Payment Integrity Policies

Policy Number Policy Name Effective Date Link
C13 ADD-ON Code 11/01/2020 View Policy
PI99 Advance Beneficiary Notice (ABN) Modifiers GA, GX, GY and GZ 1/4/2024 View Policy
PI54 After Hours and Weekend Care Professional 8/1/2023 View Policy
PI111 Allergy Test 01/04/2023 View Policy
C14 Ambulance Modifier Coding Policy 11/01/2020 View Policy
PI120 Ambulatory Echocardiograph Monitoring 01/04/2024 View Policy
PI108 Anesthesia Bundling 01/04/2023 View Policy
PI121 Annual Wellness Visit sooner than eleven whole months following Initial (IPPE) 01/04/2023 View Policy
PI122 Aortography and Peripheral Angiography 01/04/2023 View Policy
PI34 Appropriate Level of Care Reimbursement 01/07/2022 View Policy
PI119 Autonomic Function Testing 01/04/2023 View Policy
Policy Number Policy Name Effective Date Link
PI102 BRCA1 and BRCA2 Genetic Testing 01/04/2023 View Policy
PI35 Breast Cancer Genetic Testing Tier 1 vs Tier 2 01/04/2023 View Policy
Policy Number Policy Name Effective Date Link
PI97 CMS Replacement Codes 09/11/2023 View Policy
PI98 Colonoscopy and Sigmoidoscopy 09/11/2023 View Policy
PI42 Corrected Claims 10/21/2022 View Policy
PI53 Co-Surgeon_Team-Surgeon 09/01/2023 View Policy
PI38 Critical Care Codes when Discharging Home from the Emergency Department 08/04/2022 View Policy
PI93 CT (Computed Tomography) of the Abdomen and Pelvis 09/11/2023 View Policy
Policy Number Policy Name Effective Date Link
C16 Decision for Surgery Modifier 57 Coding Policy 11/01/2020 View Policy
PI59 Discontinued Procedures 04/06/2023 View Policy
PI65 DME KF Modifier 08/01/2023 View Policy
PI73 DME Non-Invasive Ventilator Settings 06/21/2023 View Policy
PI90 DME Place of Service 31 or 32 09/11/2023 View Policy
PI123 DME Place of Service separately reimbursable 09/11/2023 View Policy
PI124 DME Rental Vs Purchase 12/01/2023 View Policy
PI25 DRG Clinical Validation 01/07/2022 View Policy
PI45 Duplicate Claims 11/01/2022 View Policy
Policy Number Policy Name Effective Date Link
CXX Emergency E&M Codes and Place of Service 23 Coming Soon Coming Soon
CXX ESRD Billing for J0406 or J0606 with Modifier AX Coming Soon Coming Soon
C24 Excludes1 Note Coding Policy 11/01/2020 View Policy
Policy Number Policy Name Effective Date Link
PI39 Facility Emergency Department Evaluation and Management leveling 08/15/2022 View Policy
PI80 Fee Schedule 09/01/2023 View Policy
Policy Number Policy Name Effective Date Link
C0 General Coding Policy 11/01/2020 View Policy
PI51 Global Surgical Packages 09/01/2023 View Policy
Policy Number Policy Name Effective Date Link
PI56 High Dollar Pharmacy 08/01/2023 View Policy
PI37 High Level Evalution and Managment with Preventive Medicine 10/18/2022 View Policy
CXX Hospice Value Code 61 Coming Soon Coming Soon
PI70 Hospice 01/01/2023 View Policy
PI01 Hospital Routine Supplies Services 12/01/2017 View Policy
PI36 Hydrolyzed Enteral Formula Diagnosis 01/01/2023 View Policy
Policy Number Policy Name Effective Date Link
C20 ICD-10 First Listed Diagnosis Coding Policy 11/01/2020 View Policy
C3 ICD-10 Specificity Coding Policy 11/01/2020 View Policy
C18 Image Guided Radiation Therapy Coding Policy 11/01/2020 View Policy
PI77 Injection and Infusions in the ER with 25 Modifier 09/01/2023 View Policy
PI71 Inpatient services billed on Outpatient bill types 09/01/2023 View Policy
PI125 Interim Hospital Claims 01/02/2024 View Policy
Policy Number Policy Name Effective Date Link
Policy Number Policy Name Effective Date Link
Policy Number Policy Name Effective Date Link
C4 Lab Codes with Modifiers 59 and 91 Coding Policy 11/01/2020 View Policy
C17 Lab Panel Coding Policy 11/01/2020 View Policy
PI101 Labs Overlapping with Facility 09/25/2023 View Policy
Policy Number Policy Name Effective Date Link
PI126 Medical Supplies Home Health Consolidated Billing 01/02/2024/td> View Policy
C15 Medically Unlikely Edits Coding Policy 11/01/2020 View Policy
Cxx Modifer 25 Coding Policy coming soon/td> coming soon
