ModifiedEmblemHealthPolicy RP20210017

Coding Edit Rules (Commercial, Medicare & Medicaid)

Defines EmblemHealth's procedure and diagnosis code editing rules applied to professional and outpatient facility claims across Commercial, Medicare, and Medicaid products; affects providers submitting claims to EmblemHealth.

Policy Summary

PayerEmblemHealth

PolicyCoding Edit Rules (Commercial, Medicare & Medicaid)

Policy CodePolicy RP20210017

Change TypeEffective date updatesclarifications to laterality and test unit limits

Effective Date

Next Review DateDec 5, 2025

Key ActionProviders should follow EmblemHealth coding edits sourced from industry standards; noncompliance may result in denial or recoupment.

SourceLink

POLICY UPDATE CHANGES

Effective dates for several edits were updated (examples: 3D rendering codes effective date changed to 9/26/2025; multiple edits had effective date updates to 9/26/2025 or 10/15/2025).

Added clarity to Diagnosis Procedure Policy regarding laterality coding when bilateral code exists (excludes breast malignancy codes).

Updated limit language for certain SARS-CoV-2 nucleic-acid based tests to one unit per day unless modifier 59 is present; removed prior code deletions and corrected examples.

Facility & ProfessionalApplies to claim types

36 unitsCardiac rehab limit

200Breast milk bag monthly limit

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Frequent effective date

2021–2025Revision span

Coverage, Denial and Edit-Based Criteria

Edit-based denial and limitation criteria

Specific edit rules that cause denial or payment limitation when conditions are not met.

Ambulance claims lacking appropriate origin/destination modifiers or required arrangement modifiers (QM/QN), or with inconsistent origin/destination modifiers across two lines for the same date/provider/claim → recommend denial.

Emergency ambulance services (A0427, A0429, A0433) billed without permitted destination modifiers (H, I, X) are not payable.

Ambulance mileage or transport billed without a corresponding ambulance transport code on the same date → not payable.

Ambulance transport services billed outside required Place of Service values (not POS 41 or 42 where required) are not payable.

Anesthesia/professional crosswalk rules: surgical codes billed by anesthesiologists or CRNAs that do not crosswalk to an anesthesia code are not payable; when multiple general anesthesia codes (00100-01999) are billed with CRNA modifiers (QX/QZ) payment limited to the code with the highest submitted charge.

Anesthesia services billed without appropriate anesthesia modifiers (AA/QX/QZ) or duplicate anesthesia codes billed for same day may be limited to highest charge or not payable.

Assistant/co-surgeon restrictions: assistant surgeon reporting is limited by policy (only one assistant allowed; documentation required; certain obstetrical global codes may not be payable with assistant modifier); primary surgeon acting as assistant may be denied.

Bilateral procedure reporting must follow CMS bilateral indicators: when bilateral indicator requires modifier 50 (or LT/RT), report as specified and adjust quantity accordingly; reporting same code once with RT and once with LT is not allowed—use modifier 50 and apply 150% payment adjustment.

Denial and limitation criteria based on code, frequency, and packaging

Edits deny or limit payment in the following common scenarios:

Disposable breast milk collection/storage bags (K1005, A4287) are not payable when billed in excess of 200 bags within a calendar month.

Laboratory and ancillary services with CMS packaging/conditional package status indicators (Q4, N, S/T/V) are packaged per CMS OPPS rules and will deny when billed in disallowed combinations or bill types (e.g., Q4 services deny when billed with non-lab services on certain outpatient hospital bill types).

Outpatient cardiac rehabilitation (CPT 93797-93798) beyond 36 units in 36 weeks is not payable unless reported with modifier KX indicating requirements have been met.

Pulmonary rehabilitation (G0424) is not payable when billed to certain outpatient hospital bill types or when lifetime units exceed 36; generally limited to two units per date of service and claims exceeding limits will deny.

Mohs micrographic surgery and surgical pathology reported separately by different providers for the same date of service will be denied.

Coverage criteria and exclusion nodes

Selected examples of coverage criteria and exclusions from this document segment:

High-cost skin substitute application procedures (CPT 15271-15278) billed to specified hospital bill types (0120-012Z, 0130-013Z, 0140-014Z) are not payable unless a qualifying high-cost skin substitute product code has been paid or denied for the same date of service.

Set-up portable X-ray equipment (HCPCS Q0092) is not payable unless transportation of portable X-ray equipment (HCPCS R0070 or R0075) has been billed or paid for the same date of service.

When Mohs surgery (CPT 17311 or 11713) and surgical pathology (CPT codes 88300-88309, 88312, 88313, 88331, 88342, 88344) are reported separately for the same date by different providers, the pathology or Mohs claim lines will be denied.

Vitrectomy CPTs (67005, 67010, 67036, 67039-67043) are payable only for specified indications (e.g., vitreous loss during cataract surgery, vitreous hemorrhage, certain retinal detachments, proliferative retinopathy, vitreous retraction) and are constrained by required revenue code reporting.

Payability criteria and billing rules

Claims are payable only when specific code, diagnosis, modifier, frequency, place of service, and documentation requirements are met as outlined below.

Diagnosis requirement: Many procedure and laboratory codes are not payable without a requisite covered diagnosis present on the claim (examples: vitrectomy, PET oncology services, screening tests); encounter/administrative or manifestation codes cannot be the sole diagnosis.

Modifier requirements: Certain codes require specific modifiers to be present (examples: vaccine/drug modifiers EA/EB/EC for J0881/J0885; co-surgeon modifier 62 with required documentation; PET oncology requires PI or PS), and missing or inappropriate modifiers can cause denial.

Frequency and unit limits: Services limited by frequency or units (examples: lipid testing <=6/year; diabetes self-management training ≤24 combined units/year [non-Medicaid]; obesity counseling ≤22 times/year); claims exceeding specified timeframes/units will deny or be adjusted.

Laterality and sequencing: When laterality-specific ICD‑10 codes exist, unspecified codes are inappropriate; do not report both left and right when a bilateral code exists (exception: breast malignancy). Mutually exclusive ICD-10 combinations (Excludes1) will deny.

Coding edit coverage rules

Claims will be denied or not payable when coding rules or required supporting diagnosis/modifiers are not met. Specific examples and exceptions are listed.

Laterality specificity: Do not report unspecified codes when laterality-specific diagnosis codes exist; report bilateral codes per CMS guidance rather than separate RT/LT pairings (exception: breast malignancy).

Administrative diagnosis principal: Procedures/services reported with an administrative or encounter diagnosis as the principal/primary diagnosis are incorrect coding and not payable.

Preventive E/M exclusions: Non-preventive E/M services billed using preventive medicine CPTs (99381-99412, 99420, 99429) with only a 'Z' ICD‑10 code are not payable.

Chemotherapy and clinical trial requirements: Chemotherapy administration will deny when only antineoplastic encounter codes are present; clinical trial services billed with Q0/Q1 will deny if the required trial participation diagnosis is not present.

