Reimbursement Policy Manual

To learn about our reimbursement policies, please reference the linked policies on the topics listed below

Reimbursement Policies are each assigned a number (RPMxxx) for reference. Policies are available for the following topics or services:

Moda Health Reimbursement Policy Overview last updated February 2024 (RPM001)

Administrative

• Add-on Codes last updated April 2024 (RPM025)
• After Hours and Other Special Circumstances last updated February 2024 (RPM004)
• Clinical Editing last updated February 2024 (RPM002)
• Diagnosis Code Requirements - Level of Detail, Number of Characters, and Laterality last updated September 2024 (RPM053)
• Diagnosis Code Requirements - Invalid As Primary last updated August 2024 (RPM054)
• Incident-To Services last updated September 2024 (RPM040)
• Medical Records Documentation Standards last updated June 2024 (RPM039)
• Medical, Surgical, and Routine Supplies (including but not limited to 99070) last updated June 2024 (RPM021)
• Medically Unlikely Edits (MUEs) last updated September 2024 (RPM056)
• Never Events, Adverse Events, Hospital-Acquired Conditions (HAC), and Serious Reportable Events (SRE) last updated July 2024 (RPM071)
• Procedures Designated as "Separate Procedure" last updated September 2024 (RPM051)
• Records Fees, Copying Fees last updated April 2024 (RPM005)
• Risk Adjustment/HCC Coding and Documentation last updated August 2024 (RPM050)

Anesthesia

• Anesthesia Physical Status Modifiers (P1 - P6) last updated August 2024 (RPM032)
• Modifiers AA, AD, GC, QK, QX, QY, QZ – Anesthesia Payment Modifiers last updated September 2024 (RPM034)
• Modifier 47 - Modifier 47 - Anesthesia By Surgeon last updated June 2024 (RPM031)
• Qualifying Circumstances for Anesthesia last updated June 2024 (RPM033)

Behavioral Health

• Behavioral Health Case Management & Care Coordination last updated October 2024 (RPM058)
• Evaluation and Management (E/M) Services With Psychotherapy Services last updated March 2024 (RPM081)
• Supervised Behavioral Health Provider Program Requirements   last updated February 2024 (RPM079)

Documentation

• E0486 Oral Sleep Apnea Device/Appliance Documentation last updated October 2024 (RPM055)
• Medical Records Documentation Standards last updated November 2023 (RPM039)

Evaluation & Management

• 2021 & 2023 Updates to Evaluation and Management (E/M) Visits and Prolonged Services last updated April 2024 (RPM076)
• Clinic Services In the Hospital Outpatient Setting - Commercial last updated October 2024 (RPM061)
• Critical Care, Evaluation and Management Services (99291, 99292) last updated September 2024 (RPM041)
• Emergency Department Visit Leveling last updated November 2024 (RPM075)
• Gynecologic or Annual Women’s Exam Visit & Use of Q0091 (Pap, Pelvic, & Breast Visit) last updated March 2024 (RPM044)
• Scope Of License For Evaluation & Management Codes last updated November 2024 (RPM080)

Facility-Specific

• DRG Payment With Patient Transfers last updated July 2023 (RPM066)
• Facility DRG Validation last updated April 2024 (RPM069)
• Facility Guidelines, General Overview last updated July 2024 (RPM065)
• Facility Reimbursement of Respiratory Therapy Services last updated July 2024(RPM047)
• Hospital Routine Supplies and Services last updated July 2024 (RPM043)
• Level of Care Review last updated June 2024 (RPM067)
• Readmissions last updated January 2024 (RPM068)
• Revenue Codes Ending in "9" ("Other" Categories) last updated July 2024 (RPM042)

Laboratory & Pathology

• Clinical Drug Screening and/or Drug Testing last updated August 2024 (RPM016)
• Routine Venipuncture and/or Collection of Specimens last updated February 2024 (RPM012)

