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Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules.  They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies.  Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information. 

All policies found in the PA Health & Wellness Clinical Policy Manual apply to PA Health & Wellness members. Policies in the PA Health & Wellness Clinical Policy Manual may have either a PA Health & Wellness or a “Centene” heading.  PA Health & Wellness utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a PA Health & Wellness clinical policy does not exist.  InterQual is a nationally recognized evidence-based decision support tool.  You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling PA Health & Wellness. In addition, PA Health & Wellness may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or  InterQual®criteria is payable by PA Health & Wellness.   

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-H I-Q R-Z

Dental Anesthesia in the Outpatient Hospital or in the Ambulatory Surgical Center (PDF)

Effective Date: 11/17/2014

Insulin Testing in Pediatrics (PDF)

Effective Date: 07/01/2018

Summary Guidelines on Prevention and Management of Diabetes Complications (PDF)

Effective Date: 01/01/2006

Hyperbaric Oxygen Therapy (PDF)

Effective Date: 06/30/2009

Physical, Occupational, Speech, and/or Feeding Therapy (PDF)

Effective Date: 03/23/2009

Reduction Mammaplasty (PDF)

Effective Date: 07/31/2012

Allogeneic Hematopoietic Cell Transplants for Sickle Cell (PDF)

Effective Date: 03/31/2016

Medical Necessity for Infant Apnea Monitors (PDF)

Effective Date: 11/18/2015

Stereotactic Body Radiation Therapy (PDF)

Effective Date: 12/30/2008

Articular Cartilage Defect Repairs (PDF)

Effective Date: 10/31/2008

Medical Necessity for Authorizing Incontinence Supplies (PDF)

Effective Date: 11/18/2015

Vagus Nerve Stimulation (PDF)

Effective Date: 09/30/2008

Clinical Trials (PDF)

Effective Date: 01/27/2014


Intradiscal Steroid Injections for Pain Management (PDF)


Effective Date: 08/31/2018


Ventriculectomy and Cardiomyoplasty (PDF)

Effective Date: 05/06/2013

Digital EEG Spike Analysis (PDF)

Effective Date: 01/15/2016


OB Home Health Programs (PDF)


Effective Date: 01/27/2014

Selective Nerve Root Blocks and Transforaminal Epidural Injections for Pain Management (PDF)

Effective Date: 08/31/2018

Donor Lymphocyte Infusion (PDF)

Effective Date: 12/01/2015


Outpatient Testing for Drugs of Abuse (PDF)


Effective Date: 09/30/2012

Sacroiliac Joint Interventions for Pain Management (PDF)

Effective Date: 08/31/2018

Endometrial Ablation (PDF)

Effective Date: 03/01/2016


Nerve Blocks for Pain Management (PDF)


Effective Date: 08/31/2018

Trigger Point Injections for Pain Management (PDF)

Effective Date: 08/31/2018

Ferriscan R2-MRI (PDF)

Effective Date: 11/14/2012



Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)

Effective Date: 04/30/2018

Radial Head Implant (PDF)

Effective Date: 08/31/2017

Fractionated Exhaled Nitric Oxide (FeNO) measurement (PDF)

Effective Date: 01/27/2016

Inhaled Nitric Oxide (PDF)

Effective Date: 08/30/2013

Sacroiliac Joint Fusion (PDF)

Effective Date: 09/30/2016

Functional MRI (PDF)

Effective Date: 09/23/2009

Intensity-Modulated Radiotherapy (PDF)

Effective Date: 03/31/2014

Sclerotherapy for Varicose Veins (PDF)

Effective Date: 06/30/2017

Gastric Electrical Stimulation (PDF)

Effective Date: 07/30/2009

Intestinal and Multivisceral Transplant (PDF)

Effective Date: 02/28/2014

Sickle Cell Disease Observation (PDF)

Effective Date: 09/30/2013

Hyperemesis Gravidarum Treatment (PDF)

Effective Date: 03/31/2009

Laser Therapy for Skin Conditions (PDF)

Effective Date: 08/30/2016

Spinal Cord Stimulation (PDF)