Debridement pressure ulcer staging: Debridement CPTs (11042-11047) are not payable when billed with only stage 1 or 2 pressure ulcer diagnosis unless a stage 3/4 or non-pressure chronic ulcer diagnosis is also reported.

Coverage and denial rules

Rules that deny or limit payment based on duplicate services, frequency, modifier presence, place-of-service, and combinations of codes.

Duplicate professional component: Only one professional component for the same service is payable when billed by different providers; duplicate technical component services are likewise not payable.

Lab POS 81 denial: Pathology and laboratory codes (80000-89999) billed by an outpatient hospital will be denied when the same code has been billed by an independent laboratory (POS 81).

DME and supply frequency/unit limits: DME items (enteral feeding kits, intermittent/indwelling catheters, drainage bags) have monthly or three-month unit caps (examples: enteral kits >31/month; intermittent catheters >600 units/3 months; drainage bags >6 units/3 months) and will be denied when limits exceeded.

Modifier and required-identifier enforcement: Many prosthesis/orthosis and DME codes require specific modifiers (LT/RT, KX, AU, GA, GZ) to avoid denial; lack of required modifier triggers denial.

Extracted coverage and billing criteria

Selected coverage/deny criteria and billing rules extracted from the coding edits include:

Urological supply rules: Examples (A4310, A4332) — urological supplies and lubricants billed by the same provider on the same date may be not payable per DME policy.

Parenteral nutrition compounds: Amino acid/carbohydrate parenteral nutrition compounds (B4189-B4199) and parenteral supply kits (B4220/B4222) are limited to a maximum of 31 units per month; excess units will be denied.

DME modifier requirements: Many DME, pressure-reducing devices, and orthotics require modifiers (KX, GA, GZ, AU) to avoid denial; absence of required modifier results in denial.

Quantity/frequency limits for supplies and devices: Drainage bags (A4357), home glucose monitors (E0607), and diabetic footwear/inserts (A5500-A5514) are subject to unit/timeframe limits and will be denied or adjusted when exceeded.

Place of service constraints for DMEPOS: Certain DME items are payable only when reported with specified POS codes for DMEMAC providers; billing outside permitted POS may cause denial.

Global obstetric claim requirements

Global obstetrical billing requirements and example reporting

When billing global obstetric codes for NYS Medicaid members, claims must include Category II CPT codes for prenatal/postpartum services: 0500F (Initial Prenatal Visit), 0502F (Subsequent Prenatal Visit) and 0503F (Postpartum Visit) for each corresponding visit provided within the global period; claims submitted without these Category II CPT codes will be denied.

Example reporting: Routine vaginal delivery plus prenatal/postpartum units can be reported as shown in policy example: 1 unit CPT 59400; 1 unit CPT 0500F; 7 units CPT 0502F; 1 unit CPT 0503F for a member with 8 prenatal visits and 1 postpartum visit.

Global surgery and E/M billing constraints

Global surgery and postoperative evaluation & management (E/M) restrictions

E/M services performed within postoperative global periods (0, 10, 90 days) are generally not payable as specified: E/M services same day, day prior, or within the postoperative window are denied when related to the procedure and billed by the same Provider ID (or by NPPs under same Tax ID in specific scenarios).

Modifier 25/24 rules: E/M services billed with modifier 25 or 24 on the same day as procedures with a 0/10/90-day global period are not payable under specified conditions (same primary diagnosis, within defined timeframes) unless documentation supports a distinct service as defined by policy.

Certain care management and transitional care services (CPT 99487-99491, 99495-99496, G2058, etc.) are not payable when performed within 10 postoperative days of a 10-day service or when overlapping with global periods per CMS/Cotiviti guidance.

Provider-relationship enforcement: E/M denial rules may depend on Provider ID vs Tax ID relationships (same Provider ID regardless of Tax ID and Specialty, or NPP with same Tax ID regardless of Provider ID) as specified in global surgery policy.

Laboratory and COVID coding rules

Laboratory and COVID testing coding constraints

COVID specimen collection (G2023, G2024) is considered integral to COVID testing and is not separately reimbursable when a COVID test is rendered.

Co-billing restrictions: Specific COVID lab codes (U0002, U0003, U0004, 87635 and related CPTs) have co-billing prohibitions and are not payable when billed with certain other COVID lab codes or when previously billed/paid on the same date by any provider.

Nucleic-acid SARS‑CoV‑2 tests listed (e.g., 87631, 87635-87637, 87811, U0001, U0003, etc.) are limited to one unit per day unless reported with modifier 59; 0240U/0241U were terminated effective 7/01/2025 per policy update.

Laboratory-pathology coverage constraints

Surgical pathology and laboratory supply rules

Surgical pathology gross & microscopic exam codes (e.g., 88304, 88305, 88307, 88309) are not payable when the only diagnosis on the claim line is a specified single-diagnosis list (examples: hemorrhoid, hydrocele/spermatocele, polyp, cornea, ganglion cyst, appendix, gallbladder, sterilization encounter Z30.2).

Modifier QW (CLIA waived) is not payable when billed with a procedure code that is not designated as CLIA waived on the clinical laboratory fee schedule.

Supplies inherent to laboratory services (e.g., dipsticks, syringes, swabs) are considered part of the lab service and not separately reimbursable.

Unit limits: Codes billed for units exceeding allowed or assigned annual/daily units are not payable per the Maximum Units Policy; appeals may require documentation where allowed by MAI rules.

Coding edit enforcement rules

Payment denial and adjustment rules apply when coding edits detect noncompliance with modifier usage, unit limits, MUEs, NCCI pairs, or multiple procedure reductions.

MUE enforcement: If a claim line quantity exceeds the MUE allowed value (MAI=1) that line will be denied; MAI=2 and MAI=3 are date-of-service edits with no modifier override (modifier 59 will not override MAI=3); clinical documentation may be submitted on appeal where allowed.

Modifier/compatibility enforcement: Procedures incompatible with specific modifiers (e.g., modifier 92, anatomical modifiers where not applicable) are not payable; codes requiring anatomical or distinct modifiers and billed without them will be denied.

Multiple procedure reduction: Modifier 51 or rank-based multiple-procedure reductions are applied per CMS rules; modifiers appended to ineligible codes will be denied or payment adjusted.

NCCI column edits

NCCI edits prevent separate payment of column two codes when billed with column one codes; rules apply to mutually exclusive and non-mutually exclusive pairs.

Column two denial: Column two procedure codes are not payable when billed with an associated column one procedure code; this applies to mutually exclusive and non-mutually exclusive pairs and enforces denial when billed by the same Provider ID regardless of Tax ID or Specialty.

Column one non-payable when column two paid: Column one procedure codes may be denied when a related column two procedure code has been previously paid for the same date of service, including DME-specific column edits and facility considerations.

Maximum units policy

Maximum units policy limits units per day or per defined timeframes and enforces denials or adjustments when exceeded.

Excess units adjustment and denial: When billed units exceed assigned allowed daily or annual units for a procedure/item, excess units will be adjusted to the allowed amount and excess denied for any provider; some state-specific limits (e.g., topical fluoride, allergen IgE) apply as specified.

