CurrentCareFirstPolicy N/A

Medical Policy Reference Manual, Claims Adjudication and Payment Procedures

Governs CareFirst's medical policy reference manual structure, technology assessment process, clinical editing applications, and claims adjudication practices affecting providers and members under local CareFirst lines of business.

Policy Summary

PayerCareFirst

PolicyMedical Policy Reference Manual, Claims Adjudication and Payment Procedures

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit complete clinical records when requested for prior authorization, unlisted codes, or claims using certain modifiers to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

00-11,99Manual sections

100%Primary procedure rule

50%Secondary procedure rule

3 yrsNew patient timeframe

Denied w/o procedureImaging agent rule

Coverage and Reimbursement Criteria

Claims Adjudication Criteria

Claims are adjudicated based on member benefits and claim editing policies; specific editing categories determine reimbursement eligibility.

Claims are adjudicated first based on member benefits and subsequently based on claim editing policies; claims may be manually reviewed and clinical staff may request medical documentation or medical director review as needed.

Editing categories applied include

Global surgical period edits: services within a global surgical period are included in a single payment and not eligible for separate reimbursement.
Frequency validation and duplicate procedure edits: procedure codes that are not clinically warranted multiple times on the same date are edited; duplicate or lifetime-limited events are enforced.
Incidental / integral / included procedure edits: procedures considered incidental or integral to a primary procedure are not separately reimbursed.
Mutually exclusive edits: overlapping or impossible procedure combinations are edited; typically the procedure with the higher RVU is eligible for reimbursement.
Multi-code re-bundling: when multiple codes represent a single comprehensive procedure, services are re-bundled to the comprehensive code.
Medically Unlikely Edits (MUE): maximum units of service reportable per beneficiary per date of service are enforced.

Invalid modifier-to-procedure code combinations are identified and may result in non-payment; certain modifier submissions (e.g., -22, -62, -66, -78) may prompt Medical Review and require supporting records.

Providers must furnish requested clinical information without charge when CareFirst requests medical records for prior authorization, medical necessity determinations, unlisted codes, certain modifiers, appeals, or fraud investigations.

Place of Service and code assignment rules apply; use nationally recognized code sets (CPT/HCPCS/ICD-10) when filing claims and follow CareFirst place-of-service guidance available on carefirst.com/providerguides.

Procedural coverage criteria

Multiple procedures and RVU-based allowance methodology:

Primary procedure (most clinically intense) is reimbursed at 100% of the allowed benefit; subsequent non-integral procedures are typically reimbursed at 50% of the allowed benefit.

CareFirst uses the non-facility total RVU (CMS) to determine fee schedule allowance and to rank procedures for payment priority when multiple procedures occur in the same session.

Procedures that are clinically integral to a primary procedure (including many endoscopic components and procedures on the same body system/rout e) are usually considered incidental/included and are not separately reimbursed.

Endoscopic and open surgical procedures in the same anatomic area that are clinically integral are usually not separately reimbursed; the more clinically intense procedure is reimbursed.

Serial surgery or 'one or more sessions' codes and duplicate services are not reimbursed separately for each stage; duplicate services are reimbursed only once and fragmented billing across claims is not acceptable.

E/M and related service coverage rules

Reimbursement is provided according to member benefit contracts, CPT guidelines, and documentation standards. Specific rules and included/excluded services are outlined below.

E/M services must be reported per CPT guidelines and fully supported in the medical record according to CareFirst Medical Record Documentation Standards.

Preventive services (CPT 99381-99397) should be reported only when providing the complete health maintenance exam; routine immunizations are reported separately.

Append Modifier -25 when a significant, separately identifiable E/M service is provided in addition to a preventive service or immunization; significant additional effort requires additional time and initiation of a treatment plan by the end of the visit.

Prolonged service codes (CPT 99354-99359) are time-based add-on codes and are not eligible with emergency services, observation/inpatient services, or critical care codes; documentation must reflect exact times.

Providers may only submit claims for services they personally provide; supervising physicians may submit for resident-provided services only if they personally examine and document as required.

