Clinical Payment and Coding Policies

Clinical payment and coding policies are based on criteria developed by specialized professional societies, national guidelines (e.g. Milliman Care Guidelines (MCG)) and the Centers for Medicare and Medicaid Services (CMS) Provider Reimbursement Manual. Additional sources are used and can be provided upon request. The clinical payment and coding guidelines are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.

In the event of a conflict between a Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. Plan documents include but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

In the event of a conflict between a Clinical Payment and Coding Policy and any provider contract pursuant to which a provider participates in and/or provides services to eligible member(s) and/or plans, the provider contract will govern.

For inactive Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) codes that have been replaced by a new code(s), the new code(s) is required to be submitted.

View the current policies below:

For Clinical Payment and Coding policy effective dates for in-network providers, please refer to the effective date listed on the policy. For out-of-network providers, the policy will be effective on the date the policy is posted to the provider website.

CPT copyright 2018 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Policy Name Policy NumberPostedEffective DateArchived Documents
Anesthesia Clinical Payment and Coding Information PDF Document CPCP010 10/26/2018 02/01/2019 View Archive
Applied Behavior Analysis for Autism Spectrum Disorders PDF Document CPCP011 05/28/2018 06/01/2018 N/A
Co-Surgeon/Team Surgeon Modifiers PDF Document CPCP009 10/15/2018 10/15/2018 View Archive
Chiropractic Services PDF Document CPCP016 08/14/2018 09/01/2018 N/A
Coordinated Home Care Policy PDF Document CPCP005 11/15/2018 02/15/2019 N/A
Evaluation and Management of Emergency Department Coding CPCP003 05/28/2018 06/01/2018 View Archive
Global Surgical Package PDF Document CPCP014 03/29/2018 06/28/2018 N/A
Hernia Repair PDF Document CPCP012 03/29/2018 06/28/2018 N/A
Implant Payment and Coding Policy PDF Document CPCP007 11/15/2018 11/15/2018 View Archive
Increased Procedural Services (Modifier 22) PDF Document CPCP013 03/29/2018 06/27/2018 N/A
Inpatient/Outpatient Unbundling Policy CPCP002 11/15/2018 11/15/2018 View Archive
Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy PDF Document CPCP004 05/28/2018 06/01/2018 View Archive
Observation Services Tool for Applying MCG Care Guidelines CPCP001 05/28/2018 09/01/2018 View Archive
Preventive Services Policy PDF Document CPCP006 07/26/2018 11/01/2018 View Archive
Psychological and Neuropsychological Testing PDF Document CPCP008 07/26/2018 08/01/2018 View Archive
Revenue Codes Requiring CPT or HCPCS Codes PDF Document CPCP018 07/26/2018 11/01/2018 N/A
Telemedicine and Telehealth Services TXCPCP01 11/01/2018 11/01/2018 View Archive
Wasted/Discarded Drugs and Biologicals Guideline CPCP017 07/11/2018 10/12/2018 N/A