Example state limits: CDT D1206/CPT 99188 limited to one unit per 3 months (age 6 months-6 years) for NY Medicaid; CPT 86003 allergen-specific IgE limited per NY Medicaid guidance per revision history.

Non-payable and constrained coding scenarios

Coding edits that result in denial or non-payment under specified circumstances:

Column and mutually exclusive denials: Column one or column two codes may be denied depending on previously paid lines or paired billing relationships; mutually exclusive code pairs will result in denial per NCCI rules.

Diagnosis-based noncoverage: Procedure lines may be denied when paired with ICD‑10 diagnosis codes included on CMS non-payable/NCD exclusion lists.

Frequency and place constraints: Specific procedures have frequency/unit limits (ophthalmology imaging, polysomnography, neuromuscular testing) and place-of-service constraints (e.g., IONM payable only in specified POS); violations result in denial.

Never events: Procedures billed with modifiers PA/PB/PC (wrong body part/patient/surgery) are not payable as never events.

Extended ophthalmoscopy criteria

Ophthalmology code coverage limitations

Extended ophthalmoscopy (CPT 92201-92202) is not payable when billed without an appropriate diagnosis or when billed with fundus photography (92250); frequency limits apply by diagnosis: not payable >2 times/eye/year without diagnosis, >4 times/eye/year with neoplasm, >6 times/eye/year with disorders of globe/choroid/retina/iris/ciliary body or glaucoma, and up to 12 times/eye/year for exudative senile macular degeneration as specified.

Visual field (92081-92083) and scanning ophthalmic imaging (92132-92134) are not payable without requisite diagnosis; scanning imaging 92134 has additional frequency constraints (e.g., not payable more than once within 28 days for retinal disease).

Place of Service criteria

Place-of-service coverage constraints for E/M and other services

E/M and consultation POS restrictions: Many new and established office/outpatient visit codes (99201-99205, 99211-99215, etc.), observation codes, initial inpatient consultations (99251-99255), and other E/M groups are payable only in specified POS lists; claims billed in POS values not on the allowed list will be denied (telehealth POS 02 allowed in some exceptions per policy).

Home visit and nursing facility POS rules: Home visit E/M codes (99341-99350) payable only in POS 02 (Telehealth) or 12 (Patient's home); nursing facility E/M codes limited to specified facility POS values with telehealth exceptions as described.

Scope of practice exclusions

Scope-of-practice and specialty-specific denials

Scope-of-practice exclusions: Procedures or services billed by providers outside their licensed specialty scope (examples: audiology, physical therapy, clinical psychology/social work billing E/M, pathology, podiatry, chiropractic procedures requiring anesthesia) are not payable.

Specialty restriction example: Determination of refractive state (CPT 92015) is not payable when provider specialty is not Ophthalmology or Optometry.

Modifier and component rules

Modifier and component billing rules

PC/TC and modifier enforcement: Modifiers 26 (professional) and TC (technical) must be used appropriately; 26 and TC cannot be appended to the same claim line; technical-only services are not payable to professional providers in facility settings and professional-only codes are not payable with TC in facility contexts.

Immunization pairing requirement: Immunization administration codes (90460-90461, 90471-90474) are not payable unless billed with the appropriate vaccine/toxoid code on the same date of service.

Place of Service rules

Place of service constraints

POS mismatch denials: Many E/M, consultation, observation, and other service codes are not payable when billed in POS values that do not match the code-specific allowed POS lists (examples and detailed lists provided in policy); telehealth and certain POS exceptions apply as specified.

Outpatient consultation POS restriction: Office/outpatient consultation codes (99241-99245) are not payable when billed in POS 21 (Inpatient hospital) or other disallowed POS values per policy.

Non-payable and bundling criteria

Key criteria that will cause non-payment or bundling:

Specialty restriction: Determination of refractive state (CPT 92015) is not payable if provider specialty is not Ophthalmology or Optometry.

Rib x-ray mutual exclusivity: CPT 71101-LT is not payable when billed with 71101-RT; CPT 71111 represents bilateral imaging and additional unilateral/bilateral rib series are not payable if another rib series was paid the same date.

3D rendering bundling: CPT 76376 and 76377 (3D rendering) are considered integral to the primary imaging service and are not separately reimbursable (effective date updated in revision history).

Revenue code HCPCS requirement: Revenue codes that CMS OPPS requires a HCPCS will be denied when submitted without the required HCPCS on specified bill types; edit fires only when no HCPCS present.

Telehealth modifier misuse: Services billed with telehealth modifiers (G0, GQ, 95) inappropriately or with incorrect POS will be denied.

Selected coding edit criteria

Selected edit rules and clarifications that affect coverage adjudication and billing practices.

Post-operative nasal endoscopy: CPT 31237 (post-op nasal endoscopy with debridement) is not payable when billed more than 3 times within six weeks following nasal/sinus endoscopy surgery; CPT 31231 (diagnostic endoscopy) will not be reimbursed separately following a surgical procedure with a 10-day or 90-day global period.

Allergen-specific IgE (86003) limits: CPT 86003 unit limits have changed across revisions (examples: NY Medicaid limits and updates to 30–40 units per year or 30 units per 5 years depending on claim type and effective dates); check applicable effective dates for claim type.

Glucose monitor equipment noncoverage: HCPCS A9275-A9279 are not payable as they do not meet CMS definition of DME.

SARS‑CoV‑2 NAAT unit limit: Nucleic-acid based SARS‑CoV‑2 tests are limited to one unit per day unless reported with modifier 59; 0240U/0241U termination and other revision history changes are documented in policy revisions.

Code-Specific Rules, Limits and Status

Allergy Testing — Professional/Facility limitsCPTCovered

86003	Allergen specific IgE — limited to 40 units per year (facility/professional) effective 3/1/2023; previously limited to 30 units per year (terminated 2/28/2023).
95004	Percutaneous tests — limited to 60 units in a five-year period when billed by any provider (P) effective 9/15/2021.
95017	Allergy testing — limited to 60 units in a five-year period when billed by any provider (P) effective 9/15/2021.
95018	Allergy testing — limited to 60 units in a five-year period when billed by any provider (P) effective 9/15/2021.
95024	Intradermal tests with allergenic extracts — limited to 40 units in a five-year period when billed by any provider (P) effective 9/15/2021; facility limit: included in 137 units per year aggregate for selected allergy studies (F) effective 3/1/2023.
95027	Intradermal tests with allergenic extracts — limited to 40 units in a five-year period when billed by any provider (P) effective 9/15/2021.
95028	Intradermal tests with allergenic extracts — limited to 40 units in a five-year period when billed by any provider (P) effective 9/15/2021.
95044	Patch tests — limited to 40 units in a five-year period when billed by any provider (P) effective 9/15/2021.
95165	Professional services for supervision of preparation and provision of antigens for allergen immunotherapy — limited to 137 units per year when billed by any provider (F) effective 3/1/2023.