Effective Date: 07/31/2016

Hyperhidrosis Treatments (PDF)

Effective Date: 05/16/2013

Long Term Care Placement Criteria (PDF)

Effective Date: 07/11/2018

Tandem Transplant (PDF)

Effective Date: 07/31/2018

Facet Joint Interventions for Pain Management (PDF)

Effective Date: 08/31/2018

Low-Frequency Ultrasound Therapy for Wound Management (PDF)

Effective Date: 02/28/2017

Testing for Select Genitourinary Conditions (PDF)

Effective Date: 06/15/2016

Caudal or Interlaminar Epidural Steroid Injections for Pain Management (PDF)

Effective Date: 08/31/2018

Lung Transplantation (PDF)

Effective Date: 02/28/2014

Thyroid Hormones and Insulin Testing in Pediatrics (PDF)

Effective Date: 12/29/2017

25-Hydroxyvitamin D Testing in Children and Adolescents (PDF)

Effective Date: 12/29/2017

Lysis of Epidural Lesions (PDF)

Effective Date: 07/31/2016

Total Artificial Heart (PDF)

Effective Date: 12/30/2016

ADHD Assessment and Treatment (PDF)

Effective Date: 12/31/2013

Measurement of Serum 1,25-dihydroxyvitamin D (PDF)

Effective Date: 12/29/2017

Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)

Effective Date: 05/31/2016

Allergy Testinng and Therapy (PDF)

Effective Date: 08/31/2016

Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)

Effective Date: 04/30/2017

Transcather Closer of Patent Foramen Ovale (PDF)

Effective Date: 12/29/2017

Ambulatory EEG (PDF)

Effective Date: 09/30/2015

Monitored Anesthesia Care for Gastrointestinal Endoscopy (PDF)

Effective Date: 05/31/2018

Ultrasound in Pregnancy (PDF)

Effective Date: 01/31/2011

Applied Behavioral Analysis for Autism (PDF)

Effective Date: 08/31/2019

Multiple Sleep Latency Testing (PDF)

Effective Date: 10/31/2008

Urinary Incontinence Devices and Treatments (PDF)

Effective Date: 04/30/2017

Ambulatory Surgery Center Optimization (PDF)

Effective Date: 02/16/2018

Neonatal Abstinence Syndrome Guidelines (PDF)

Effective Date: 10/30/2013

Urodynamic Testing (PDF)

Effective Date: 10/30/2015

Assisted Reproductive Technology (PDF)

Effective Date: 03/31/2014

Neonatal Sepsis Management (PDF)

Effective Date: 08/30/2013

Ventricular Assist Devices (PDF)

Effective Date: 12/31/2009

Balloon Sinus Ostial Dilation (PDF)

Effective Date: 07/29/2016

NICU Apnea Bradycardia Guidelines (PDF)

Effective Date: 06/30/2013

Wheelchair Seating (PDF)

Effective Date: 10/31/2015

Biofeedback (PDF)

Effective Date: 07/31/2017

NICU Discharge Guidelines (PDF)

Effective Date: 06/30/2013

Wireless Motility Capsule (PDF)

Effective Date: 04/30/2017

Bronchial Thermoplasty (PDF)

Effective Date: 05/31/2016

Non-myeloablative Allogeneic Stem Cell Transplants (PDF)

Effective Date: 04/28/2017

Zika Virus Testing (PDF)

Effective Date: 06/30/2016

Cardiac Biomarker Testing (PDF)

Effective Date: 12/29/2017

Optic Nerve Decompression Surgery (PDF)

Effective Date: 09/30/2016

Testing of Rupture of Fetal Membranes (PDF)

Effective Date: 08/30/2017

Carrier Screening in Pregnancy (PDF)

Effective Date: 07/31/2013

Pancreas Transplant (PDF)

Effective Date: 04/29/2016

 

Cell-Free Fetal DNA Testing (PDF)

Effective Date: 08/31/2013

Panniculectomy (PDF)

Effective Date: 04/30/2016

 

Cosmetic and Reconstructive Surgery (PDF)

Effective Date: 03/31/2009

Pediatric Heart Transplant (PDF)

Effective Date: 01/31/2017

 