Reimbursement criteria for incidental and ancillary services

Stance on reimbursement eligibility for various ancillary and procedure-related services:

If an E/M service is allowed during a global surgical period, a claim may be submitted and applicable copayment/coinsurance may be collected; if disallowed/bundled, do not submit a claim or collect copayment/coinsurance.

Services designated as incidental or integral to other services (e.g., handling/conveyance CPT 99000-99002, hot/cold packs CPT 97010, pulse oximetry CPT 94760-94762 when reported with other services, routine venipuncture CPT 36415, medical photography) are not eligible for separate reimbursement unless reported as stand-alone on that date.

Non-invasive pulse oximetry (CPT 94760-94762) is eligible only when reported as stand-alone procedures; when reported with other services they are considered incidental and not eligible for separate reimbursement.

Venipuncture requiring physician skill (CPT 36400-36410) may be reimbursed when reported with CPT 8xxxx laboratory tests; routine venipuncture (CPT 36415) is incidental to lab services and generally not separately reimbursed—may be eligible if billed with an office visit.

Lesion removal reimbursement criteria

Lesion removals and biopsies

Non-cosmetic lesion removals are eligible for separate reimbursement per member contract and applicable medical policies; follow CPT guidelines for excision, destruction and shaving of benign and malignant lesions.

Multiple lesion removals reported with the same CPT code are usually considered duplicates or mutually exclusive; append Modifier -59 for lesion removals subsequent to the primary procedure to indicate distinct sites/lesions and follow multiple procedure editing rules.

Wound closure reimbursement criteria

Wound closures with lesion excisions

Simple wound repair (e.g., CPT 12001) performed in the same anatomic site as a lesion excision is considered incidental to the excision and is not eligible for separate reimbursement.

Intermediate, complex or reconstructive closures reported with lesion excisions may be eligible for separate reimbursement when documentation supports distinct, separately reportable closure services per CPT guidelines.

Surgical supplies

Surgical trays and supplies

A portion of the RVU accounts for practice expense including trays; additional charges for surgical trays (HCPCS A4550) used during office procedures are considered incidental and are not eligible for separate reimbursement.

Sinus endoscopy reimbursement criteria

Nasal sinus endoscopy/debridement

CPT 31237 (nasal sinus endoscopy, separate procedure) is eligible for separate reimbursement when performed as postoperative care following functional endoscopic sinus surgery with a zero-day global period or after a ten-day global period.

Endoscopic sinus cavity debridement is not eligible for separate reimbursement when performed as postoperative treatment related to major surgeries that have a 90-day global period.

When both a zero/10-day global and a 90-day global are present, append Modifier -79 to CPT 31237 to indicate unrelated debridement and ensure documentation and ICD-10 codes accurately state which procedure the debridement addresses; append Modifier -50 for bilateral procedures as appropriate.

Chemotherapy reimbursement criteria

Chemotherapy

Chemotherapy procedures (CPT 96401-96549) are considered independent from E/M services; any E/M services reported with chemotherapy require CPT Modifier -25 to be eligible for reimbursement as a significant, separately identifiable service.

Select IV fluids, needles, tubing and associated supplies are considered incidental to chemotherapy administration and are not eligible for separate reimbursement.

Medically necessary, non-experimental chemotherapeutic agents and drugs are usually eligible for separate reimbursement when reported with the appropriate HCPCS codes; documentation must support correct code assignment and amounts administered.

Breast tomosynthesis reporting rules

Digital breast tomosynthesis

Report CPT 77061/77062 (diagnostic tomosynthesis) in conjunction with CPT 77055/77056 (conventional diagnostic mammography); report CPT 77063 (bilateral screening tomosynthesis) in conjunction with CPT 77057 (conventional bilateral screening mammography).

Do not report CPT 77063 with CPT 77055/77056 or CPT 76376/76377; do not report CPT 77061/77062 with CPT 77057 or CPT 76376/76377 per exclusionary guidance.

Ultrasound reimbursement criteria

Ultrasound and ultrasound guidance

When limited diagnostic ultrasound (CPT 76705) and ultrasound guidance (CPT 76942) are reported on the same date in the same session/anatomic area, the limited ultrasound is considered mutually exclusive to the guidance and is not eligible for separate reimbursement; the procedure with the higher RVU is eligible for reimbursement.

