CurrentBlue Cross Blue Shield - MainePolicy N/A

Frequency Editing (unit and frequency limits for CPT/HCPCS codes)

Defines Anthem Medicare Advantage coding and claims-processing rules that limit units and frequency of CPT/HCPCS/revenue codes for Medicare Advantage PPO members; applies to submitting providers and facilities when billing Anthem Medicare Advantage (non-Anthem Medicare Advantage Blue Plans).

Policy Summary

PayerBlue Cross Blue Shield - Maine (Anthem Medicare Advantage)

PolicyFrequency Editing (unit and frequency limits for CPT/HCPCS codes)

Policy CodePolicy N/A

Change TypeMultiple revised frequency limits and enforcement clarifications

Effective Date11/01/19

Next Review DateN/A

Key ActionProviders must follow authorization and medical necessity guidelines and ensure services meet billing rules because services billed in excess of frequency limits are not eligible for reimbursement.

SourceLink

POLICY UPDATE CHANGES

Added frequency limit of one unit per date of service to definitive test codes 80321-80322, 80324-80337, 80339-80344, 80346-80347, 80350-80352, 80361-80364, 80369-80370 and 80375-80377.

Updated 95250/95251 to read one per 30 days as stated in CPT instead of one per three days.

Added frequency limits for numerous codes including A4556, A4557, 88305, 95165, A4253 and others (examples: A4556 two units per 30 days; A4557 four units per 365 days; 95165 120 doses per 365 days).

Added one-per-seven-day frequency for unattended/home sleep study codes and applied across related code groups.

Documented that services billed in excess of these restrictions are not eligible for reimbursement even when billed with override modifiers (e.g., 59 or 91).

1Typical per-date limit (example)

18/365dCommon drug-test annual cap (example)

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Frequency and Unit Editing — Coverage Criteria

Frequency/unit editing criteria

Anthem applies frequency/unit limits based on code descriptors, CMS MUEs, clinical feasibility, CPT parenthetical notes, add-on relationships, service grouping, manufacturer/FDA guidance for drugs, and claims data analysis.

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

Anthem will apply unit/frequency edits pre-adjudication using both the unit field and multiple submissions of line items.

A base code that has related add-on code(s) listed in CPT Appendix D is eligible for reimbursement only once per date of service; related add-on code(s) describe each additional service.

Frequency edits may be applied across dates of service by accumulating claim history (previous, current and subsequent dates) to enforce limits across a date span.

Frequency maximums per day and/or per date span may be applied based on CMS MUEs, industry standards, code description, and/or claims data analysis.

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

Anthem has customized unit/frequency logic for specific procedure codes listed in the coding tables; services reported in excess of these restrictions are not eligible for reimbursement even when reported with an override modifier.

Examples of code-specific frequency limits

The table below lists representative codes and the frequency/quantity limits Anthem applies (examples). Some entries specify that modifier override is not permitted.

C9257: Limit to 10 units per date of service (no modifier override); typically described as 5 units per eye.

A4230/A4231/A4232: Infusion sets/syringes for external insulin pump — limit 60 per 86 days.

A4253: Blood glucose test strips (per 50) — example limit 22 per 86 days (revised in policy).

G0398/G0399/95800/95801/95806: Unattended/home sleep study codes — limit 1 per 7 days; grouping applies across related sleep study codes.

Frequency and reimbursement rules

Frequency-based coverage and reimbursement rules — applies to listed code groups and individual codes.

Definitive drug test codes: Codes in the definitive test ranges (80321–80322, 80324–80337, 80339–80344, 80346–80347, 80350–80352, 80361–80364, 80369–80370, 80375–80377) are limited to 1 unit per date of service.

95250/95251: Continuous glucose monitoring codes updated to 1 per 30 days as stated in CPT.

A4556: Electrodes — example limit 2 units per 30 days.

A4557: Lead wires — example limit 4 units per 365 days.

95165:

Codes, Units and Period Limits

Sample codes with explicit frequency/unit limitsCPT | HCPCSCovered

36415	Collection of venous blood by venipuncture (1 per date of service)
36416	Collection of capillary blood specimen (1 per date of service)
88305	Level IV surgical pathology, needle biopsy prostate (9 units per date of service when reported for specimens related to needle biopsies of the prostate)
80320	Definitive drug testing: Alcohols (1 per date of service and 18 per 365 days)
80321	Definitive drug testing: Alcohol biomarkers (1 per date of service and 18 per 365 days)

Additional codes with period-based limitsCPTCovered

95800	Sleep study, unattended (1 per 7 days; code group includes 95800, 95801, 95806, G0398, G0399 and G0400)
95250	Continuous glucose monitoring (1 per 30 days)
96116	Neurobehavioral status exam (5 hours per 365 days)