C5 Modifer 26 Coding Policy 11/01/2020 View Policy
C6 Modifier KK Coding Policy 11/01/2020 View Policy
C7 Modifier TC Coding Policy 11/01/2020 View Policy
PI131 Modifiers XE XS XP XU and 59 Usage 01/02/2024/td> View Policy
PI94 Molecular Pathology 09/25/2023 View Policy
PI118 Molina Healthcare Audit.Recovery Policy for Diagnosis Codes 01/02/2024/td> View Policy
PI115 Molina Healthcare: Audit/Recovery Policy for Revenue to CPT Code Review 01/02/2024/td> View Policy
PI113 Molina Healthcare Audit/Recovery Policy: Variable Discount Payments for Providers 01/02/2024 View Policy
PI116 Molina Healthcare Audit Recovery Policy for Billed Units 01/02/2024 View Policy
PI117 Molina Healthcare Audit.Recovery Policy for CPT to CPT Code 01/02/2024/td> View Policy
PI66 Molina Healthcare Billing Requirements 06/01/2023 View Policy
PI112 Molina Healthcare Cross-Departmental Audit and Recovery Policy 01/02/2024/td> View Policy
PI67 Multiple EM codes for the same provider same date of service 09/01/2023 View Policy
PI127 Multiple Procedure Payment Reduction 01/02/2024 View Policy
Policy Number Policy Name Effective Date Link
C12 NCCI PTP with Modifiers Coding Policy 11/01/2020 View Policy
PI44 NDC 11/01/2022 View Policy
PI32 Newborn and NICU 01/07/2022 View Policy
PI83 Non-Invasive Abdominal/Visceral Vascular Studies 09/25/2023 View Policy
C19 Non-Invasive Prenatal Testing Coding Policy 11/01/2020 View Policy
PI128 NPFS Status Indicator T 01/02/2024 View Policy
Policy Number Policy Name Effective Date Link
PI50 Observation 06/01/2023 View Policy
PI110 Opioid Treatment Service 01/02/2024 View Policy
PIXX Optum Pause and Pay/td> coming soon Coming Soon
PI33 Outpatient Definitive Drug Testing 09/01/2021 View Policy
PI84 Overlapping Room and Board 09/25/2023 View Policy
Policy Number Policy Name Effective Date Link
C10 Packaged and conditionally packaged lab services Coding Policy 11/01/2020 View Policy
PI129 Paid Amount Exceeded Billed Amount 1/02/2024 View Policy
PI130 Physical Therapy Max Units Per Day 1/02/2024 View Policy
PI106 Physician Office Laboratory Testing 10/18/2022 View Policy
PI172 Podiatric Q Modifiers 09/25/2023/td> View Policy
PI104 Polysomnography Studies and Home Sleep Testing 09/25/2023 View Policy
PI48 Post-Pay Authorization Audit 06/01/2023 View Policy
PI00 Post Pay General Policy 06/01/2023 View Policy
PI96 Presumptive and Definitive Drug Testing Limitation 09/25/2023 View Policy
PI47 Psychotherapy Add On with High Level EM 10/18/2022 View Policy
PI105 PT/OT Initial Evaluations 09/25/2023 View Policy
PI87 PT/OT/ST Yearly Limit 09/25/2023 View Policy
PI68 Pulmonary Function Testing 09/25/2023 View Policy
Policy Number Policy Name Effective Date Link
Policy Number Policy Name Effective Date Link
PI88 Radiology Bone Density 09/25/2023 View Policy
PI95 Radiology for Chest 09/25/2023 View Policy
PI41 Readmission 06/01/2023 View Policy
PI60 Reduced Services and Discontinued Procedures 07/10/2023 View Policy
PIXX Repeat Procedure Modifiers 76 & 77. Coming Soon Coming Soon
PI103 Respiratory Pathogen Panel Test 09/25/2023 View Policy
Policy Number Policy Name Effective Date Link
PI91 Self-Administered Drugs 01/07/2022 View Policy
PI57 Semiprivate Vs Private Room 09/25/2023 View Policy
PI26 Sepsis 01/07/2022 View Policy
PI99 Specimen Validity Testing 09/25/2023 View Policy
PI46 Split-Night-Sleep-Study 10/18/2022 View Policy
PI92 Status Indicator Flag B Bundled Codes 09/25/2023 View Policy
PI89 STI Lab Panel Testing 09/25/2023 View Policy
Policy Number Policy Name Effective Date Link
PI82 Tendon Injections Missing Diagnosis 09/01/2023 View Policy
C10 Therapy Modifier Coding Policy 11/01/2020 View Policy
Policy Number Policy Name Effective Date Link
PI61 Unspecified Codes in an Inpatient Setting Policy 04/01/2022 View Policy
Policy Number Policy Name Effective Date Link
Policy Number Policy Name Effective Date Link
Policy Number Policy Name Effective Date Link
Policy Number Policy Name Effective Date Link
Policy Number Policy Name Effective Date Link