Bilateral / Duplicate Ocular Biometry — Not payable examplesCPTNot Covered

76519	Ophthalmic biometry by ultrasound echography with IOL power calculation — not payable when billed twice on same date of service (global or otherwise).
92136	Ophthalmic biometry by partial coherence interferometry with IOL power calculation — not payable when billed twice on same date of service (global or otherwise).

Anesthesia Billing Rules — Covered with criteria / restrictionsCPTCovered

00100-01999

General anesthesia codes — reimbursement and frequency limited to the code with the highest submitted charge when multiple general anesthesia service codes are billed; special crosswalk rules apply for anesthesiologists and CRNAs; anesthesia services not payable when billed by CRNA without appropriate CRNA modifiers (QX, QZ).

Breast Milk Bag Supply Limits — Not payable when exceeding monthly limitHCPCSNot Covered

K1005	Disposable collection and storage bags for breast milk — not payable when limit of 200 milk bags is exceeded within a calendar month.
A4287	Disposable collection and storage bags for breast milk — not payable when limit of 200 milk bags is exceeded within a calendar month.

CMS Packaging / OPPS Status Indicator Groups — Packaged/Conditional packaging examplesmixed

Status indicator Q4	Laboratory services subject to conditional packaging — may be paid separately only when the lab is the only service on outpatient hospital bill types 0130-013Z; otherwise packaged when billed with an OPPS payable service.
Status indicator N	Items and services packaged into APC rates — no separate APC payment when billed by outpatient hospital.
STV-Packaged (S/T/V)	Services considered packaged when billed on same day as a code with APC status S, T or V; STV-packaged service will deny when billed with an STV service.
T-Packaged	Certain ancillary HCPCS codes considered packaged in presence of a T-status service — denied when billed with a code with APC status indicator T.

Cardiology Study Bundling and Frequency Rules — Not payable examplesCPTNot Covered

78451	Myocardial perfusion imaging; single study — not payable when billed more than once on the same claim for same or previous date of service (facility).
93260-93261,93282-93284,93289,93292	Programming/interrogation device evaluation (in-person) — not payable when billed greater than once in a three-month period for diagnoses indicating presence of an implantable cardiac defibrillator.
93228-93229,93268-93272	External mobile cardiovascular telemetry or external patient activated ECG event recording — not payable when billed more than once in a six month period by any provider (terminated 3/26/2023 for some edits).
93922-93931	Arterial studies — not payable when billed with venous studies (93970-93971) without supporting arterial diagnosis.

Pulmonary Rehabilitation Limits — Not payable examplesHCPCSNot Covered

G0424

Pulmonary rehabilitation — not payable when billed with bill type 0130-013Z and revenue code not 0948; not payable when billed for more than 36 units in a patient's lifetime by any provider; not payable beyond two units per date of service.

Mohs and Surgical Pathology Coordination — Not payable examplesCPTNot Covered

17311	Mohs micrographic surgery — when reported separately from surgical pathology examination (88300-88309, 88312, 88313, 88331, 88342, 88344) by different providers for same date of service, one or both may be denied as per CMS guidance.
11713	Mohs micrographic surgery (alternate code) — same coordination rules with surgical pathology as above.
88300-88309,88312,88313,88331,88342,88344	Surgical pathology exam codes — may be denied when billed separately for same date of service as Mohs by different providers unless billing/clinical circumstances meet coverage rules.

Portable X-ray Non-payable / Packaged ExamplesHCPCSNot Covered

Q0092	Set-up portable X-ray equipment — not payable when billed and transportation of portable x-ray equipment (R0070 or R0075) has not been billed or paid for same date of service.
R0070	Transportation of portable x-ray equipment — example transport code referenced in portable X-ray set-up rule.
R0075	Transportation of portable x-ray equipment — example transport code referenced in portable X-ray set-up rule.

Vitrectomy Payment Conditions — Covered with criteria / Not payable without diagnosis or revenue codeCPTCovered

67005,67010,67036,67039-67043

Vitrectomy codes — only payable when rendered to treat specified conditions (vitreous loss incident to cataract surgery, vitreous opacities due to hemorrhage or other causes, retinal detachments secondary to vitreous strands, proliferative retinopathy, vitreous retraction) and when billed with appropriate revenue codes (0360-0369 or 0490-0499 for facility) as applicable; not payable without required diagnosis or correct revenue code.

HIV Screening / Obstetric Panel Restrictions — Not payable when over-frequency or without diagnosisCPTNot Covered

80081, G0432, G0433, G0435, G0475

HIV screening tests/obstetric panel — not payable when billed more frequently than three times per term of pregnancy by any provider (P) or when billed without a screening HIV diagnosis as applicable.

Laboratory Frequency / Diagnosis Restrictions — Not payable examplesCPTNot Covered

87086,87088	Bacterial urine cultures — not payable when billed without a covered diagnosis.
82728	Ferritin — not payable when billed without a covered diagnosis or more than once in a 90-day period for ESRD diagnosis (P).
82378	Carcinoembryonic antigen — not payable when billed without a covered diagnosis or more than twice in a patient's lifetime for certain diagnoses.
U0001,U0003,U0002,U0004,87635,87631,87636-87637,87811	COVID-19 nucleic-acid and related test codes — subject to unit/day limits and mutual exclusivity rules; certain combinations are not payable when billed together or when duplicate high-throughput variants are billed the same date of service (effective 2/01/2022); some codes terminated per revision history.

Medical Nutrition Therapy / MNT Rules — Covered with conditionsCPTCovered

97802-97804,G0270,G0271

Medical nutrition therapy codes — subject to provider type restrictions (registered dietitian, nutritional professional, or hospital), frequency limitations, and coupling rules (G0270/G0271 reassessment/subsequent intervention not payable unless 97802-97804 billed within same calendar year). Additional unit limits applied historically; see policy for current allowable units.

Procedure-specific Payability Examples — Multiple covered/conditional examplesmixedCovered

G0424	Pulmonary rehabilitation — see separate entry for limits; covered when billed with appropriate bill/revenue codes and within frequency limits.
J1642	Heparin lock flush (per 10 units) — not payable (facility).
A4648,A4650	Tissue marker / implantable radiation dosimeter — not payable when placement procedures (10035-10036,19081-19086,19281-19288 etc.) not billed or paid for same date of service.

Screening and Diabetes-related Codes — Coverage / Frequency examplesmixedCovered

G0101,Q0091	Screening pelvic exam / Pap smear services — subject to frequency restrictions; Q0091 not payable for low risk more than once in two-year period when billed by any provider.
G0245-G0247	E/M and routine foot care services for diabetic LOPS — not payable without appropriate diabetes with neurological complications diagnosis; frequency coupling rules with routine footcare apply.
80061,82465,83718,83721,84478	Lipid testing — limited to six times per year in any combination by any provider.

New CPT Restriction / Status Indicators — Examplesmixed

61715

MRgFUS for Tremor (HCPCS 61715) — not payable without diagnosis of Tremor-Dominant Parkinson's disease or Essential Tremor (effective 1/1/2025).