When ultrasound guidance (CPT 76942) and diagnostic ultrasound (CPT 76536) are reported on the same date in the same session/anatomic area, the diagnostic ultrasound is considered mutually exclusive to the guidance and is not eligible for separate reimbursement; the procedure with the higher RVU is eligible for reimbursement.

Maternity and contraceptive device rules

Maternity and contraceptive device services

Maternity benefits are defined by the member contract; follow CPT guidelines for reporting non-global maternity services and refer to Medical Policy 4.01.006A and Payment Policy PP CO 080.01.

Established patient E/M services reported with IUD insertions/removals (CPT 58300-58301) are included in the surgical package and not eligible for separate reimbursement unless the E/M is significant and separately identifiable; append Modifier -25 when appropriate.

Coverage criteria for ultrasound procedures and imaging agents

When multiple ultrasound-related procedures are billed on the same date, apply mutual exclusivity and documentation/modifier rules; imaging agents must be billed with requisite imaging procedures.

When CPT 76705 (limited diagnostic ultrasound) and CPT 76942 (ultrasound guidance) are reported the same date in the same anatomic area, the limited ultrasound is mutually exclusive to the guidance and not eligible for separate reimbursement; the higher RVU procedure is reimbursed.

When CPT 76536 (diagnostic ultrasound) and CPT 76942 (ultrasound guidance) are reported the same date in the same anatomic area, the diagnostic ultrasound is mutually exclusive to the guidance and not eligible for separate reimbursement; the higher RVU procedure is reimbursed.

When multiple ultrasound guidance codes (e.g., CPT 76930 and 76942) are reported the same date in the same session/anatomic area for similar indications, the lower RVU code is mutually exclusive and not eligible; if performed on separate anatomic sites or for distinct indications, append appropriate modifier(s) and maintain supporting documentation.

Imaging agents will be denied when billed without the requisite imaging procedures per National and Regional CMS Guidelines.

Codes, Modifiers, and Coding Rules

Recognized code setsmixed

CPT	Use Current Procedural Terminology (HCPCS Level I) for procedure reporting; refer to current coding manuals.
HCPCS	Use HCPCS Level II codes as appropriate.
ICD-10	Use ICD diagnosis codes as appropriate.

Procedure grouping and exclusion rulesmixedCovered

Unbundled, incidental, integral/included, and mutually exclusive procedure concepts: report the most comprehensive code available; incidental/included/mutually exclusive procedures are not separately reimbursed; append Modifier -59 when reporting a distinct, independent procedure not related to the primary procedure; when mutually exclusive, the higher RVU procedure is usually eligible for reimbursement.

Unlisted codesCPT | HCPCSCovered

Unlisted CPT and HCPCS codes have no assigned RVU and should be reported only when no established code exists; claims with unlisted codes require submission of a complete description and applicable records for Medical Review to establish an allowance; modifiers are invalid with unlisted codes.

Preventive services (health maintenance exams)CPTCovered

99381-99397

Preventive services (health maintenance exams)

Advance care planningCPTCovered

99497-99498

Advance care planning

Complex chronic care coordination servicesCPTCovered

99487-99490

Complex chronic care coordination services

Prolonged physician servicesCPT

99354-99359

Prolonged physician services (add-on/time-based)

Modifier -25 guidanceModifier

Modifier -25

Significant, separately identifiable E/M service on the same day as another service (e.g., preventive service or immunization) — append when appropriate per CPT guidelines.

Cerumen removalCPTCovered

69209	Cerumen removal, irrigation/lavage, unilateral
69210	Cerumen removal, direct instrumentation

Cerumen removal modifier guidanceModifier

Modifier -50

Append when cerumen removal is performed bilaterally (both ears) as indicated in CPT parenthetical notes.

