Molinalogo

• Coding Policies

  PI Coding Policy General

  PI Coding Policy Diagnosis Code

  PI Coding Policy ICD-10 Specificity

  PI Coding Policy Lab Codes with Modifiers 59 and 91

  PI Coding Policy Modifier 26

  PI Coding Policy Modifier KK

  PI Coding Policy Modifier TC

  PI Coding Policy Packaged and conditionally packaged lab services

  PI Coding Policy Therapy Modifier

  PI Coding Policy NCCI PTP with Modifiers

  PI Code Coding Policy Add-On

  PI Coding Policy Ambulance Modifier

  PI Coding Policy Medically Unlikely Edits

  PI Coding Policy Decision for Surgery

  PI Coding Policy Lab Panel

  PI Coding Policy Image Guided Radiation Therapy

  PI Coding Policy Non-Invasive Prenatal Testing

  PI Coding Policy ICD-10 First Listed Diagnosis

  PI Coding Policy Excludes1 Note

• Payment Policies

  PI Payment Policy 01 Hospital Routine Supplies Services Reimbursement
  PI Payment Policy 26 Sepsis
  PI Payment Policy 29 Optum Pause and Pay
  PI Payment Policy 35 Breast Cancer Genetic Testing Tier 1 vs Tier 2
  PI Payment Policy 36 Hydrolyzed Enteral Formula Diagnosis
  PI Payment Policy 37 High-Level EM with Preventive Medicine
  PI Payment Policy 38 Critical Care Codes when Discharging Home from the ED
  PI Payment Policy 46 Split-Night Sleep Study
  PI Payment Policy 47 Psychotherapy Add-On with High Level EM
  PI Payment Policy 61 Unspecified Codes in an Inpatient Setting Policy

  Clinical Payment Policy G2002 Cervical Cancer Screening

  Clinical Payment Policy F2019 Flow Cytometry

  Clinical Payment Policy G2005 Vitamin D Testing
  

  Clinical Payment Policy G2006 Hemoglobin A1c
  

  Clinical Payment Policy G2007 Prostate Biopsies
  

  Clinical Payment Policy G2008 Prostate Specific Antigen PSA Testing
  

  Clinical Payment Policy G2009 Preventive Screening in Adults
  

  Clinical Payment Policy G2011 Diagnostic Testing of Iron Homeostasis and Metabolism
  

  Clinical Payment Policy G2013 Testosterone Testing
  

  Clinical Payment Policy G2014 Vitamin B12 and Methylmalonic Acid Testing
  

  Clinical Payment Policy G2022 ANA ENA Testing
  

  Clinical Payment Policy G2031 Allergen Testing
  

  Clinical Payment Policy G2036 Hepatitis C
  

  Clinical Payment Policy G2042 Pediatric Preventive Screening
  

  Clinical Payment Policy G2043 Celiac Disease Testing
  

  Clinical Payment Policy G2044 Helicobacter pylori Testing
  

  Clinical Payment Policy G2045 Thyroid Disease Testing
  

  Clinical Payment Policy G2048 Biochemical Markers of Alzheimer Disease and Dementia
  

  Clinical Payment Policy G2050 Cardiovascular Disease Risk Assessment
  

  Clinical Payment Policy G2051 Bone Turnover Markers Testing
  

  Clinical Payment Policy G2056 Diagnosis of Idiopathic Environmental Intolerance
  

  Clinical Payment Policy G2059 Epithelial Cell Cytology In Breast Cancer Risk Assessment
  

  Clinical Payment Policy G2060 Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing
  

  Clinical Payment Policy G2061 Fecal Calprotectin Testing in Adults
  

  Clinical Payment Policy G2063 Testing for Diagnosis of Active or Latent Tuberculosis
  

  Clinical Payment Policy G2098 Immune Cell Function Assay
  

  Clinical Payment Policy G2099 Intracellular Micronutrient Analysis
  

  Clinical Payment Policy G2100 In Vitro Chemoresistance and Chemosensitivity Assays
  

  Clinical Payment Policy G2105 Immunopharmacologic Monitoring of Therapeutic Serum Antibodies
  

  Clinical Payment Policy G2107 Measurement of Thromboxane Metabolites for ASA Resistance
  

  Clinical Payment Policy G2110 Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
  

  Clinical Payment Policy G2113 Oral Screening Lesion Identification Systems and Genetic Screening
  

  Clinical Payment Policy G2115 Metabolite Markers of Thiopurines Testing
  

  Clinical Payment Policy G2119 Diagnostic Testing of Influenza
  

  Clinical Payment Policy G2120 Salivary Hormone Testing
  

  Clinical Payment Policy G2121 Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease
  

