Payment Integrity Policies

Policy Number Policy Name Effective Date Service Area Policy Type Link
13 ADD-ON Code 11/01/2020 Outpatient Coding Payment Policy View Policy
14 Ambulance Modifier Coding Payment Policy 11/01/2020 Professional Coding Payment Policy View Policy
34 Appropriate Level of Care Reimbursement 01/07/2022 Outpatient/Inpatient Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
35 Breast Cancer Genetic Testing Tier 1 vs Tier 2 01/04/2023 Professional Labs Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
98 Colonoscopy and Sigmoidoscopy 09/11/2023 Professional Labs/Inpatient/Outpatient Clinical Payment Policy View Policy
42 Corrected Claims 10/21/2022 Professional Labs/Inpatient/Outpatient Payment Policy View Policy
53 Co-Surgeon_Team-Surgeon 09/01/2023 Professional Coding Payment Policy View Policy
38 Critical Care Codes when Discharging Home from the Emergency Department 08/04/2022 Professional Clinical Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
16 Decision for Surgery Modifier 57 Coding Payment Policy 11/01/2020 Professional Clinical Payment Policy View Policy
2 Diagnosis Code Coding Payment Policy 11/01/2020 Professional Coding Payment Policy View Policy
59 Discontinued Procedures 04/06/2023 Professional Labs/Inpatient/Outpatient Coding Payment Policy View Policy
65 DME KF Modifier 08/01/2023 DME Professional Services Coding Payment Policy View Policy
25 DRG Clinical Validation 01/07/2022 Inpatient Payment Policy View Policy
45 Duplicate Claims 11/01/2022 Professional Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
24 Excludes1 Note Coding Payment Policy 11/01/2020 Professional Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
39 Facility Emergency Department Evaluation and Management leveling 08/15/2022 Facility Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
0 General Coding Payment Policy 11/01/2020 Professional Coding Payment Policy View Policy
51 Global Surgical Packages 09/01/2023 Professional Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
56 High Dollar Pharmacy 08/01/2023 Pharmacy Payment Policy View Policy
37 High Level Evalution and Managment with Preventive Medicine 10/18/2022 Professional Coding Payment Policy View Policy
01 Hospital Routine Supplies Services 12/01/2017 Inpatient Payment Policy View Policy
36 Hydrolyzed Enteral Formula Diagnosis 01/01/2023 Professional Clinical Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
20 ICD-10 First Listed Diagnosis Coding Payment Policy 11/01/2020 Professional Coding Payment Policy View Policy
3 ICD-10 Specificity Coding Payment Policy 11/01/2020 Professional Coding Payment Policy View Policy
18 Image Guided Radiation Therapy Coding Payment Policy 11/01/2020 Professional Clinical Payment Policy View Policy
77 Injection and Infusions in the ER with 25 Modifier 09/01/2023 Outpatient Coding Payment Policy View Policy
71 Inpatient services billed on Outpatient bill types 09/01/2023 Outpatient Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
Policy Number Policy Name Effective Date Service Area Policy Type Link
Policy Number Policy Name Effective Date Service Area Policy Type Link
4 Lab Codes with Modifiers 59 and 91 Coding Payment Policy 11/01/2020 Modifier, Professional Coding Payment Policy View Policy
17 Lab Panel Coding Payment Policy 11/01/2020 Labs Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
15 Medically Unlikely Edits Coding Payment Policy 11/01/2020 Professional Outpatient Coding Payment Policy View Policy
5 Modifer 26 Coding Payment Policy 11/01/2020 Modifier, Professional Coding Payment Policy View Policy
6 Modifier KK Coding Payment Policy 11/01/2020 Modifier, Professional Coding Payment Policy View Policy
7 Modifier TC Coding Payment Policy 11/01/2020 Modifier, Professional Coding Payment Policy View Policy
66 Molina Healthcare Billing Requirements 06/01/2023 Professional Payment Policy View Policy
67 Multiple EM codes for the same provider same date of service 09/01/2023 Professional Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
12 NCCI PTP with Modifiers Coding Payment Policy 11/01/2020 Modifier, Professional Coding Payment Policy View Policy
19 Non-Invasive Prenatal Testing Coding Payment Policy 11/01/2020 Professional Clinical Payment Policy View Policy
44 NDC 11/01/2022 Professional Outpatient Coding Payment Policy View Policy
32 Newborn and NICU 01/07/2022 Inpatient Payment Policy View Policy
83 Non-Invasive Abdominal/Visceral Vascular Studies 09/25/2023 Professional Clinical Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
50 Observation 06/01/2023 Professional Outpatient Clinical Payment Policy View Policy
33 Outpatient Definitive Drug Testing 09/01/2021 Outpatient Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
10 Packaged and conditionally packaged lab services Coding Payment Policy 11/01/2020 Outpatient Payment Policy View Policy
106 Physician Office Laboratory Testing 10/18/2022 Labs Coding Payment Policy View Policy
00 Post Pay General Policy 06/01/2023 Professional Payment Policy View Policy
48 Post-Pay Authorization Audit 06/01/2023 Professional Labs/Inpatient/Outpatient Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
Policy Number Policy Name Effective Date Service Area Policy Type Link
41 Readmission 06/01/2023 Inpatient Payment Policy View Policy
60 Reduced Services and Discontinued Procedures 07/10/2023 Professional Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
26 Sepsis 01/07/2022 Inpatient Coding Payment Policy View Policy
46 Split-Night-Sleep-Study 10/18/2022 Professional Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
Policy Number Policy Name Effective Date Service Area Policy Type Link
61 Unspecified Codes in an Inpatient Setting Policy 04/01/2022 Inpatient Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
Policy Number Policy Name Effective Date Service Area Policy Type Link
Policy Number Policy Name Effective Date Service Area Policy Type Link
Policy Number Policy Name Effective Date Link
Policy Number Policy Name Effective Date Service Area Policy Type Link

For Medicare and Marketplace Policies Please visit

Medicare and Marketplace Payment Integrity Policies