New Claims Editing Rules To Be Implemented in July 2026

Intensity Modulated Radiation Therapy

This rule identifies intensity modulated radiation therapy procedure codes submitted on an outpatient facility or professional claim when planning procedure code 77301 is found within 30 days before or on the same date of service for the same provider.

This rule is appropriate for professional and outpatient facility claims.

Sexually Transmitted Infection Multi-Code Rebundle

This rule identifies codes billed for the same member for the same date of service for rebundling to a more comprehensive code:

• When any two or more Current Procedural Terminology (CPT^®) test codes (87491, 87591 and/or 87661) are billed separately for the same member, provider and the same date of service, the payment policy recommendation would be based on the rate for 87801, which is the more comprehensive code for multiple organisms.

• If the comprehensive procedure code (87801) has been billed by the same provider for the same date of service, then the separate single test codes (87491, 87591 and/or 87661) are disallowed.

This rule is appropriate for professional and outpatient facility claims. 

J9299 - Nivolumab (Opdivo)

This rule identifies claims billed with J9299 and limits a maximum of 480 units every four weeks.

This rule is appropriate for professional and outpatient facility claims. 

Colonoscopy Injections

This rule recommends denying claim lines when injection code 45381 is billed in conjunction with biopsy or polypectomy procedures (45383–45385, 45388 or G6024). The injection is considered incidental to the primary procedure.  

This rule is appropriate for professional and outpatient facility claims. 

Hospital Discharge 

This rule recommends denying claim lines for a hospital or observation discharge code when it is billed on the same date of service as an initial hospital or observation care code.  

This rule is appropriate for professional claims. 

Symptom Diagnosis Sequencing

This rule identifies when a symptom diagnosis is sequenced before a definitive diagnosis. The symptom and definitive diagnoses will be grouped. When the symptom diagnosis is sequenced before a definitive diagnosis and they are part of the same group, the rule will regroup them.

This rule is appropriate for professional and outpatient facility claims. 

Treatment Room with Evaluation/Management Service

This rule will deny an evaluation and management service when the member has a bill for a treatment room on the same date of service.

This rule is appropriate for outpatient facility claims. 

Administrative Diagnosis Primary

This rule recommends the denial of claims that list an administrative diagnosis code in the primary diagnosis position.

This rule is appropriate for all claim types.

Social Determinants of Health

This rule recommends the denial of the line when a social determinant of health diagnosis is billed as the primary diagnosis.

This rule is appropriate for professional and facility claims.

Psoriasis Laser Treatment

This rule identifies claims that include laser treatment codes for psoriasis (96920–96922) when there is no corresponding diagnosis of psoriasis reported on the claim.

This rule is appropriate for professional claims. 

End Stage Renal Disease – In-home setting

This rule identifies a professional claim billed with a home ESRD procedure code when submitted with an inappropriate place of service.

This rule is appropriate for professional claims. 

Anesthesia No Medical Direction Modifier

This rule identifies a claim line when any anesthesia service is billed without an appropriate anesthesia modifier.

This rule is appropriate for professional claims.

Missing Modifier 54

This rule identifies claim lines that should have a reduction in payment for surgical services provided in an emergency room where the follow-up care is not provided by the physician, and modifier 54 was not billed.

This rule identifies surgical procedures with a 10 or 90-day global period submitted without modifier 54 and recommends denying and adding a new line with the same procedure appended with modifier 54.

This rule is appropriate for professional claims.

Durable Medical Equipment Place of Service

This rule identifies a claim line when medical supplies, surgical supplies or DME are billed by professional providers in an inpatient or facility place of service.

This rule is appropriate for professional claims.

Bilateral Modifier

This rule identifies a claim line when it contains modifier 50 and one of either side modifiers RT or LT.

This rule is appropriate for professional and outpatient facility claims. 

Hospital Inpatient Place of Service

This rule identifies a claim line when billed with a hospital inpatient and observation care service E/M with an inappropriate place of service.

This rule is appropriate for professional claims.

Trauma Activation Services

This rule identifies a claim line on a facility claim when billed with a trauma activation fee, if the member did not receive initial critical care services.

This rule is appropriate for outpatient facility claims. 

Professional Codes with Facility Place of Service (PC/TC)

This rule identifies procedure codes billed with modifier PC/TC with an indicator of 3 when reported by a provider on a professional claim with a facility place of service.

This rule is appropriate for professional claims. 

Emergency Room Evaluation/Management Place of Service

This rule identifies a claim line when billed with an emergency department service E/M with an inappropriate place of service.

This rule is appropriate for professional claims.