Disc Decompression Procedures (PDF)

Effective Date: 07/31/2016

Pediatric Liver Transplant (PDF)

Effective Date: 04/30/2018

 

Discography (PDF)

Effective Date: 08/30/2016

Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)

Effective Date: 07/31/2017

 

DNA Analysis of Stool to Screen for Colorectal Cancer (PDF)

Effective Date: 09/30/2016

Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF)

Effective Date: 10/30/2016

 

Durable Medical Equipment (DME) (PDF)

Effective Date: 06/30/2009

Proton and Neutron Beam Therapy (PDF)

Effective Date: 03/31/2014

 

Electric Tumor Treating Fields (PDF)

Effective Date: 05/31/2017

 

 

Electroencephalography in the Evaluation of Headache (PDF)

Effective Date: 12/29/2017

 

 

EpiFix Wound Treatment (PDF)

Effective Date: 04/30/2017

   

Essure Removal (PDF)

Effective Date: 11/30/2016

   

Evoked Potential Testing (PDF)

Effective Date: 11/30/2016

   

Experimental Technologies (PDF)

Effective Date: 06/30/2009

   

Facet Joint Interventions for Pain Management (PDF)

Effective Date: 09/14/2018

   

Fecal Calprotectin Assay (PDF)

Effective Date: 11/30/2016

   

Fecal Incontinence Treatments (PDF)

Effective Date: 12/30/2016

   

Fertility Preservation (PDF)

Effective Date: 10/30/2016

   

Fetal Surgery in Utero for Prenatally Diagnosed Malformations (PDF)

Effective Date: 10/30/2016

   

Gender Reassignment Surgery (PDF)

Effective Date: 11/28/2014

   

Genetic Testing (PDF)

Effective Date: 11/30/2013

   

H. Pylori Serology Testing (PDF)

Effective Date: 12/29/2017

   

Heart-Lung Transplant (PDF)

Effective Date: 06/30/2017

   

Holter Monitors (PDF)

Effective Date: 08/30/2016

   

Home Birth (PDF)

Effective Date: 12/30/2016

   

Home Phototherapy for Neonatal Hyperbilirubiniemia (PDF)

Effective Date: 12/21/2017

   

Homocysteine Testing (PDF)

Effective Date: 08/30/2016

   

Hospice Services (PDF)

Effective Date: 07/31/2014

   
A-K L-Z

72 Hour Supply of Medication (PDF)

Effective Date: 06/01/2006


Lost, Stolen, Spilled or Broken Medications (PDF)

Effective Date: 04/01/2007

Appropriate Use and Safety Edits (PDF)

Appropriate Use and Safety Edits: Attachment A (PDF)

Effective Date: 05/01/2012


Medication Safety Policy (PDF)

Effective Date: 07/01/2017

Blocking Adjudication of Controlled Substance Prescriptions for Selected Prescribers (PDF)

Effective Date: 11/01/2001


Pharmaceutical Management (PDF)

Effective Date: 02/01/2003

Dose Escalation of Biologics (PDF)

Effective Date: 09/01/2017


Pharmacy and Therapeutics Committee (PDF)

Effective Date: 08/19/2011

Drug Recall Notification Process (PDF)

Effective Date: 07/01/2008


Pharmacy Prior Authorization and Medical Necessity Criteria (PDF)

Effective Date: 07/09/2010


Drug Utilization Review (PDF)

Effective Date: 04/01/2007

Progesterone (Crinone, Endometrin) (PDF)

Effective Date: 11/16/2016

Filgrastim (Neupogen, Zarxio) (PDF)

Effective Date: 11/16/2016

Somatropin (HGH) (PDF)

Effective Date: 11/16/2016

Filagrastim (Neupogen), Filagrastim-sndz (Zarxio), Tbo-filagrastim (Granix) (PDF)

Effective Date: 12/01/2016

Lumacaftor-Ivacaftor (Orkambi) (PDF)

Effective Date: 05/01/2016

Ibalizumab-uiyk (Trogarzo) (PDF)

Effective Date: 04/17/2018

Nusinersen (Spinraza®)(PDF)