Selected codes and limits from excerptmixedCovered

96150-96155	Health and behavior assessment/intervention; each 15 minutes; limit 8 per date of service
96367	Additional sequential infusion, up to 1 hour; limit 6 per date of service
96401	Chemotherapy administration, subcutaneous or intramuscular; limit 1 per date of service per drug
A4230-A4232	Infusion sets and syringes for external insulin pump; limit 60 per 86 days
A4253	Blood glucose test strips, per 50 strips; example limit 22 per 86 days
C9257	Bevacizumab injection (Avastin), 0.25 mg; limit 10 per date of service (5 per eye)
G0398-G0399	Home sleep test codes (type II/III monitors); limit 1 per 7 days
J0585	OnabotulinumtoxinA (Botox), per unit; example historical limit noted (600 per date of service in excerpt)
J2505	Pegfilgrastim, 6 mg; limit 1 per date of service
S9123-S9124	In-home nursing care (RN/LPN), per hour; limit 24 per date of service

Examples of updated frequency limitsCPTCovered

80321-80322,80324-80337,80339-80344,80346-80347,80350-80352,80361-80364,80369-80370,80375-80377	Definitive test codes — frequency limited to one unit per date of service
95250/95251	Continuous glucose monitoring codes — updated to 1 per 30 days per CPT (revised from 1 per 3 days)

DME/ Supply limitsHCPCSCovered

A4556	Electrodes — limit two units per 30 days
A4557	Lead wires — limit four units per 365 days
95165	Preparation and provision of allergen antigens — 120 doses per 365 days
A4253	Blood glucose test strips — frequency noted in policy (per 50 strips; example limits shown)

Maximums applied pre-adjudication

Pre-adjudication editsAnthem applies unit/frequency edits pre-adjudication using the unit field and multiple line submissions; edits may limit units reimbursed.

Modifier override behaviorServices reported in excess of customized unit/frequency restrictions are not eligible for reimbursement even when reported with an override modifier (e.g., 59 or 91).

Basis for editsEdits are informed by CPT/HCPCS nomenclature, CMS MUEs, clinical feasibility, add-on relationships and claims data analysis.

Application across lines/datesFrequency edits may be applied across service groupings and across dates by accumulating claim history to enforce period limits.

Provider Requirements, Claims and Appeals

Billing Rule

Claims editing and modifier override rules (historical notes)

Providers must follow claims editing and modifier override rules as Anthem Medicare Advantage applies unit/frequency edits during claims processing. Historical policy notes indicate that these edits are based on CMS MUEs, industry standards, code descriptions, claims data analysis, and customized unit/frequency logic. The coding table and historical entries document prior decisions and rationale for limits applied to specific codes.

Edits may be driven by CMS Medically Unlikely Edits (MUEs), code descriptions, industry standards, and internal claims data analysis.
Anthem Medicare Advantage uses customized unit/frequency logic for certain procedure codes; historical policy entries document additions, removals, and rationale for specific code limits.
Historical notes reflect prior changes to code limits (examples include limits added for G0482-G0483, CPT 90882, and various imaging and injection codes).

Key Terms and Editing Definitions

Definition: Frequency edit

TermFrequency edit

DefinitionA claims-processing rule that limits the number of times a procedure code is eligible for reimbursement on a single date of service or within a specified date span based on code descriptors, clinical feasibility, MUEs and other factors.

PurposeTo ensure reimbursement aligns with clinical norms and coding nomenclature and to prevent inappropriate multiple unit reporting.

Definition: MUE

TermMUE (Medically Unlikely Edit)

DefinitionMaximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service (CMS definition).

Policy Summary

PayerBlue Cross Blue Shield - Maine (Anthem Medicare Advantage)

PolicyFrequency Editing (unit and frequency limits for CPT/HCPCS codes)

Policy CodePolicy N/A

Change TypeMultiple revised frequency limits and enforcement clarifications

Effective Date11/01/19

Next Review DateN/A

SourceLink

On This Page

Denial Risk

Reimbursement denial for excess frequency

Services billed in excess of established frequency or unit restrictions are not eligible for reimbursement even if billed with an override modifier (for example, modifier 59 or 91). Providers should ensure units billed comply with Anthem Medicare Advantage frequency maximums per date of service and/or specified date spans.

Explicit rule: excess units beyond Anthem’s frequency restrictions will be denied and are not eligible for reimbursement even with override modifiers.
Frequency maximums are applied per date of service and/or per date span and may be based on CMS MUEs, industry standards, HCPCS/CPT descriptions, or Anthem’s customized logic.
Examples in historical policy: imaging and other codes were added with one-per-date-of-service limits; documentation of these changes appears in policy history.