Implementation of Payment Policy Initiatives Beginning March 1, 2026
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Notifies providers of new payment policy initiatives effective for dates of service beginning March 1, 2026 that affect billing, coding documentation, and reimbursement for Blue Cross Blue Shield of Arizona Health Choice members.
New payment policy initiatives (sepsis DRG coding reviews, E/M with psychotherapy time documentation requirement, preventive E/M paired with problem-oriented E/M 50% reduction, and S9480 behavioral health billing restriction) effective for dates of service beginning March 1, 2026.
Claims missing evidence of start and stop times for specified high-level E/M codes billed with psychotherapy add-on codes will not be reimbursed.
When preventive E/M codes are billed with problem-oriented E/M codes, payment for the problem-oriented E/M code will be reduced by 50%.
HCPC code S9480 must be billed with a primary behavioral health diagnosis (not substance use disorder); claims otherwise will be denied.
For specified sepsis APR-DRG and MS-DRG claims with short admissions and certain discharge dispositions, full medical record submission will be required for coding review.
Payment Policy Initiatives (Effective 2026-03-01)
Payment policy initiatives (effective 3/1/2026)
Rules and coverage stance for combinations and billing behaviors effective March 1, 2026:
ALL of the following
ALL of the following
- Applies to claims with APR-DRG 720.3 or 720.4, or for DSNP/ACA MS-DRG 870 or 871
- Admission length is 3 days or less
Admission length criterion triggers full medical record submission for review
ANY of the following
- Discharged to home (01)
- Discharged to step-down care (03)
ALL of the following
- When high-level E/M codes are billed with psychotherapy add-on codes, medical record documentation must show start and stop times for each service performed
- Claims missing evidence of start and stop times within the member's documented medical records will not be reimbursed.
ALL of the following
ALL of the following
- HCPC code S9480 must be billed with a primary behavioral health diagnosis that is not a substance use disorder
- Claims with a non-behavioral health or substance use disorder primary diagnosis will be denied.
Affected Codes, Code Groups, and Operational Criteria
| 99204 | High-level E/M (office/outpatient) |
| 99205 | High-level E/M (office/outpatient) |
| 99214 | High-level E/M (established patient) |
| 99215 | High-level E/M (established patient) |
| 90833 | Psychotherapy add-on with E/M, requires time documentation |
| 90836 | Psychotherapy add-on with E/M, requires time documentation |
| 90838 | Psychotherapy add-on with E/M, requires time documentation |
| TIME_DOC | When E/M codes 99204, 99205, 99214, or 99215 are billed with psychotherapy add-on codes 90833, 90836, or 90838, medical records must show start and stop times for each service; claims missing this evidence will not be reimbursed. |
| APR-DRG 720.3 | Sepsis related DRG |
| APR-DRG 720.4 | Sepsis related DRG |
| MS-DRG 870 | Sepsis DRG (DSNP/ACA context) |
| MS-DRG 871 | Sepsis DRG (DSNP/ACA context) |
| MEDICAL_RECORD_SUBMISSION | Full medical records required for Clinical Coding Team review when admission is 3 days or less and discharge disposition is home (01) or step-down care (03). |
Provider Documentation, Billing Rules, and Denial Risks
Sepsis DRG coding review — submit full medical record for short admissions
Clinical Coding Team will review claims and full medical records for APR-DRG 720.3 or 720.4 and for DSNP/ACA MS-DRG 870 or 871 when the inpatient admission is 3 days or less and the member is discharged to home (01) or to step-down care (03). Providers must submit the complete medical record for these claims to support coding accuracy.
- Applies to APR-DRG 720.3, 720.4 and MS-DRG 870, 871
- Admission length criterion: 3 days or less
- Discharge dispositions: home (01) or step-down care (03)
- Full medical record submission required for Clinical Coding Team review
E/M with psychotherapy — provide start/stop times or claim denied for reimbursement
For dates of service on or after 03/01/2026, claims that include E/M codes 99204, 99205, 99214, or 99215 billed with psychotherapy add-on codes 90833, 90836, or 90838 must include medical record evidence of start and stop times for each service; claims missing these start/stop times will not be reimbursed.
Preventive + problem-oriented E/M — 50% reduction to problem-oriented E/M
When preventive E/M codes are billed together with problem-oriented E/M codes, payment for the problem-oriented E/M code will be reduced by 50%.
S9480 requires primary behavioral health diagnosis — claims will be denied otherwise
HCPC code S9480 must be billed with a primary diagnosis of behavioral health that is not a substance use disorder; claims with a non-behavioral health or substance use disorder primary diagnosis will be denied.
- Applicable code: S9480 (Behavioral health intensive outpatient treatment)
- Denial condition: primary diagnosis not behavioral health or is a substance use disorder
Code Group Definitions and Mappings
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