Intravitreal Drugs, JW/JZ and Device Linkage — Drug wastage and administration rulesHCPCSNot Covered

J2778,J0178,J7312,J7313,J7316	Intravitreal drug codes — not payable when billed without intravitreal injection procedure (CPT 67028) or when intravitreal injection lacks laterality modifier (LT/RT/50) as required; JW modifier rules apply as noted in Drug and Biological Policy.
JW	Modifier JW (drug amount discarded) — denied for drugs dispensed in single-use vials when billed with JW and billed units equal or exceed package insert units; multiple HCPCS-specific JW unit thresholds defined (examples J9035, J9041, J9044, J9055, J0585, J1745, J0587, J0588, J9171 with specified unit cutoffs).

Duplicate Services — Professional/Technical duplicate rulesmixedNot Covered

professional component duplicates

Only one professional component for the same service is payable when billed by different providers; identical codes billed same date by NPP with same Tax ID and matching diagnoses are not payable.

Pharmacy / DME Dispensing Fee and Diabetic Footwear — ExamplesHCPCSNot Covered

Q0514,Q0513,G0333	90-day and 30-day pharmacy dispensing fee codes — not payable when billed within restricted timeframes or without the inhalation drug on same claim per policy.
A5500,A5501,A5503-A5514	Diabetic footwear and inserts — diabetic footwear A5500-A5501 limited to 2 units per calendar year; inserts A5503-A5514 not payable when billed with orthopedic footwear or more than six units per calendar year.

Urological Supplies, Catheters and Related Limits — Not payable / quantity limitsHCPCSNot Covered

A4351-A4353	Intermittent urinary catheters — not payable for more than 600 combined units per three months.
A4311-A4316,A4338-A4346	Indwelling catheters — not payable when reported for more than three units within three months when billed in combination.
A4357	Drainage bags — not payable for more than six units within a three-month span when billed individually or as part of catheter change.
A4216,A4217	Sterile saline — not payable when billed with oropharyngeal suction catheter (A4628) or when a tracheal suction catheter (A4605/A4624) has not been billed within same month.
E0194,E0935,E0575	Large equipment / devices — subject to place-of-service, timing, and unit limits (examples: air fluidized bed, ultrasonic osteogenesis stimulator, large volume nebulizers).
A5500-A5501	Diabetic footwear — not payable when more than 2 units billed within a calendar year (facility/professional updated inclusion).

E/M Billing Edits and New Patient Codes — Coverage / Not payable scenariosCPTNot Covered

99201-99205,99211-99215,99202-99205	New and established office/outpatient visit codes (99202-99205, 99211-99215) — not payable when billed in places of service other than allowed POS values as specified in Place of Service Policy; E/M codes are subject to multiple edits (global surgery, critical care, modifier 25, same-day co-billing restrictions).
99221-99223,99231-99233,99238-99239,99291-99292	Hospital initial/subsequent/discharge and critical care codes — subject to timing, sequencing, and mutual exclusivity rules (e.g., not separately payable when billed with critical care 99291 in same POS unless distinct service modifiers and documentation support).
new patient frequency	New patient codes are not payable when a face-to-face service has previously been billed and paid by the same provider within the last three years (New Patient Code Frequency Policy).

Global Surgery / E/M Postoperative Period Edits — Not payable examplesCPTNot Covered

01996	Daily management of epidural or subarachnoid drug administration — not payable when billed with a 0-day, 10-day or 90-day surgical procedure.
modifier 24/25 interactions	E/M services billed with modifier 24 or 25 during global periods or postoperative windows are often not payable per global surgery policy; see policy for specific 0/10/90-day rules and provider/Tax ID constraints.

Surgical Pathology Exclusions — Not payable examplesCPTNot Covered

88304,88305,88307,88309	Surgical pathology gross & microscopic exam — not payable when the only diagnosis on the claim line is certain listed diagnoses (appendix, gallbladder, hemorrhoid, cornea, polyp, ganglion cyst, hydrocele/spermatocele) or when billed for sterilization encounters without requisite clinical support.
QW modifier	Modifier QW (CLIA waived test) — not payable when billed with a procedure code not designated as CLIA waived on the CLFS.

Medically Unlikely Edits (MUE) and Maximum Units — Unit limit enforcement examplesmixedNot Covered

MUE (MAI 1/2/3)	CMS Facility and Professional MUEs enforced — claim line denial or date-of-service edits when allowed MUE units exceeded; MAI rules dictate modifier override allowance and appeal guidance.
units with anatomical modifiers	Units of service greater than 1 are not payable for codes with anatomical modifiers (E1-E4, FA-F9, TA-T9) unless guidelines permit multiple units; excess units adjusted/denied per Maximum Units Policy.

NCCI / Column One-Two Edits and TEE-Anesthesia Interaction — Not payable examplesCPTNot Covered

NCCI column two vs column one	Column two procedure codes are not payable when billed with associated column one procedure codes (mutually exclusive or non-mutually exclusive), including DME column edits; denials apply when billed by same Provider ID regardless of Tax ID or specialty.
TEE (93312-93317,93318,93355) and anesthesia (00100-01999)	Transesophageal echocardiography (TEE) codes are not payable when billed with anesthesia services unless appropriate distinct service modifiers are present; certain TEE codes require modifier to indicate distinct service.

EEG and Neurology Sequencing Rules — Not payable examplesCPTNot Covered

95937	EEG methods — not payable beyond two units per day for certain diagnoses (motor neuron disease, muscular dystrophies, etc.).
95957,95700-95726	Digital analysis EEG and long-term EEG monitoring — 95957 not payable when billed same date as long-term EEG monitoring codes by any provider; other sequencing rules apply.

Ophthalmology Frequency / Diagnosis Constraints — Covered/Not payable examplesCPTCovered

92201-92202	Extended ophthalmoscopy with retinal/optic nerve drawing — not payable without appropriate diagnosis; frequency limits per diagnosis (multiple thresholds e.g., >2, >4, >6, >12 times per eye per year depending on diagnosis).
92250	Fundus photography — not payable when billed more than two units within one year except when specific diagnoses present.
76514	Ophthalmic ultrasound corneal pachymetry — not payable more than once in a patient's lifetime with glaucoma or ocular hypertension diagnosis.

Place of Service and POS-Restricted E/M Codes — Not payable examplesCPTNot Covered

99202-99205,99211-99215	New and established office/outpatient visit codes — not payable when billed in places of service other than allowed POS values; POS-specific restrictions apply (see Place of Service Policy).
99241-99245	Office/outpatient consultation codes — not payable in many POS values outside the allowed list; consult POS restrictions apply.
99406-99407	Smoking and tobacco cessation counseling — not payable when billed without a diagnosis of tobacco or nicotine dependence and frequency limited to eight units per year in some settings.