Pulse oximetryCPTCovered

94760-94762

Non-invasive pulse oximetry determinations

Nasal/sinus endoscopy (separate procedure)CPTCovered

31237

Nasal sinus endoscopy (separate procedure)

Chemotherapy administration proceduresCPTCovered

96401-96549

Chemotherapy administration procedures

Digital breast tomosynthesisCPTCovered

77061-77063

Digital breast tomosynthesis (diagnostic and screening)

Ultrasound guidance vs diagnosticCPTCovered

76705	Limited diagnostic ultrasound
76942	Ultrasound guidance procedure
76536	Ultrasound procedure (diagnostic)

Surgical tray supplyHCPCSNot Covered

A4550

Surgical tray

Ultrasound and guidance codes referencedCPT | mixedCovered

76705	Limited diagnostic ultrasound
76942	Ultrasound guidance procedure
76536	Ultrasound procedure (diagnostic)
76930	Ultrasound guidance (other)

Medically Unlikely Edits (MUE) — maximum units per beneficiary per date of service

DefinitionMedically Unlikely Edits (MUE) — the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.

PurposeEdits claims when a procedure code is submitted more times than clinically expected (e.g., lifetime limits, units per date).

Policy referenceSee clinical editing applications and PP CO 090.01 NCCI Editing for professional, DME supplier and facility rules.

Secondary procedure reimbursement rate

Standard payment rulePrimary procedure reimbursed at 100% of the allowed benefit; second and subsequent non-integral procedures reimbursed at 50%.

When appliedApplies when multiple procedures are performed in the same operative session and are not clinically integral to the primary procedure.

Modifier guidanceReport second and subsequent procedures with CPT modifier -51 as appropriate per CPT guidelines.

New patient timeframe

DefinitionNew patient — a patient who has not had services from the same physician or group in the same specialty in the past three years.

ImplicationIf a new patient E/M code is reported more than once by the same provider/group within three years, it will be automatically replaced with the corresponding established E/M code.

Facility noteFor OP Hospital and ASC, 'new patient' is defined similarly by registration history; services billed as new when facility records show prior registration within 3 years will be denied.

Hearing aid code frequency

Codes coveredCPT 92590-92595 and HCPCS V5010-V5298.

Frequency ruleClaims for these codes should be submitted with a frequency of one; hearing aid codes specifying monaural/binaural are eligible only once per date of service.

Modifier guidanceDo not append CPT modifier 50 or RT/LT (Category II) to these codes; fee schedule allowance set accordingly for monaural vs binaural.

Nasal endoscopy reimbursement timing

Eligible timingCPT 31237 (nasal sinus endoscopy) is eligible for separate reimbursement when performed as postoperative care following procedures with a zero-day global period or after a ten-day global period.

Ineligible timingEndoscopic sinus cavity debridement is not eligible for separate reimbursement when performed as postoperative treatment related to major surgeries within a 90-day global period.

Modifier and documentationWhen both a zero/10-day global and a 90-day global are present, append modifier -79 to CPT 31237 to indicate unrelated debridement and ensure documentation and ICD-10 codes reflect which procedure the debridement addresses.

Reimbursement preference for mutually exclusive procedures

Preference ruleWhen procedures are mutually exclusive (overlapping or anatomically impossible combinations), only the procedure with the higher RVU (higher valued/most clinically intense) is eligible for reimbursement.

ExamplesMutually exclusive edits apply to many ultrasound/ guidance combinations and other overlapping procedures; the lower RVU code is considered mutually exclusive to the higher RVU code.

ExceptionIf procedures are performed on separate anatomic sites or for distinct indications, append appropriate modifier(s) and maintain supporting documentation to justify multiple reporting.

Provider Requirements, Documentation, and Prior Authorization

Billing Rule

Unlisted Code Submission

Submissions of claims containing an unlisted CPT or HCPCS code are reviewed by CareFirst's Medical Review Department. An allowance for reimbursement is established based on review of the submitted documentation and comparison to similar procedures with established RVUs. To be considered for reimbursement, an unlisted procedure code must be submitted with a complete description of the service or procedure provided and any applicable records or reports. All applicable reimbursement policies (for example, incidental procedures, multiple procedures, bilateral procedures, global periods) will apply to claims submitted with unlisted codes. Do not append modifiers to unlisted procedure codes; modifiers reported with unlisted codes will be considered invalid.

