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 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 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 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.

View the current policies below:

Policy Name Policy Number Posted Archived Documents
Lab Benefit Management Program - Avalon  CPCPLABs  08/22/2022 View Archive
Observation Services Policy  CPCP001  07/12/2023 View Archive
Inpatient/Outpatient Unbundling Policy  CPCP002  01/14/2022 View Archive
Coordinated Home Care/Private Duty Nursing Policy  CPCP005  01/14/2022 View Archive
Preventive Services Policy  CPCP006  06/30/2023 View Archive
Psychological and Neuropsychological Testing  CPCP008  12/16/2022 View Archive
Co-Surgeon/Team Surgeon Modifiers  CPCP009  11/04/2021 View Archive
Anesthesia  CPCP010  03/30/2023 View Archive
Applied Behavior Analysis  CPCP011  06/12/2023 View Archive
Hernia Repair  CPCP012  05/17/2023 View Archive
Increased Procedural Services (Modifier 22)  CPCP013  05/17/2023 View Archive
Global Surgical Package - Professional Providers  CPCP014  06/26/2023 View Archive
Multiple Surgical Procedures  CPCP015  06/24/2022 View Archive
Chiropractic Care Services  CPCP016  03/28/2023 View Archive
Wasted/Discarded Drugs and Biologicals Guideline  CPCP017  02/13/2023 View Archive
Home Infusion  CPCP019  01/03/2023 View Archive
Drug Testing Clinical Payment and Coding Policy  CPCP020  03/30/2022 View Archive
Laboratory Panel Billing  CPCP021  06/26/2023 View Archive
Pneumatic Compression Devices – Outpatient Use  CPCP022  02/13/2023 View Archive
Modifier Reference Guideline  CPCP023  03/30/2023 View Archive
Evaluation and Management (E/M) Coding – Professional Provider Services  CPCP024  06/22/2023 View Archive
Corrected Claim Submissions  CPCP025  05/01/2020  
Therapeutic, Prophylactic and Diagnostic Injection and Infusion Coding V1  CPCP026  05/17/2023 View Archive
Inpatient Readmissions  CPCP027  07/05/2023 View Archive
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)  CPCP028  08/24/2023 View Archive
Medical Record Documentation Guidelines  CPCP029  09/16/2022 View Archive
Trauma Activation- Facility Services  CPCP031  07/12/2023 View Archive
Intraoperative Neurophysiology Monitoring (IONM) Coding and Reimbursement Guideline  CPCP032  04/28/2022 View Archive
Telemedicine and Telehealth Services CPCP033  04/28/2022 View Archive
Unbundling Policy-Professional Providers V1 CPCP034  05/17/2023 View Archive
Unlisted/Not Otherwise Classified (NOC) Coding Policy CPCP035  09/02/2022 View Archive
Paravertebral Facet Injection Procedure Coding & Billing Policy CPCP036  01/03/2023 View Archive
Outpatient Services Prior to an Inpatient Admission CPCP038  04/11/2023  
Outpatient Facility Service(s) Overlapping During an Inpatient Stay CPCP039  05/17/2023  
Physical Medicine and Rehabilitation Services CPCP040  03/28/2023 View Archive
Emergency Department Evaluation and Management (E/M) Services Coding - Professional Services CPCP042  07/25/2023

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