Immunization and Procedure Pairing Requirements — Covered when paired appropriatelyCPTCovered

90460-90461,90471-90474	Immunization administration codes — not payable when billed without an associated vaccine/toxoid code on same date of service; pair with 90476-90750,90756,J3530,Q2033-Q2039,S0195 as applicable.
S0620-S0621,99188	Ophthalmology screening / visual acuity and related codes — pairing and frequency rules apply; certain codes considered components of other services and not separately reimbursable.

Radiology / 3D Imaging and Rib X-ray Rules — Not payable examplesCPTNot Covered

76376,76377	3D rendering of imaging services — considered integral to primary service and not separately reimbursable.
71100,71101,71110,71111	Rib x-ray series — mutual exclusivity rules; unilateral codes not payable when billed with opposite laterality; bilateral code 71111 is for bilateral studies; additional rib series not payable when another rib series previously paid for same date of service.

Separate Procedures, Add-on Codes and Bundling — Not payable when primary absentmixedNot Covered

add-on CPT codes	Add-on CPT codes are not payable when the primary code has not been billed and paid for the same date of service by the same provider; separate procedure designations not payable when submitted with a related major procedure by same provider on same date of service.
99050,99051,99053,99056,99058,99060,99026,99050	E/M add-on codes — not payable in certain POS or when billing rules for emergency/urgent care apply; must follow Place of Service Policy.

Revision / Effective Date Notes and Policy Referencesmixed

policy revisions

This coding section consolidates multiple policy edits and effective dates. See revision history entries (e.g., 2/01/2022, 3/01/2023, 9/01/2021, 10/15/2024, 9/26/2025, etc.) for time-based applicability and terminated edits. Providers must reference the current policy effective dates and payer bulletins for enforcement timelines and terminated code guidance.

Quantity, Frequency and Unit Limits (Key Values)

Allergy testing unit limits — examples

Example CPT code86003 — Allergen-specific IgE; unit limits revised (30 units per 5 years for NY Medicaid in earlier revisions; updated to 40 units per year effective 3/1/2023; facility claims included effective 10/15/2025).

Example skin testing codes95024, 95027, 95028 (intradermal tests) — limited to 40 units in a five-year period (effective 9/15/2021).

Percutaneous/patch tests95004 (percutaneous) and 95017-95018 — limited to 60 units in a five-year period (effective 9/15/2021).

Breast milk bag limit — monthly limit and not payable threshold

Affected HCPCSK1005, A4287 — disposable breast milk collection/storage bags.

Monthly cap200 bags per calendar month — items not payable when this limit is exceeded.

Provider Obligations, Billing Guidance and Denial Risks

Denial Risk

General provider obligations and consequences

Follow coding edits or risk denial or recoupment. Providers must follow all coding edits in this section; unresolved edit exceptions may result in claim denials, payment recoupment, or requests for additional documentation.

Providers must bill correctly for add-on codes and ensure primary procedure is present when required.
Adhere to CMS and plan-specific unit limits (e.g., allergy testing unit limits).

Billing Rule

Modifier override rule

When modifier -59 (distinct procedural service) is reported on the same claim line with modifier -50 (bilateral), the system default is to override the edit and allow the claim line when -59 is present. Ensure -59 is used only when documentation supports a distinct procedural service separate from the bilateral procedure.

Key Definitions and Terms

Code editing — definition and scope

Code editingApplication of industry-standard and proprietary edits to procedure and diagnosis codes on professional and facility claims to determine appropriate payment or denial

SourcesEdits sourced from CMS, CPT/AMA, LCDs, HCPCS, ICD-10, FDA, specialty organizations, and EmblemHealth policies

ScopeApplies across claim types and providers; noncompliance may result in denial or recoupment

Bilateral indicator

DefinitionBilateral indicator — CMS-provided code attribute guiding whether bilateral modifiers (50, LT, RT) apply and how quantities should be billed

Billing effectSome codes require modifier 50 and a quantity of 1; others should be billed RT/LT or not billed with bilateral modifier depending on indicator code (0–3,9)

Revision History and Material Changes

5/13/2025revision

Post-operative nasal endoscopy guidance clarified: CPT 31237 not payable when billed >3 times within six weeks after surgery; CPT 31231 not reimbursed separately following procedures with 10- or 90-day global periods.

6/18/2024revision

Multiple edits added effective 10/15/2024 and other effective-date updates (6 new edits effective 10/15/2024); earlier revision log notes several new edits across 2024–2025.

3/14/2025revision

Policy Summary

PayerEmblemHealth

PolicyCoding Edit Rules (Commercial, Medicare & Medicaid)

Policy CodePolicy RP20210017

Change TypeEffective date updatesclarifications to laterality and test unit limits

Effective Date

Next Review DateDec 5, 2025

Key ActionProviders should follow EmblemHealth coding edits sourced from industry standards; noncompliance may result in denial or recoupment.

SourceLink

On This Page

Examples: Additional code/frequency examples that trigger denial or limitation: pneumococcal vaccine lifetime/interval restrictions; annual wellness and screening visit frequency limits as specified in policy.

HIV screening codes (G0432, G0433, G0435, G0475) require an appropriate screening diagnosis and are not payable when patient age or place of service restrictions are not met.

Place of Service restrictions: Certain diagnoses and services will be denied when billed with disallowed POS values (example: claims with acute stroke I63.- or sepsis A41.- denied when billed in POS 11, 2, 19, 22, 31, 50 per policy).

Status indicator and packaging: Codes assigned CMS status indicators (I, N, Q4, S/T/V, etc.) are subject to packaging rules; packaged or conditional-packaged services will be denied when billed in disallowed combinations or bill types per OPPS/CLFS guidance.

DME ownership and rental enforcement: Deny DME rental when the same item is beneficiary-owned in history; enforce ownership modifiers (-NU, -NR, -UE) and rental modifiers (-RR) and capped rental limits per CMS-defined rules.

Drug wastage submission: Reporting wastage from single-dose vials with JW requires two claim lines (administered drug without modifier + wasted units with JW) or JZ when no wastage; HCPCS-specific JW unit thresholds will deny when exceeded.

Intravitreal injection linkage: CPT 67028 must include laterality modifiers (LT/RT/50) when billed with intravitreal drug HCPCS (e.g., J2778, J0178) and drug codes billed without corresponding procedure or modifier linkage will deny.

Duplicate services: Duplicate professional or technical component services billed by different providers for the same service are not payable; identical codes billed by NPPs under same Tax ID may be denied per duplicate logic.

Claim validity and diagnosis specificity: Claim lines without at least one valid, specific diagnosis code (highest-level ICD-10 specificity) are not payable.

Selected drug/biologic examples: Specific HCPCS drug codes (e.g., J0205, J7312, J7313, J2778, J0178) are not payable when required accompanying procedure codes, FDA-approved indications, or modifiers are missing.

Pharmacy dispensing fee rules: 30-day and 90-day dispensing fee codes (G0333, Q0513, Q0514) have co-billing and timing restrictions and will deny when billed improperly or within restricted windows.

Specific non-payable HCPCS items: Certain HCPCS codes (e.g., disposable nebulizers A7008, glucose monitor equipment A9275-A9279, dual mode battery chargers E2367, batteries E2358/E2360 etc.) are designated non-payable per policy.