Unlisted CPT/HCPCS codes should be used only when no established code accurately describes the service.
Include a full narrative description of the service and submit all relevant operative reports, office notes, imaging, and other records with the claim.
Medical Review will establish reimbursement using comparable procedures and other factors; absence of adequate documentation may result in denial or delay.
All usual payment rules (multiple procedure, bilateral, global periods, etc.) apply to unlisted code adjudication.
Do not report modifiers with any unlisted procedure codes; modifiers are considered invalid with unlisted codes.

Prior Authorization

Gender Affirmation Authorization Reference and Contact

Gender-affirming care and gender dysphoria services may be defined by the member's contract and certain services require prior authorization. For authorization requirements and clinical criteria, refer to CareFirst medical policy 7.01.123 (Gender Reassignment Services) and 7.01.017 (Cosmetic and Reconstructive Surgery) and the attached companion table. CareFirst maintains a dedicated Gender Services specialist to support members and providers.

Refer to medical policy 7.01.123 and 7.01.017 for specific authorization and clinical documentation requirements.
Contact the Gender Services team for authorization assistance, case coordination, or educational support: gender.services@carefirst.com.

Key Definitions and Concepts

Medical Policy Reference Manual

DefinitionMedical Policy Reference Manual — an informational database of evidence-based medical policies and operating procedures used to assist CareFirst in making medical policy decisions; not a guarantee of coverage.

ContentOrganized by specialty/subspecialty (sections 00–06, etc.); includes definitions, interpretive guidelines and the medical policy process.

UseReference prior to reviewing individual medical policies and operating procedures; member coverage varies by contract and line of business.

Technology Assessment (TAC) process and BCBS TEC criteria

DefinitionTechnology Assessment — a process to research and evaluate current or new/emerging technologies (drugs, devices, procedures, techniques) and formulate evidence-based policy.

CriteriaCareFirst adopts the BlueCross BlueShield Association TEC criteria for determining appropriateness for coverage.

Committee processAssessments are presented to the Technology Assessment Committee (TAC); determinations are made by consensus and become effective the first day of the month following the meeting.

Unbundled procedures (single comprehensive code preferred)

DefinitionUnbundled Procedures — use of multiple procedure codes when a single, more comprehensive code more accurately represents the service; unbundled services will be re-bundled and are not separately reimbursed.

Reporting guidanceAlways report the most comprehensive code(s) available; if the comprehensive code is missing, unbundled services will be re-bundled into the comprehensive code for adjudication.

Modifier guidanceWhen a separate procedure is truly distinct from the primary service, append CPT Modifier -59 per CPT guidelines to indicate distinct procedure.

Unbundled procedures (mapping duplicate)

Definition (duplicate)Unbundled Procedures — when two or more procedure codes are used but a single, more comprehensive procedure code exists; unbundled services are not separately reimbursed.

AdjudicationIf the comprehensive code is covered, it will be eligible for reimbursement; unbundled component codes will be re-bundled into the comprehensive code.

Provider actionReport the most comprehensive code(s) to describe the services provided to avoid re-bundling adjustments.

Incidental procedures — definition and reimbursement implication

DefinitionIncidental Procedures — procedures performed at the same time as a more complex primary procedure and clinically integral to the primary procedure's outcome; not eligible for separate reimbursement when reported with the related primary procedure.

Reimbursement implicationIncidental procedures reported with a primary procedure on the same date of service are not eligible for separate reimbursement.

Examples/guidanceProviders should follow CPT guidelines; use modifiers only when a procedure is truly distinct from the primary service.

Integral / included procedures — definition and reimbursement implication

DefinitionIntegral/Included Procedures — services that are part of an overall episode of care or major procedure and are not eligible for separate reimbursement.

ExamplesPortions of surgical RVUs include supplies/trays (e.g., HCPCS A4550) and other components; such items are considered incidental/included and not reimbursed separately.

Reporting guidanceWhen a service is separate and distinct, append CPT Modifier -59 and document accordingly; otherwise, do not report separate procedures.