Effective Date: 11/28/2017

Brentuximab Vedotin (Adcetris) (PDF)

Effective Date: 02/01/2017

Somatropin (Growth Hormone) (PDF)

Effective Date: 03/01/2011

Interferon Gamma- 1b (Actimmune) (PDF)

Effective Date: 06/01/2010

Step Therapy (PDF)

Effective Date: 08/01/2017

Bendamustine (Bendeka®, Treanda®) (PDF)

Effective Date: 02/01/2017

Riociguat (Adempas®) (PDF)

Effective Date: 03/01/2016

Belimumab (Benlysta) (PDF)

Effective Date: 10/01/2011

Tadalafil (Adcirca®) (PDF)

Effective Date: 03/01/2016

C1 Esterase Inhibitors (Berinert®, Cinryze®, Haegarda®) (PDF)

Effective Date: 03/01/2016

Tocilizumab (Actemra) (PDF)

Effective Date: 07/01/2016

Immune Globulins (PDF)

Effective Date: 08/01/2012

OnabotulinumtoxinA (Botox) (PDF)

Effective Date: 07/01/2016

Blinatumomab (Blincyto) (PDF)

Effective Date: 02/01/2017

Vandetanib (Caprelsa®) (PDF)

Effective Date: 10/01/2011

Ibandronate sodium (Boniva®) (PDF)

Effective Date: 11/15/2017

Reslizumab (Cinqair) (PDF)

Effective Date: 05/01/2016

Bosutinib (Bosulif) (PDF)

Effective Date: 10/01/2012

Tesamorelin (Egrifta) (PDF)

Effective Date: 03/01/2014

Cerliponase alfa (Brineura) (PDF)

Effective Date: 07/01/2017

Perampanel (Fycompa) (PDF)

Effective Date: 11/16/2016

Carglumic acid (Carbaglu®) (PDF)

Effective Date: 05/01/2016

Taliglucerase Alfa (Elelyso) (PDF)

Effective Date: 02/01/2016

Imiglucerase (Cerezyme) (PDF)

Effective Date: 02/01/2016

Pralatrexate (Folotyn®) (PDF)

Effective Date: 02/01/2017

Certolizumab (Cimzia) (PDF)

Effective Date: 08/01/2016

Teriparatide (Forteo®) (PDF)

Effective Date: 11/15/2017

Cabozantinib (Cometriq®, Cabometyx®) (PDF)

Effective Date: 06/01/2013

Levoleucovorin (Fusilev®) (PDF)

Effective Date: 11/09/2017

Glatiramer (Copaxone, Glatopa) (PDF)

Effective Date: 08/01/2016

Teduglutide (Gattex) (PDF)

Effective Date: 05/01/2013

Daratumumab (Darzalex) (PDF)

Effective Date: 07/01/2017

Obinutuzumab (Gazyva®) (PDF)

Effective Date: 02/01/2017

Desmopressin Acetate (DDAVP, Stimate, Noctiva) (PDF)

Effective Date: 05/01/2016

Trastuzumab (Herceptin), Trastuzumab-dkst (Ogivri) (PDF)

Effective Date: 06/01/2016

Deferoxamine (Desferal) (PDF)

Effective Date: 11/01/2015

Repository Corticotropin Injection (H.P. Acthar Gel) (PDF)

Effective Date: 03/01/2016

Dupilumab (Dupixent) (PDF)

Effective Date: 05/01/2017

Topotecan (Hycamtin)(PDF)

Effective Date: 06/01/2011

AbobotulinumtoxinA (Dysport) (PDF)

Effective Date: 07/01/2016

RimabotulinumtoxinB (Myobloc) (PDF)

Effective Date: 07/01/2016

Etanercept (Enbrel) (PDF)

Effective Date: 08/01/2016

Pegfilgrastim (Neulasta) (PDF)

Effective Date: 12/01/2016

Epoetin Alfa (Epogen® and Procrit) (PDF)

Effective Date: 06/01/2016

sorafenib (Nexavar) (PDF)

Effective Date: 07/01/2011

Cetuximab (Erbitux®) (PDF)