Prosthetic repair and replacement rules: Repair labor services and replacement parts have timing constraints (e.g., not payable within 3 months of prosthesis billing; diagnostic sockets limited to two per date/site); claims violating these rules will be denied.

Oxygen and accessories: Oxygen systems, rentals, and accessories follow purchase vs rental restrictions and monthly limits; accessories billed in prohibited combinations or frequencies will be denied.

E/M service exclusion rules: Telephone E/M (99441-99443) and observation/initial care codes have exclusionary timing and sequencing rules relative to other E/M services (same-day, prior day, subsequent day restrictions).

Infusion pump supply coverage: Supplies for external infusion pumps (A4222, A4225, K0552) are covered only during period of covered pump use with allowance based on cassettes/bags/syringes used; intermittent/continuous rules apply.

Unbundled/incidental services: Services considered integral or incidental to a primary procedure (venipuncture with lab, intraoperative monitoring by operating surgeon, etc.) are not separately payable.

Bilateral reporting clarification: If the same code is reported once with RT and once with LT, report with modifier 50 for one unit; the 150% payment adjustment will apply per policy clarification.

Modifier override noteDefault override available if modifier -59 (distinct procedural service) is reported on same claim line with modifier -50 (per policy context).

breast milk bag monthly limit — numeric

Monthly cap (numeric)200 bags per calendar month

Codes referencedK1005, A4287

Effective datePolicy entry effective 1/1/2023 for breast milk bag limit

Cardiac rehabilitation unit limit

Unit limit36 units per 36 weeks for outpatient cardiac rehabilitation (CPT 93797-93798)

Modifier required to exceedModifier KX must be appended to avoid denial when exceeding 36 units in 36 weeks

ApplicabilityApplies to any provider; edits in CMS Coverage Policies as noted

Pulmonary rehabilitation limits

Lifetime limitPulmonary rehabilitation (HCPCS G0424) limited to 36 units lifetime

Per-date limitMaximum two units per date of service (claims beyond deny)

Bill type restrictionNot payable when billed to certain outpatient hospital bill types without proper revenue code (per CMS packaging guidance)

Smoking/tobacco cessation visit limit

CodesCPT 99406, CPT 99407 (smoking/tobacco cessation counseling)

Annual unit capMaximum 8 units per year in any combination by any provider

Effective datePolicy effective 1/01/2018 for this limit

G0166 unit limit

CodeHCPCS G0166

LimitNot payable when greater than 35 units billed within a two-month period

Effective datePolicy effective 1/01/2018

PSA frequency limit

TestPSA — CPT 84153 (Prostate specific antigen, total)

Frequency ruleDenied when billed more than once per year for diagnoses indicative of lower urinary tract signs/symptoms

Related codesG0102, G0103 referenced for prostate screening service rules

Service frequency limits — assorted examples

Diabetes trainingDiabetes self-management training limited to 24 combined units per year (40 units under Medicaid in some entries)

Obesity counselingFace-to-face behavioral counseling for obesity (G0447/G0473) not payable when billed more than 22 times per year

Lipid testingLipid testing maximum 6 times per year (example frequency limit)

HCPCS-specific JW unit thresholds — examples

Example J-codes and JW thresholdsJ9035 / Q5107 / Q5118 — not payable with modifier JW when units ≥10; J9041/J9044 — JW units ≥35; J9055 — JW units ≥10; J0585 — JW units ≥100

Additional examplesJ1745, Q5103/Q5104/Q5109/Q5121 — JW units ≥10; J0587 — JW units ≥25; J0588 — JW units ≥50; J9171 — JW units ≥20

Billing requirementWhen reporting wastage with JW, submit separate claim line for administered drug and wasted units per CMS guidance

Intermittent catheter unit limit

Item groupIntermittent urinary catheters — HCPCS A4351-A4353

Limit600 combined units per three months (not payable beyond this)

Related rulesIndwelling and external catheters have separate per‑3‑month/unit caps described in policy

Drainage bag limit

CodeA4357 — drainage bags

LimitNot payable for more than six units within a three-month span

ContextLimit applies when billed individually or as part of catheter change (A4314-A4316) per DME policy

Prosthetic repair labor service limit

ServiceProsthetic repair labor services — HCPCS L7520

RestrictionNot payable when billed within 3 months of a new prosthesis (specified L-codes) being billed for the member

ApplicabilityApplies to lower- and upper-limb prosthesis ranges listed in policy (L5000-L5420, L5500-L5600, L6000-L6370, etc.)

Quantity limits — assorted examples

Drainage bagsA4357 — not payable >6 units/3 months

Parenteral nutrition compoundsB4189-B4199 — limited to 31 units per month

BatteriesCertain DME batteries (e.g., replacement batteries) limited to once per 6 months or are non-covered as specified

Nucleic-acid test daily limit

ScopeNucleic-acid based SARS-CoV-2 tests (CPTs 87631, 87635-87637, 87811, U0001, U0003, etc.)

Daily limitLimited to one unit per day unless reported with modifier 59

Notes0240U/0241U terminated as of 7/01/2025; edit updated in revision history

Unit/maximum limits — policy summary

General ruleCodes billed for units exceeding assigned allowed daily or annual units are not payable; excess units will be adjusted/denied

EnforcementMaximum Units Policy applies across providers and dates of service; MAI/MUE behavior informs adjudication

State examplesState-specific limits (e.g., NY Medicaid limits) are included where applicable

Unit limits (examples)

CDT/CPT exampleCDT D1206 / CPT 99188 — topical fluoride limited to one unit per 3 months for ages 6 months–6 years (NY Medicaid)

86003 exampleCPT 86003 — allergen-specific IgE limits: NY Medicaid historically 30 units/5 years; other revisions list 30–40 units per year depending on claim type and effective date

Other exampleCPT 30117 — report once per surgical session; denied when submitted more than once

Frequency limits — ophthalmoscopy, fundus photography

Scanning ophthalmoscopyCPT 92134 — not payable more than once within 28 days when diagnosis is retinal disease

Fundus photographyCPT 92250 — not payable >2 units/year except with specific diagnoses

Other ophthalmology capsCPT 92101/92102 frequency limits per eye/year described in policy

Unit limits for polysomnography and related sequencing

Polysomnography codesCPT 95782, 95783, 95808, 95810, 95811

Unit/sequencing restrictionNot payable in combination more than one unit per date of service by any provider (policy terminated 9/24/2023)

Neuromuscular junction testingCPT 95937 — not payable beyond 3 units/day for myoneural disorders and beyond 2 units/day for other specified diagnoses

Neuromuscular junction testing unit limits

CodeCPT 95937 — neuromuscular junction testing

Per-day caps by diagnosisNot payable beyond three units per day for myoneural disorders; not payable beyond two units per day for other specified diagnoses

