CurrentAnthemPolicy C-08012

Frequency Editing - Professional, Commercial Reimbursement Policy

Defines Anthem's rules for limiting units/frequency of CPT/HCPCS codes billed for a single member on a single date of service and across date spans; affects providers submitting professional/commercial claims.

Policy Summary

PayerAnthem

PolicyFrequency Editing - Professional, Commercial Reimbursement Policy

Policy CodePolicy C-08012

Change TypeCode list revisions and removals

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionProviders must bill appropriate units; frequency/unit edits are applied pre-adjudication and modifiers will not override single-unit limits in many circumstances.

SourceLink

POLICY UPDATE CHANGES

Updated Related Coding section for CPT Maximum Frequency code list by removing codes 96158-96159 and 96164-96165; added same codes to Health and Behavioral Assessment/Intervention - Professional.

Removed G0480-G0483 and moved them to Drug Screen Testing - Professional policy (C-12004).

Removed multiple HCPCS drug codes from HCPCS Maximum Frequency Per Day code list and will manage specific code J0586 through Clinical UM Guideline (CUMG).

C-08012Policy identifier

2026-04-01Effective date

2026-01-01Last approval

MultipleHistory entries

Frequency and Unit Reimbursement Criteria

Frequency and unit reimbursement criteria

When and how frequency/unit edits are applied for reimbursement:

Reimbursement allowed up to the maximum number of units billed for a single member on a single date of service by the same provider and/or provider group unless provider, state, federal contracts, and/or requirements indicate otherwise.

Determinations use CPT/HCPCS nomenclature, CMS MUEs designation, industry standards, and the clinical ability to perform or report a service more than once in a date span per member, per provider.

Factors that may limit units or the number of times a code is eligible for reimbursement on a single date of service include: the code description containing 'bilateral' or 'unilateral or bilateral'; a code described as 'unilateral' when a separate bilateral code or add-on exists; code descriptions or parenthetical statements that specify a specific time frame; wording that implies multiplicity; the clinically possible or reasonable number of times a procedure may be performed on a single date; and situations where a procedure is reported multiple times but typically not performed more than once.

Site- or modifier-specific allowance

Policy Summary

PayerAnthem

PolicyFrequency Editing - Professional, Commercial Reimbursement Policy

Policy CodePolicy C-08012

Change TypeCode list revisions and removals

Effective DateApr 1, 2026

Next Review DateN/A

Key ActionProviders must bill appropriate units; frequency/unit edits are applied pre-adjudication and modifiers will not override single-unit limits in many circumstances.

SourceLink

On This Page

In some circumstances, RT/LT or site-specific modifiers will allow a code to process when used more than once by identifying the specific side or digit being treated or evaluated.

If a procedure is submitted with multiple units but only a single unit is acceptable, reimbursement will be based on one unit; modifiers will not override this edit.

All unit/frequency edits are applied pre-adjudication using both the unit field and multiple submissions of line items.

Frequency edits apply to base codes with related add-on codes listed in CPT Appendix D; where an add-on phrase indicates 'each additional' or 'list separately in addition to the primary procedure,' the base code is eligible for reimbursement only once per date of service.

Frequency edits may be applied across dates of service by using claim history (previous, current, and subsequent dates) to accumulate and enforce limits.

Scope of frequency maximums

Frequency maximums may be applied per date and/or per date span, which may be based on CMS MUEs, industry standards, and/or code description.
Frequency maximums may be applied when procedures are within the same service grouping.

Unit maximums for drugs may be based on manufacturer guidelines, FDA approval, and/or code description.

The health plan has customized unit/frequency logic for procedure codes listed in attachments (related coding lists).

Operational note

Services reported in excess of these restrictions are not eligible for reimbursement even when reported with an override modifier.

Operational note

Related Coding and Application Rules

Related coding lists - CPT Maximum FrequencyCPT

No codes listed

Related coding lists - HCPCS Maximum FrequencyHCPCS

No codes listed

Unit/frequency application rules

Application scopesLimits may be applied per date of service, per date span, across dates using claim history, across providers for the same member/date, and within service groupings.

Basis for maximumsFrequency maximums may be based on CMS Medically Unlikely Edits (MUEs), industry standards, code descriptions, manufacturer/FDA guidance for drugs, and claims data analysis.

Add-on/base code ruleA base code with related add-on codes (CPT Appendix D) is eligible for reimbursement only once per date when related phrasing indicates 'each additional' or 'in addition to the primary procedure'.

Pre-adjudication enforcementAll unit/frequency edits are applied pre-adjudication using the unit field and multiple line submissions.

Modifier guidanceWhen only a single unit is acceptable, reimbursement will be based on one unit and modifiers will not override the edit; RT/LT or site-specific modifiers may allow multiple processing in some circumstances.

Billing and Modifier Guidance for Providers

Billing Rule

Frequency/unit billing and modifier requirements (pre-adjudication edits and modifier limits)

Bill the actual number of units up to the plan's maximum; all unit/frequency edits are applied pre-adjudication and modifiers will not override single-unit limits in many cases. Frequency edits may be applied across dates of service or across providers where indicated, and services reported in excess of these restrictions are not eligible for reimbursement even when reported with an override modifier.

Reimbursement allowed up to the maximum number of units billed for a single member on a single date of service by the same provider/provider group unless contracts or requirements indicate otherwise. [[supported by cited chunks]]
If a procedure is submitted with multiple units but only a single unit is acceptable, reimbursement will be based on one unit; modifiers will not override this edit.
All unit/frequency edits are applied pre-adjudication using the unit field and multiple line submissions.
Frequency edits may be applied across dates of service using claim history and, in certain circumstances, across providers. Services reported in excess of restrictions are not eligible for reimbursement even with an override modifier.

Key Definitions

Medically Unlikely Edit (MUE)

DefinitionMedically Unlikely Edit (MUE): Maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.

PurposeUsed as a basis for frequency maximums per date and/or per date span to limit reimbursable units.

Use in policyPolicy applies CMS MUEs among other standards when determining unit/frequency maximums for codes and may customize logic for specific procedure codes.