  Clinical Payment Policy G2123 Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases
  

  Clinical Payment Policy G2124 Serum Tumor Markers for Malignancies
  

  Clinical Payment Policy G2125 Urinary Tumor Markers For Bladder Cancer
  

  Clinical Payment Policy G2127 Vectra DA Blood Test for Rheumatoid Arthritis
  

  Clinical Payment Policy G2130 ST2 Assay for Chronic Heart Failure
  

  Clinical Payment Policy G2132 Erectile Dysfunction
  

  Clinical Payment Policy G2133 ZIKA Virus Risk Assessment
  

  Clinical Payment Policy G2138 Evaluation of Dry Eyes
  

  Clinical Payment Policy G2143 Lyme Disease
  

  Clinical Payment Policy G2149 Pathogen Panel Testing
  

  Clinical Payment Policy G2150 Cardiac Biomarkers for Myocardial Infarction
  

  Clinical Payment Policy G2153 Pancreatic Enzyme Testing for Acute Pancreatitis
  

  Clinical Payment Policy G2154 Folate Testing
  

  Clinical Payment Policy G2155 General Inflammation Testing
  

  Clinical Payment Policy G2156 Urine Culture Testing For Bacteria
  

  Clinical Payment Policy G2157 Diagnostic Testing of Common Sexually Transmitted Infections
  

  Clinical Payment Policy G2158 Testing for Mosquito- or Tick-Related Infections
  

  Clinical Payment Policy G2159 BHemolytic Streptococcus Testing
  

  Clinical Payment Policy G2164 Parathyroid Hormone Phosphorus Calcium and Magnesium Testing
  

  Clinical Payment Policy G2173 Gamma-Glutamyl Transferase
  

  Clinical Payment Policy M2041 Venous and Arterial Thrombosis Risk Testing
  

  Clinical Payment Policy M2057 Diagnosis of Vaginitis Including Multi Target PCR Testing
  

  Clinical Payment Policy M2058 Genetic Testing for Adolescent Idiopathic Scoliosis
  

  Clinical Payment Policy M2068 Testing for Alpha 1 Antitrypsin Deficiency
  

  Clinical Payment Policy M2091 Transplant Rejection Testing
  

  Clinical Payment Policy M2093 HIV Genotyping and Phenotyping
  

  Clinical Payment Policy M2097 Identification Of Microorganisms Using Nucleic Acid Probes
  

  Clinical Payment Policy M2112 Nerve Fiber Density Testing
  

  Clinical Payment Policy M2116 Plasma HIV1 and HIV2 RNA Quantification for HIV Infection
  

  Clinical Payment Policy M2136 DNA Ploidy Cell Cycle Analysis
  

   

  Clinical Payment Policy M2172 Onychomycosis Testing
  

   

  Clinical Payment Policy P2018 Immunohistochemistry
  

   

  Clinical Payment Policy R2162 Laboratory Procedures Reimbursement Policy

• Reimbursement Policies

  Molina Healthcare Billing Requirements
  Post Pay General Policy
  Reimbursement Policy for Corrected Claims
  Reimbursement Policy for Co-Surgeon Team-Surgeon
  Reimbursement Policy for Duplicate Claims
  Reimbursement Policy for Facility Emergency Department Evaluation and Management Leveling
  Reimbursement Policy for Fee Schedule
  Reimbursement Policy for Global Surgical Packages
  Reimbursement Policy for Inpatient services billed on Outpatient bill types
  Reimbursement Policy for NDC
  Reimbursement Policy for Post-Pay Authorization Audit
  Reimbursement Policy for Readmission
  Reimbursement Policy for Tendon Injections Missing Diagnosis

   

Payment Integrity Policy Disclaimer

The intended audience of these Payment Integrity Policies is healthcare providers who treat Molina members. These policies are not intended to address every aspect of a reimbursement situation, nor is it intended to impact care decisions. These policies were developed using nationally accepted industry standards and coding principles. In the event of a conflict, federal and state guidelines, as well as the member’s benefit plan document always supersede the information in a payment policy. Additionally, to the extent there are any conflicts between the payment policy and the provider contract language, the provider contract language will prevail. Coverage may be mandated by applicable legal requirements of a State, the Federal government or the Centers for Medicare and Medicaid Services (CMS). References included were accurate at the time of policy approval. These policies are subject to change or termination by Molina. Not all payment policies are posted.