Mutually exclusive procedures — definition and reimbursement implication

DefinitionMutually Exclusive Procedures — procedures that represent overlapping services, impossible combinations, or reporting of initial and subsequent services on the same day; typically only the higher RVU/higher valued procedure is reimbursed.

AdjudicationCareFirst's claims system will apply mutually exclusive edits; the higher RVU procedure is usually eligible for reimbursement and the lower is denied.

Provider remedyIf procedures were performed on separate anatomic sites or for distinct indications, append appropriate modifier(s) and provide supporting documentation.

New patient — definition (3-year timeframe)

DefinitionNew patient — a patient who has not had services from the same physician or group in the same specialty in the past three years.

Operational effectEstablished patient E/M must be reported if the patient was seen by the same physician/group within three years; new patient codes reported in error will be denied or converted.

Automatic adjustmentIf a new patient E/M code is reported more than once by the same provider/group within three years, it will be replaced with the corresponding established E/M code.

Significant additional effort — definition for modifier -25

DefinitionSignificant additional effort — additional time required to diagnose and treat the presenting problem and development/initiation of a treatment program by the end of the visit; used to justify modifier -25.

Modifier useAppend CPT Modifier -25 when a significant, separately identifiable E/M service is provided in addition to a preventive service or immunization.

ExamplesMonitoring chronic conditions without a significant change in plan is not considered significant additional effort; problem-focused care or referral during preventive visit is not sufficient for -25.

Integral services — definition

DefinitionIntegral services — services or procedures considered part of the overall service or episode and not eligible for separate reimbursement.

ExamplesHandling and conveyance (CPT 99000-99002) and other routine items considered integral to most procedures.

Reporting guidanceDo not bill integral components separately; use modifiers only when a service is truly distinct from the primary procedure and supported by documentation.

Incidental / mutually exclusive — definition and ineligibility

DefinitionIncidental/mutually exclusive — services that are considered part of another service (incidental) or overlap/are incompatible (mutually exclusive) and therefore are not eligible for separate reimbursement.

ImplicationWhen such services are reported with the related primary procedure on the same date of service, they will not be reimbursed separately.

ExamplesOff-hours services (CPT 99026-99060), hot/cold packs, and certain routine services are treated as incidental or mutually exclusive.

Incidental procedures and supplies — definition and examples

DefinitionIncidental procedures/supplies — items or procedures considered part of another service (incidental) and not eligible for separate reimbursement.

ExamplesSurgical trays (HCPCS A4550) used during office procedures are considered incidental; portions of PE include tray use.

Reporting guidanceDo not submit separate charges for supplies or trays that are included in the procedure RVU; document as part of the procedure record.

Mutually exclusive services — short definition

DefinitionMutually exclusive services — short definition: overlapping or anatomically impossible combinations where only one service is eligible for reimbursement.

AdjudicationClaims edits will select the procedure with the higher RVU for reimbursement when mutual exclusivity is detected.

Provider remedyIf services are distinct by site or indication, append appropriate modifiers and provide documentation.

Modifier guidance (including -79 and -50)

Modifier -79 guidanceAppend CPT Modifier -79 when nasal sinus debridement (CPT 31237) is unrelated to a major procedure (e.g., when both zero/10-day and 90-day global procedures are present).

Modifier -50 guidanceAppend CPT Modifier -50 as appropriate when a procedure is performed bilaterally (many nasal surgery codes are unilateral).

Use caseApply modifier guidance per CPT and document to support separate reporting when required.

Mutually exclusive — duplicate short definition

Short definition (dup) Mutually exclusive — services that overlap or are anatomically incompatible; only the higher valued procedure is usually reimbursed.

ApplicationUsed to map and adjudicate multiple-reporting scenarios where services accomplish the same result.

ResolutionAppend modifiers and provide documentation when services are distinct to avoid mutually exclusive edits.

Imaging agent billing requirement per CMS

RequirementDiagnostic/Therapeutic Imaging Radiopharmaceutical and Contrast Agents — imaging agents will be denied when billed without the requisite imaging procedures as defined by National and Regional CMS Guidelines.

