Providers

Subject

Description

Durable Medical Equipment and Supplies Policy

Limit intermittent urinary catheters (A4351-A4353) to 600 combined units per three months.

Durable Medical Equipment and Supplies Policy

Deny oxygen and oxygen equipment (E0424-E0447, E1390-E1392, E1405-E1406, K0738) when billed without modifier KX, GA, GY or GZ.

Durable Medical Equipment and Supplies Policy

Deny E2402 (Negative wound therapy pressure pump) when billed more than once per month by any provider.

Durable Medical Equipment and Supplies Policy

Deny A6550, A7000 or E2402 (Negative wound therapy pressure pump) as missing a required modifier when billed without modifier KX, GA, or GZ.

Durable Medical Equipment and Supplies Policy

Deny E0675 (Pneumatic compression device, for arterial insufficiency) when billed.

Drug and Biological Policy (M-Z)

Limit J2785 to four combined units per date of service by any provider when billed and the diagnosis is coronary artery disease.

CMS National Coverage Determinations (NCD) Policy

Deny 82728 (Ferritin), 83540 (Iron), 83550 (Iron binding capacity) or 84466 (Transferrin) when billed without a covered diagnosis.

CMS National Coverage Determinations (NCD) Policy

Deny 84153 (Prostate specific antigen [PSA], total) when billed without a required diagnosis.

CMS National Coverage Determinations (NCD) Policy

Deny 99406 or 99407 (Smoking and tobacco cessation counseling visit) when billed with Bill Type 0120-012Z (Hospital inpatient Part B), 0130-013Z (Hospital outpatient), 0220-022Z (SNF inpatient part B), 0230-023Z (SNF outpatient part B), 0340-034Z (Home health services not under a plan of treatment) and the revenue code is not 0942 (Education/training).

Modifier Policy

Deny 77065, 77066 or G0279 (Diagnostic mammography) when billed with 77063 or 77067 (Screening mammography) and modifier GG (Screening and diagnostic mammogram on same day) is not appended to the diagnostic mammography procedure.

Podiatry

Deny additional units of 11055-11057, 11719-11721, or G0127 (Routine foot care) when billed more than once within a two-month period.

Podiatry

Deny 11055-11057, 11719-11721, or G0127 (Routine foot care) when billed with a qualifying diagnosis and without modifier Q7, Q8 or Q9.

Podiatry

Deny 11055-11057, 11719-11721, or G0127 (Nail paring, cutting, debridement, trimming) when billed without a requisite diagnosis on the claim.

Podiatry

Deny 11055-11057, 11719-11721, or G0127 (Nail paring, cutting, debridement, trimming) when billed with a diagnosis of thickened or mycotic nails and without a qualifying complication diagnosis or a systemic condition resulting in circulatory or neurologic impairment on the claim.

Podiatry

Deny 11730 or 11732 (Avulsion of nail plate, partial or complete, simple) when billed more than one unique date of service in a 12-week period.

Podiatry

Deny 11055-11057 (Paring or cutting of benign hyperkeratotic lesion) when billed with a diagnosis of hyperkeratosis and without an additional diagnosis such as metabolic, neurologic, or peripheral vascular disease on the claim.

Laboratory-Pathology Policy

Deny U0003 (COVID-19 infectious agent detection by nucleic acid, high throughput) when billed with 87635 (COVID-19 Infectious agent detection by nucleic acid) by any provider.

Laboratory-Pathology Policy

Deny 87635 (COVID-19 Infectious agent detection by nucleic acid) when billed and U0003 (COVID-19 infectious agent detection by nucleic acid, high throughput) has been previously billed and paid on the same date of service by any provider.

Incision and Drainage (I & D)

Deny 10060-10061 (Incision and drainage of abscess) or 10160 (Puncture aspiration of abscess) when billed without a requisite diagnosis and the provider specialty is podiatry.

Incision and Drainage (I & D)

Deny 10140 (Incision and drainage of hematoma) when billed without a requisite diagnosis and the provider specialty is podiatry.

Vitamin D Testing

Deny 82306 (Vitamin D; 25 hydroxy) when billed without a requisite diagnosis code.

Frequency Policy

Deny S5161 (Emergency response system monthly service fee) when billed by any provider more than once a month.

Bundled Facility Payment Policy

Deny ambulance services when the date of service falls on the same date of service as subsequent inpatient care and an initial hospital care or a discharge service has not been reported by any provider.

Evaluation and Management Services Policy

Deny E/M services when billed the same date of service as cardiovascular services (93260-93261, 93282-93284, 93287, 93289, 93292).

Evaluation and Management Services Policy

Deny 99291 (Critical care, evaluation, and management of the critically ill or critically injured patient; first 30-74 minutes) when billed with more than one unit per day.

Evaluation and Management Services Policy

Deny the E/M service when billed the same date as electromyography, nerve conduction tests or reflex tests.

Evaluation and Management Services Policy

Deny Transitional Care Management (TCM) services (99495-99496) when billed and another TCM Service (99495-99496) has been billed on the same date of service by any provider.

CMS Coverage Policies

Deny 76706 (Ultrasound, abdominal aorta, screening study for abdominal aortic aneurysm [AAA]) when billed for a male patient older than 75 years of age and a diagnosis of family history of AAA is not present on the claim.

CMS Coverage Policies

Deny G0420-G0421 (Face-to-face educational services related to the care of chronic kidney disease) if not accompanied by a diagnosis of chronic kidney disease, stage IV, [severe]).

CMS Coverage Policies

Deny V2785 (Processing, preserving, and transporting corneal tissue) when billed without a corneal transplant procedure (65710, 65730, 65750, 65755, 65756, 65765, 65767).

CMS Coverage Policies

Deny 76706 (Ultrasound, abdominal aorta, screening study for abdominal aortic aneurysm [AAA]) when billed for a female patient and a diagnosis of family history of AAA is not present on the claim.