Effective Date: 02/01/2017

Mepolizumab (Nucala) (PDF)

Effective Date: 04/01/2016

Eteplirsen (PDF)

Effective Date: 12/01/2016

Obeticholic (Ocaliva) (PDF)

Effective Date: 11/01/2016

Deferasirox (Exjade Jadenu) (PDF)

Effective Date: 11/1/2015

Nivolumab (Opdivo) (PDF)

Effective Date: 07/01/2015

Aflibercept (Eylea®) (PDF)

Effective Date: 03/01/2016

Lumacaftor-ivacaftor (Orkambi) (PDF)

Effective Date: 05/01/2016

Agalsidase Beta (Fabrazyme) (PDF)

Effective Date: 02/01/2016

Pertuzumab (Perjeta) (PDF)

Effective Date: 06/01/2016

Deferiprone (Ferriprox) (PDF)

Effective Date: 11/01/2015

Peginterferon beta-1a (Plegridy) (PDF)

Effective Date: 08/01/2016

Degarelix acetate (Firmagon®) (PDF)

Effective Date: 11/09/2017

Pomalidomide (Pomalyst) (PDF)

Effective Date: 07/01/2013

Dalteparin (Fragmin) (PDF)

Effective Date: 05/01/2016

Necitumumab (Portrazza®) (PDF)

Effective Date: 03/01/2017

Enfuvirtide (Fuzeon) (PDF)

Effective Date: 06/01/2010

Palbociclib (Ibrance®) (PDF)

Effective Date: 10/01/2015

Fingolimod (Gilenya) (PDF)

Effective Date: 08/01/2016

Ponatinib (Iclusig) (PDF)

Effective Date: 06/01/2013

Alpha-1 Proteinase Inhibitors (Aralast® NP, Glassia®, Prolastin-C®, Zemaira®) (PDF)

Effective Date: 03/01/2012

Ibrutinib (Imbruvica) (PDF)

Effective Date: 10/01/2015

Imatinib (Gleevec) (PDF)

Effective Date: 06/01/2011

 

Eribulin Mesylate (Halaven®) (PDF)

Effective Date: 03/01/2017

 

Adalimumab (Humira) (PDF)

Effective Date: 08/01/2016

 

Hydroxyprogesterone Caproate (Makena®) (PDF)

Effective Date: 11/20/2017

 

Galsulfase (Naglazyme) (PDF)

Effective Date: 02/01/2016

 

Ixazomib (Ninlaro) (PDF)

Effective Date: 02/01/2017

 

belatacept (Nulojix®) (PDF)

Effective Date: 11/09/2017

 

abatacept (Orencia) (PDF)

Effective Date: 08/01/2016

 

irinotecan Liposome (Onivyde®) (PDF)

Effective Date: 02/01/2017

 

Apremilast (Otezla) (PDF)

Effective Date: 08/01/2016

 

Buprenorphine implant (Probuphine) (PDF)

Effective Date: 11/16/2016

 

Alirocumab (Praluent) (PDF)

Effective Date: 10/01/2015

 

Cysteamine oral (Cystagon, Procysbi) (PDF)

Effective Date: 02/01/2016

 

Denosumab (Prolia, Xgeva) (PDF)

Effective Date: 03/01/2011

 

Eltrombopag (Promacta®) (PDF)

Effective Date: 03/01/2016

 

Canakinumab (Ilaris) (PDF)

Effective Date: 08/01/2016

 

 

Payment Policies

Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding.  They are used to help identify whether health care services are correctly coded for reimbursement.  Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for  physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.

All policies found in the PA Health & Wellness Payment Policy Manual apply with respect to PA Health & Wellness members. Policies in the PA Health & Wellness Payment Policy Manual may have either a PA Health & Wellness or a “Centene” heading.  In addition, PA Health & Wellness may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by PA Health & Wellness.     

