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  2/14/2022 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  07/01/2022 View Archive
Psychological and Neuropsychological Testing  CPCP008  04/05/2021 View Archive
Co-Surgeon/Team Surgeon Modifiers  CPCP009  11/04/2021 View Archive
Anesthesia  CPCP010  10/19/2021 View Archive
Applied Behavior Analysis  CPCP011  12/18/2020 View Archive
Hernia Repair  CPCP012 04/28/2022 View Archive
Increased Procedural Services (Modifier 22)  CPCP013  02/24/2022  
Global Surgical Package - Professional Providers  CPCP014 08/02/2022 View Archive
Multiple Surgical Procedures  CPCP015  06/24/2022 View Archive
Chiropractic Care Services  CPCP016  01/14/2022 View Archive
Wasted/Discarded Drugs and Biologicals Guideline  CPCP017  01/14/2021 View Archive
Home Infusion  CPCP019  07/09/2020 View Archive
Drug Testing Clinical Payment and Coding Policy  CPCP020  01/14/2022 View Archive
Laboratory Panel Billing  CPCP021  04/06/2022 View Archive
Pneumatic Compression Devices – Outpatient Use  CPCP022  01/14/2022 View Archive
Modifier Reference Guideline  CPCP023  05/31/2022 View Archive
Evaluation and Management (E/M) Coding – Professional Provider Services  CPCP024  12/29/2020  
Corrected Claim Submissions  CPCP025  05/01/2020  
Therapeutic, Prophylactic and Diagnostic Injection and Infusion Coding V3  CPCP026  10/05/2021  
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) V2   CPCP028  03/30/2022 View Archive
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) V3 (Effective 08/01/2022)  CPCP028 04/28/2022 View Archive
Medical Record Documentation Guidelines  CPCP029  10/05/2021 View Archive
Trauma Activation- Facility Services  CPCP031 02/24/2022 View Archive
Intraoperative Neurophysiology Monitoring (IONM) Coding and Reimbursement Guideline  CPCP032 04/28/2022 View Archive
Telemedicine and Telehealth Services CPCP033 05/19/2021 View Archive
Telemedicine and Telehealth Services (Effective 08/01/2022) CPCP033 04/28/2022 View Archive
Unbundling Policy-Professional Providers V1 CPCP034 04/05/2022 View Archive
Unlisted/Not Otherwise Classified (NOC) Coding Policy v3 CPCP035 05/31/2022 View Archive
Paravertebral Facet Injection Procedure Coding & Billing Policy CPCP036 01/14/2022 View Archive

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