New and Updated Reimbursement Policies

RECENTLY UPDATED

May 1 (Effective September 1):

RP-037 Emergency Evaluation and Management Coding Guidelines
An updated version of this policy with more detailed direction on the analyzing of code levels is available for review on the PRC, but it will not be effective until September 1, 2023. (For more information, click to read the Special Bulletin. )

May 8

RP-024 Eye Procedures Done in Stages or Sessions
This policy was reviewed as part of our standard review process. No changes in direction were made.

May 15

RP-028 Insertion and Removal of Tympanic Ventilation Tubes
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-029 Surgical Techniques, Procedures and Related Services
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-031 Fractures and Dislocations
This policy was reviewed as part of our standard review process. No changes in direction were made.

UPCOMING

May 29

Updates to these RPs will become effective on May 29, 2023, but have been published to the PRC early due to the Memorial Day holiday.

RP-003 Convenience Kits, Drug and Biological Wastage
Direction for modifier JZ and skin substitute wastage has been added. The name of the policy was changed, having formerly been Drug Wastage and Convenience Kits.

RP-026 Portable Radiography and ECG Services
A “Related Highmark Policies” section was added.

RP-041 Services Not Separately Reimbursed
Codes 38204, 90889, 92605, 92606, 92618, 93740, and R0076 were added for Commercial products. These codes will be considered not separately reimbursed and rejected as non-billable to the member.

RP-048 Independent Diagnostic Testing Facility (IDTF)
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-050 Inpatient Readmissions
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-051 Multiple Procedure Payment Reduction for Therapy Services
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-057 Evaluation & Management Services
The policy was updated to align with recent changes to Centers for Medicare and Medicaid Services (CMS) guidance for selecting the level of a reported Evaluation and Management (E/M) service and the eligibility for E/M reimbursement based on the fulfillment of the required criteria. As of January 1, 2023, all Evaluation and Management services are now selected and scored based on medical decision-making (MDM) or time.

RP-064 Government Supplied Vaccinations and Antibody Treatments
Direction was updated for the following codes that had the emergency use authorization rescinded: 0001A – 0004A, 0011A, 0012A, 0013A, 0051A, 0052A – 0054A, 0064A, 0071A – 0074A, 0081A – 0083A, 0091A – 0094A, 0111A – 0113A, 91300, 91301, 91305 – 91309, and 99311.

Codes 0121A, 0141A, 0142A, 0151A, 0171A, and 0172A were added.

REMINDER: RP-075 Appropriate Use Criteria for Advanced Diagnostic Imaging
This new policy — which was made available for review on the PRC on February 27, 2023 (click to read the Special Bulletin ) — is now in effect. Highmark created RP-075 to provide direction to practitioners on how to successfully increase the rate of advanced diagnostic imaging services based on Appropriate Use Criteria. This policy follows CMS’ current suggested direction. CMS has not indicated when, or if, this direction will become mandatory. Providers are encouraged to follow the direction in this policy, but it is not mandatory.

June 5

RP-042 Global Surgery and Subsequent Services
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-043 Care Management
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-045 Purchased Services
This policy is being updated to clarify pass-through billing direction for independent laboratories. A provider may not report a professional service that is performed by another entity.

June 12

RP-055 Nominal Charges
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-056 Delivery Payment Equivalency
This policy was reviewed as part of our standard review process. No changes in direction were made.

July 10

RP-015 Professional and Technical Components for Applicable Services
The Public Health Emergency (PHE) exception note will be removed. Codes 99000 and 99001 will return to pre-PHE policy direction. (The PHE ended on May 11, 2023.)

RP-016 Physician Laboratory and Pathology Services
The PHE exception note will be removed. Codes 99000 and 99001 will return to pre-PHE policy direction. (The PHE ended on May 11, 2023.)

RP-027 Hemodialysis and Peritoneal Dialysis
Policy exception notes pertaining to the PHE — which ended on May 11, 2023 — will be removed. A definitions section will be added.

RP-041 Services Not Separately Reimbursed
PHE exception notes and end-dated codes G2023, G2024, and U0005 will be removed. Codes 99000, 99001, 90887, 99024, 99374, 99377, 99378, 99379, 99380, and 99483 will return to pre-PHE direction. (The PHE ended on May 11, 2023.)

RP-054 Ambulance Services
The PHE exception note for destination requirements will be removed. (The PHE ended on May 11, 2023.)

August 31 (Effective September 1):

RP-019N Drugs and Biologicals
An updated version of this policy will be available for review on the PRC on August 31, 2023, and will be effective beginning September 1, 2023. Drug tiering is being eliminated for Delaware, Pennsylvania, and West Virginia. To access this reimbursement policy, log into NaviNet^® and select Resource Center from the left menu. Once redirected to the PRC, select CLAIMS, PAYMENT & REIMBURSEMENT in the left menu and then click Reimbursement Policy.