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

A-H I-Q R-Z

3 Day Payment Window (PDF)

Effective Date: 07/01/2014

Inpatient Only Procedures Policy (PDF)

Effective Date: 1/1/18

Reporting the Global Maternity Package (PDF)

Effective Date: 01/01/2013

30 Day Readmission (PDF)

Effective Date: 01/01/2015

IV Hydration Policy (PDF)

Effective Date: 01/01/2013


Robotic Surgeries (PDF)

Effective Date: 08/01/2017

Add On Policy (PDF)

Effective Date: 01/01/2013

Inpatient Consultation (PDF)

Effective Date: 01/01/2014

Same Day Visits (PDF)

Effective Date: 01/01/2014

Assistant Surgeon (PDF)

Effective Date: 01/01/2014

Moderate Conscious Sedation (PDF)

Effective Date: 01/01/2013

Status B Bundled Services (PDF)

Effective Date: 01/01/2014

Bilateral Procedures (PDF)

Effective Date: 01/01/2014

Max Units Payment Policy (PDF)

Effective Date: 01/01/2013

Status P Bundled Services (PDF)

Effective Date: 01/01/2014

Cerumen Removal Policy (PDF)

Effective Date: 01/01/2014

Modifier DOS Validation (PDF)

Effective Date: 01/01/2015

Supplies Same Day as Surgery (PDF)

Effective Date: 01/01/2013

Clean Claims Policy (PDF)

Effective Date: 01/01/2013

Multiple CPT Code Replace (PDF)

Effective Date: 01/01/2013

Transgender Related Services (PDF)

Effective Date: 01/01/2017

Clinical Laboratory Improvement Amendments (CLIA) (PDF)

Effective Date: 01/01/2016

Modifier to Procedure Code Validation (PDF)

Effective Date: 01/01/2013



Unbundled Professional Services (PDF)

Effective Date: 03/15/2017


Clinical Validation of Modifier 25 (PDF)

Effective Date: 01/01/2013

NCCI Unbundling (PDF)

Effective Date: 01/01/2013

Unbundled Surgical Procedures (PDF)

Effective Date: 03/15/2017

Clinical Validation of Modifier 59 (PDF)

Effective Date: 01/01/2013

New Patient (PDF)

Effective Date: 01/01/2014

Unlisted Procedure Codes Policy (PDF)

Effective Date: 01/01/2013

Code Editing Overview (PDF)

Effective Date: 01/01/2013

Never Paid Events (PDF)

Effective Date: 01/01/2013

Urine Specimen Validity Testing (PDF)

Effective Date: 10/01/2017

Cosmetic Procedures (PDF)

Effective Date: 01/01/2014

Outpatient Consultation (PDF)

Effective Date: 01/01/2014

Visual Field Testing (PDF)

Effective Date: 01/01/2017

Distinct Procedure Modifiers Policy (PDF)

Effective Date: 01/01/2013

Physician Visit Codes Billed with Labs (PDF)

Effective Date: 01/01/2013

Wheelchairs and Accessories (PDF)

Effective Date: 10/01/2015

Duplicate Primary Code Billing (PDF)

Effective Date: 01/01/2014


Physicians Consultation Services (PDF)

Effective Date: 10/01/2017

Ultrasound in Pregnancy (PDF)

Effective Date: 01/31/2011

EM Medical Decision Making (PDF)

Effective Date: 06/01/2017

Postoperative Visits (PDF)

Effective Date: 01/01/2014

 

E&M Bundling with Labs and Radiology (PDF)

Effective Date: 01/01/2013

Preoperative Visits (PDF)

Effective Date: 01/01/2014

 

Hospital Visit Codes Billed with Labs (PDF)

Effective Date: 01/01/2016

Problem Oriented Visits with Preventative Services (PDF)

Effective Date: 10/01/2017

 
 

Problem Oriented Visits with Surgical Procedures (PDF)

Effective Date: 10/01/2017

 
 

Professional Component Modifier (PDF)

Effective Date: 01/01/2013

 
 

Pulse Oximetry w Office Visits (PDF)

Effective Date: 01/01/2013

 
 

Place of Service Mismatch (PDF)

Effective Date: 09/01/2018

 
 

Non-obstectrical Pelvic and Transvaginal Ultrasounds (PDF)

Effective Date: 06/01/2018 

 
 

Not Medically Necessary Inpatient Service (PDF)

Effective Date: 06/01/2018