Medicine

• Additional Practice Expense Items During a Public Health Emergency (PHE) – CPT 99072 last updated February 2024 (RPM074)
• Moderate (Conscious) Sedation last updated June 2024 (RPM048)
• Supply Limits for Ongoing Medical Supplies last updated August 2024 (RPM072)

Modifiers

• Modifier 22 – Increased Procedural Services last updated August 2024 (RPM007)
• Modifier 25 - Significant, Separately Identifiable E/M Service (RPM028)
• Modifier 50 - Bilateral Procedure last updated March 2024 (RPM057)
• Modifier 51 - Multiple Procedure Fee Reductions last updated April 2024 (RPM022)
• Modifier 52 – Reduced Services last updated September 2023 (RPM003)
• Modifier 53 – Discontinued Procedure last updated September 2023 (RPM018)
• Modifiers 54, 55, and 56 - Split Surgical Care last updated July 2024 (RPM030)
• Modifier 57 - Decision For Surgery last updated August 2024 (RPM029)
• Modifiers 58, 78, and 79 - Staged, Related, and Unrelated Procedures last updated March 2024 (RPM010)
• Modifiers 62 & 66 - Co-surgery (Two Surgeons) and Team Surgery (More Than Two Surgeons) last updated August 2024 (RPM035)
• Modifier 63 - Procedure Performed on Infants Less Than 4 kg last updated October 2024 (RPM062)
• Modifiers 73 & 74 - Discontinued Procedures For Facilities last updated April 2023 (RPM049)
• Modifiers 80, 81, 82, and AS - Assistant At Surgery last updated September 2024 (RPM013)
• Modifiers CO & CQ - Therapy Assistant Services last updated March 2024 (RPM077)
• Modifiers GA, GX, GY, and GZ last updated September 2024 (RPM036)
• Modifiers JG & TB - 340B Drug Discount Program, Acquired Drugs and Biologicals” last updated March 2024 (RPM063)
• Modifiers JW & JZ – Drugs and Biologicals, Wastage and/or Discarded Amounts last updated January 2024 (RPM015) 
• Modifiers PO & PN - G0463 Clinic Visit Services at Excepted Off-Campus Provider-Based Outpatient Department - Medicare Advantage last updated July 2023 (RPM064)
• Modifier SL - State Supplied Vaccine last updated April 2024 (RPM024)
• Modifier SU - Procedure Performed in Physician's Office (Facility and equipment)  last updated July 2023 (RPM070)
• Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service last updated August 2024 (RPM027)
• Radiology Reductions for Technology Type - Modifiers FX and FY last updated December 2022 (RPM059)
• Reference (Outside) Laboratory -- Modifier 90 last updated February 2024 (RPM045)
• Technical Component (TC), Professional Component (PC/26), and Global Service Billing last updated June 2024 (RPM008)
• Transportation of Portable X-ray Equipment, Multiple Portable X-rays - Modifiers UN, UP, UQ, UR, US last updated October 2024 (RPM060)
• Valid Modifier to Procedure Code Combinations last updated March 2024 (RPM019)

Preventive Services

• Colorectal Cancer Screening And Related Ancillary Services last updated March 2024 (RPM046)
• Preventive Services versus Diagnostic and/or Medical Services last updated November 2024 (RPM037)

Surgery

• Computer Assisted Navigation last updated July 2024 (RPM038)
• Global Surgery Package for Professional Providers last updated November 2024 (RPM011)
• Intra-joint and Surgical Site Postoperative Pain Relief Drug Delivery System (Pain Pump) last updated February 2024 (RPM014)
• Operating Microscope (CPT Code 69990) (RPM026)
• Postoperative Sinus Debridement Procedures (last updated July 2024) (RPM009)
• Procedure Codes Assigned to Surgical Benefit Categories last updated February 2024(RPM023)
• Robotic Assisted Surgery last updated February 2024 (RPM006)
• Maternity Care last updated August 2024 (RPM020)

Telemedicine

• Telehealth and Telemedicine Expanded Services for COVID-19 - updated for Public Health Emergency Ending last updated November 2024 (RPM073)
• Telehealth And Telemedicine Services last updated November 2024 (RPM052)