Provider actionEnsure imaging agent charges are billed with the associated imaging procedure(s) per CMS guidelines to avoid denial.

ReferenceAdjudication follows National and Regional CMS Guidelines for requisite imaging procedure pairing.

Policy Summary

PayerCareFirst

PolicyMedical Policy Reference Manual, Claims Adjudication and Payment Procedures

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit complete clinical records when requested for prior authorization, unlisted codes, or claims using certain modifiers to support medical necessity.

SourceLink

On This Page

When multiple procedures performed during the same operative session are not integral to the primary procedure (different sites or separate incisions), report the secondary procedures with modifier -51 (second and subsequent) and appropriate multiple procedure payment reductions apply.

Standby services are not eligible for reimbursement except limited exceptions (e.g., attendance at delivery); consultations and other specialty billing must conform to member contract and documentation rules.

Submissions with certain modifiers (-22, -62, -66, -78) require supporting operative/medical records and may be subject to Medical Review audit.

Unlisted CPT/HCPCS codes require a complete description and records; Medical Review will determine allowance and modifiers are invalid with unlisted codes.

CareFirst reimburses medication and injectable administration only for the amount actually administered; providers should minimize waste and report administered amounts only.

Covered vaccines and injectables are reimbursed per fee schedule; newly recommended vaccines are eligible as of the effective date of USPSTF, AAP, or ACIP recommendations; benefits are contract-defined.

Services rendered during off-hours, weekends, holidays, emergency basis or hospital-mandated on-call (CPT 99026-99060) are considered incidental or mutually exclusive and generally are not eligible for separate reimbursement.

New patient status is defined as a patient without services from the same physician or group in the same specialty within the past three years; new patient E/M codes reported more than once within three years may be replaced with established patient codes.

Complex chronic care coordination services (CPT 99487-99490) are covered and may be reportable in addition to direct E/M services per CPT guidance, with exceptions noted for services not separately reportable during the month.

Care plan oversight services (CPT 99374-99380) may be reported by a supervising physician in addition to direct E/M services where appropriate.

Certain preventive services mandated by ACA must be covered at no cost to members when using in-network providers; use appropriate diagnosis and CPT screening codes for reimbursement.

CareFirst may replace or change E/M code levels after clinical review; it will not automatically reassign levels except for replacing new patient codes with established patient codes per CPT guidance.

Miscellaneous services (e.g., CPT 99071, 99075, 99078, 99080, 99082, 99441-99443, 99090-99091) are considered incidental or are excluded by member contract and are not eligible for reimbursement.

Many procedures performed in the ED are incidental to emergency E/M services (CPT 99281-99285) and not separately reimbursed unless personally performed by the emergency physician and eligible (e.g., wound repair, intubation); global surgical rules and modifier guidance apply.

Hearing aid procedure codes specifying monaural/binaural are eligible only once per date of service; frequency guidance applies (e.g., one per claims submission for codes 92590-92595 and V50 series).

Covered, non-cosmetic lesion removals may be eligible per member contract; when multiple lesion removals are reported together with the same CPT code they are usually considered duplicates or mutually exclusive—append Modifier -59 for distinct lesions performed subsequent to the primary.

Hydration, infusion and injection supplies (select IV fluids, needles, tubing) are considered incidental to infusion/chemotherapy administration and not separately reimbursed; routine injections (CPT 96372) are usually eligible when reported with office E/M per CPT guidance.

Introduction of IV catheter/needle (e.g., CPT 36000) is incidental to anesthesia, select radiology, critical care E/M and other procedures and not eligible for separate reimbursement.

Certain casting supplies (HCPCS A4580, A4590) may be eligible for separate reimbursement when reported with fracture care/casting procedures, per supplies and equipment guidance.

Gender affirmation/dysphoria services are defined by member contract; see referenced medical policies (7.01.123, 7.01.017) and contact gender.services@carefirst.com for assistance.

Report invasive and non-invasive diagnostic tests appropriately considering equipment ownership, place of service, performer, supervisor/interpreter; follow modifier reimbursement guidelines and duplicate services/multiple review rules for adjudication.