Fees for E&M Services on Outpatient Facility Claims Download (PDF)
From/To Date Span Download (PDF)
Hepatitis Testing (LBM) Download (PDF)
Home Health Care Services Download (PDF)
Hospital Readmissions Download (PDF)
Human Immunodeficiency Virus (HIV) (LBM) Download (PDF)
Intraoperative Neurophysiology Monitoring Services (IONM) Download (PDF)
Laboratory/Venipuncture Download (PDF)
Mid-Level Practitioner Reimbursement Policy (Commercial) Download (PDF)
Modifier SU – Procedure Performed in Physician’s Office (Commercial) Download (PDF)
Modifier Reference Policy Download (PDF)
Modifiers PN & PO for Clinic Visit Services (G0463) – (Medicare) Download (PDF)
Multiple & Bilateral Surgical Procedures Policy Download (PDF)
Multiple Diagnostic Imaging Payment Reduction Policy (Commercial) Download (PDF)
Multiple Procedure Reduction Cardiology/Ophthalmology Download (PDF)
National Drug Code (NDC) Requirements for Drug Claims – Commercial, Medicare, and Medicaid Download (PDF)
Never Events/Adverse Events & Serious Reportable Events (Commercial) Download (PDF)
No Cost/Reduced Cost Drugs, Implants & Devices Download (PDF)
Observation Stay - Commercial Download (PDF)
Observation Stay – Medicare and Medicaid Download (PDF)
Operating Microscope/Microsurgery (CPT 64727/69990) Download (PDF)
Ophthalmology Reimbursement Policy Download (PDF)
Outpatient Diagnostic Imaging Self-Referral Payment Policy Download (PDF)
Preventive Care Services (Commercial) Download (PDF)
Preventive Care Services (Medicare) Download (PDF)
Preventive Medicine and Screening (Commercial) Download (PDF)
Prolonged Services (Commercial, Medicare and Medicaid) Download (PDF)
Radiology Cardiology Ultrasound Bundling Rules (Administered by EviCore) Download (PDF)
Radiology Cardiology Ultrasound Frequency Rules (Administered by EviCore) Download (PDF)
Radiology Cardiology Ultrasound Correct Coding Rules (Administered by EviCore) Download (PDF)
Radiopharmaceuticals and Contrast Media Download (PDF)
Revenue Codes Requiring Detailed Coding Download (PDF)
Robotic Surgery Download (PDF)
Routine Foot Care Services Download (PDF)
Split Surgical Care (Modifiers 54/55/56) (Commercial) Download (PDF)
Telehealth/Virtual Care Services Download (PDF)
Treatment Room Download (PDF)
Unlisted Codes Download (PDF)
B-Hemolytic Streptococcus Testing (LBM) Download (PDF)
Biochemical Markers of Alzheimer Disease and Dementia (LBM) Download (PDF)
Bone Turnover Markers Testing (LBM) Download (PDF)
Celiac Disease Testing (LBM) Download (PDF)
Cervical Cancer Screening (LBM) Download (PDF)
Diagnosis of Vaginitis (LBM) Download (PDF)
Diagnostic Testing of Common Sexually Transmitted Infections (LBM) Download (PDF)
Diagnostic Testing of Influenza (LBM) Download (PDF)
Epithelial Cell Cytology in Breast Cancer Risk Assessment (LBM) Download (PDF)
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing (LBM) Download (PDF)
Fecal Calprotectin Testing in Adults (LBM) Download (PDF)
Flow Cytometry (LBM) Download (PDF)
Folate Testing (LBM) Download (PDF)
Gamma-Glutamyl Transferase (LBM) Download (PDF)
General Inflammation Testing (LBM) Download (PDF)
Helicobacter Pylori Testing (LBM) Download (PDF)
Immunohistochemistry (LBM) Download (PDF)
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies (LBM) Download (PDF)
In Vitro Chemoresistance and Chemosensitivity Assays (LBM) Download (PDF)
Lyme Disease Testing (LBM) Download (PDF)
Measurement of Thromboxane Metabolites for ASA Resistance (LBM) Download (PDF)
Nerve Fiber Density Testing (LBM) Download (PDF)
Onychomycosis Testing (LBM) Download (PDF)
Oral Cancer Screening and Testing (LBM) Download (PDF)
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing (LBM) Download (PDF)
Pediatric Preventive Screening (LBM) Download (PDF)
Pharmacy Medical Claim Edit Download (PDF)
Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection (LBM) Download (PDF)
Prescription Medication and Illicit Drug Testing in Outpatient Setting (LBM) Download (PDF)
Prostate Biopsy Specimen Analysis (LBM) Download (PDF)
Salivary Hormone Testing (LBM) Download (PDF)
Testing For Alpha-1 Antitrypsin Deficiency (LBM) Download (PDF)
Testing for Diagnosis of Active or Latent Tuberculosis (LBM) Download (PDF)
Testing for Vector-Borne Infections (LBM) Download (PDF)
Testing of Homocysteine Metabolism-Related Conditions (LBM) Download (PDF)
Testosterone Testing (LBM) Download (PDF)
Thyroid Disease Testing (LBM) Download (PDF)
Urine Culture Testing for Bacteria (LBM) Download (PDF)
Vitamin B12 & Methylmalonic Acid Testing (LBM) Download (PDF)
Vitamin D Testing (LBM) Download (PDF)
Zika Virus Risk Assessment (LBM) Download (PDF)
Allergen Testing (LBM) Download (PDF)
Biomarkers for Myocardial Infarction and Chronic Heart Failure (LBM) Download (PDF)
Cardiovascular Disease Risk Assessment (LBM) Download (PDF)
Diabetes Mellitus Testing (LBM) Download (PDF)
Diagnosis of Idiopathic Environmental Intolerance (LBM) Download (PDF)
Diagnostic Testing of Iron Homeostasis & Metabolism (LBM) Download (PDF)
Erectile Dysfunction (LBM) Download (PDF)
Evaluation of Dry Eyes Testing (LBM) Download (PDF)
Genetic Testing for Adolescent Idiopathic Scoliosis (LBM) Download (PDF)
Identification of Microorganisms Using Nucleic Acid Probes (LBM) Download (PDF)
Immune Cell Function Assay (LBM) Download (PDF)
Intracellular Micronutrient Analysis (LBM) Download (PDF)
Lab Testing for the Diagnosis of IBD (LBM) Download (PDF)
Metabolite Markers of Thiopurines Testing (LBM) Download (PDF)
Medicare Part D Vaccines Download (PDF)
Pancreatic Enzyme Testing for Acute Pancreatitis (LBM) Download (PDF)
Pathogen Panel Testing (LBM) Download (PDF)
Prenatal Screening-Nongenetic (LBM) Download (PDF)
Preventive Screening in Adults (LBM) Download (PDF)
Prostate Specific Antigen (PSA) Testing (LBM) Download (PDF)
Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease (LBM) Download (PDF)
Serum Tumor Markers for Malignancies (LBM) Download (PDF)
ST2 Assay for Chronic Heart Failure (LBM) Download (PDF)
Split/Fragmented Billing Download (PDF)
Urinary Tumor Markers for Bladder Cancer (LBM) Download (PDF)
Vectra DA Blood Test for Rheumatoid Arthritis (LBM) Download (PDF)
Venous Thrombosis Risk Testing (LBM) Download (PDF)