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Policy Number

Policy Name

Policy Description

Lines of Business

CC.PP.071

Evaluation and Management Services Billed with Treatment Rooms

Disallows E&M services in treatment rooms as this does not represent a treatment type of service.

Marketplace

CP.MP.209

Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing

Restricts reimbursement of GI pathogen panels with 12+ targets to only inpatient settings, including inpatient, ED, and outpatient hospitals.

Medicaid, Marketplace

Policy Number

Policy Name

Policy Description

Lines of Business

N/A

Cotiviti 8

The purpose of this policy is to serve as a reference guide for general coding and claims editing information. Cotiviti 8 is a correct coding edit of ICD-10 diagnosis codes. Source: ICD-10 CM Diagnosis Code Manual 

N/A

WCG Integration Value Capture - Correct Coding Batch 2 (Cotiviti 8)

The purpose of this policy is to serve as a reference guide for general coding and claims editing information. Cotiviti 8 is a correct coding edit of ICD-10 diagnosis codes. Source: ICD-10 CM Diagnosis Code Manual 

N/A

Procedure Modifier Revenue Necessary (PMRN) - Correct Coding Batch #3

The PMRN edit will deny procedures that require an associated modifier and also identify situations where a correct modifier and revenue code are required. The edit applies to both professional (HCFA) and outpatient facility (UB-04) claims.
• Per CMS and AMA, procedures that can be performed on different sides of the body, separate anatomical areas, or separate patient encounters, require the use of modifiers whenever appropriate.
• Additionally, on professional claims, each code designated as “always therapy” must always be furnished under an SLP, OT, or PT plan of care and as such must always be accompanied by one of the therapy modifiers.
• Medicare recognizes the services furnished under the OPT service benefit as either “always” or “sometimes” therapy. “Always therapy” codes require modifier GN, GO, or GP appended to the therapy CPT code.
• CMS approved “sometimes therapy” codes require the appropriate modifier and revenue code combination when furnished by a therapist.