Effective datePolicy effective 1/01/2018 for this rule

Extended ophthalmoscopy frequency limits

CodesCPT 92201-92202 — extended ophthalmoscopy

Frequency capsNot payable >2 times/eye/year without diagnosis; >4 times/eye/year with neoplasm; >6 times/eye/year for globe/choroid/retina/iris/ciliary body disorders or glaucoma; >12 times/eye/year for exudative senile macular degeneration

Pairing ruleNot payable when billed with fundus photography (92250) or without an appropriate diagnosis

Trigger point injection frequency

Procedure groupTrigger point injections — CPT 20552, 20553

Frequency limitNot payable when billed more than three times within a 90-day period

ApplicabilityApplies to any provider; enforced per Pain Management policy

Preadmission testing inclusion window

Commercial windowPreadmission testing performed within 14 days of admission included in payment for related inpatient stay or outpatient surgical procedure

Medicare/Medicaid windowPreadmission testing performed within 3 days of admission included in payment for related inpatient stay or outpatient surgical procedure

Effective datePreadmission testing policy effective date updated to 9/26/2025 per revision history

Post-op nasal endoscopy limit

CodeCPT 31237 — post-operative nasal endoscopy with debridement

LimitNot payable when billed more than 3 times within six weeks following surgery

Related code noteCPT 31231 (diagnostic nasal endoscopy) not reimbursed separately following surgery with 10- or 90-day global period

Allergen-specific IgE (NY Medicaid) unit limit

CodeCPT 86003 — Allergen-specific IgE

NY Medicaid five-year limitLimited to 30 units within a five-year period when billed by any provider; facility claims included effective 10/15/2025

ApplicabilityApplies to all provider claim types per NY Medicaid guidance updated in revision history

86003 unit limit — range and revisions

Range of limits86003 limits noted across revisions as 30 units (five-year) under NY Medicaid and 40 units per year effective 3/1/2023 for general edits

Claim-type updatesLimit language revised to include facility claim types effective 10/15/2025 in NY Medicaid entry

Revision history notePolicy revisions between 2023–2025 modified 86003 limits and effective dates; check claim-type and date-specific applicability

SARS-CoV-2 NAAT unit limit

Daily NAAT capSARS-CoV-2 nucleic-acid tests limited to one unit per day unless modifier 59 reported

Codes referencedCPT 87631, 87635-87637, 87811, U0001, U0003 (and related NAAT CPTs) per Laboratory-Pathology policy

Termination/updates0240U/0241U terminated effective 7/01/2025; revisions reflected in history

Modifier -59 may override certain bundling edits when reported with modifier -50 on the same line.
Clinical documentation must support use of modifier -59 to avoid denial.
Misuse may lead to denials or audits.

Billing Rule

Portable X‑ray set‑up billing dependency

Set-up portable X‑ray (Q0092) is not payable unless transportation of the portable x‑ray (R0070 or R0075) has also been billed and paid for the same date of service by the same or a different provider. Verify transportation codes are submitted when billing Q0092 to avoid denials.

Q0092 requires R0070 or R0075 billed/paid same date of service to be payable.
Transportation may be billed by a different provider than the radiology supplier.

Documentation Required

Co‑surgeon billing and documentation rules

Co‑surgeon procedures require correct modifier use and supporting documentation. Procedures designated as co‑surgeons allowed must be billed with modifier 62; claims billed with modifier 62 are not payable when the co‑surgeon concept does not apply or when documentation is not provided.

Bill co‑surgeon procedures with modifier 62 when applicable and include clinical documentation justifying two surgeons.
Co‑surgeon claims may be denied if both surgeons have the same subspecialty, if modifier 62 is used where co‑surgery is not allowed, or when prior same‑procedure claims from other providers create conflicts.
Facility rules apply for certain bill types (e.g., 0850‑085Z CAH) and revenue codes (0960‑0989).

Denial Risk

Denial risk for specific diagnoses and place of service

Claims with principal diagnoses of acute stroke (I63.-) or sepsis (A41.-) billed in inappropriate Places of Service will be denied. Do not bill these diagnoses in Office (11), Telehealth (2, use POS 2 guidance), Off‑campus outpatient hospital (19), On‑campus outpatient hospital (22), Skilled nursing facility (31), or Federally Qualified Health Center (50).

Claims with I63.- or A41.- in POS 11, 2, 19, 22, 31, or 50 will be denied.
Follow POS coding guidance for telehealth and facility settings to avoid denials.

Documentation Required

Clinical trial billing documentation requirement

Clinical trial/research billing requires correct encounter codes and documentation. Services billed with Q0/Q1 trial modifiers or that indicate participation in an approved clinical research study must include the required diagnosis code indicating trial participation; absence will result in denial.

Use the correct encounter code for clinical trial participation and append Q0/Q1 as required.
Include a diagnosis that identifies participation in an approved clinical research study.

Billing Rule

Drug wastage claim submission

When reporting drug wastage with modifier JW for single‑dose containers, submit two claim lines: one for the drug administered (no JW) and a second for the wasted units with JW appended. Claims reporting JW without an administered drug line will be denied.

Line #1: HCPCS for drug administered without JW (quantity administered).
Line #2: Same HCPCS with JW appended for units wasted (quantity wasted).
Modifier JZ is used when there is no wastage — submit a single line with JZ and units given.

Billing Rule

Global obstetrical Category II code requirement

Global obstetrical claims billed using global codes must include the appropriate Category II CPT code for each prenatal or postpartum visit. Omission of the required Category II codes will result in denial for NYS Medicaid members.

Include 0500F (Initial Prenatal Visit), 0502F (Subsequent Prenatal Visit), or 0503F (Postpartum visit) on the global claim for each corresponding visit within the global period.
Claims submitted without the Category II CPT code will be denied.

Billing Rule

COVID specimen collection billing

COVID‑19 specimen collection codes (G2023, G2024) are considered integral to COVID testing and are not separately reimbursable when COVID testing is performed. Do not bill these collection codes separately with COVID test reimbursement.

G2023 and G2024 are integral to COVID testing; separate reimbursement is not warranted.
Ensure specimen collection is not billed in addition to COVID testing reimbursement.

Documentation Required

Consultation and modifier 25 rule

Consultation codes are not separately payable when billed with a primary procedure unless modifier 25 is appended and clinical documentation supports a distinct, separately identifiable E/M service on the same day.

Append modifier 25 to the consultation code and retain supporting clinical documentation to justify separate payment.
Absent modifier 25 and supporting notes, consultation codes billed with a procedure will be denied.

Billing Rule

IONM place‑of‑service constraint

Continuous intraoperative neurophysiology monitoring (IONM) codes are payable only in specific Places of Service. Report IONM only when performed in POS 19 (Outpatient Hospital‑Off campus), 21 (Inpatient Hospital), 22 (Outpatient Hospital‑On Campus), or 24 (Ambulatory Surgical Center).

CPT 95940 and HCPCS G0453 are payable only when reported in POS 19, 21, 22, or 24.
IONM reported both in‑OR and externally by the same provider on the same day may be denied.

Denial Risk

Never events non‑payable

Never events billed with modifiers PA, PB, or PC (wrong body part, wrong patient, wrong surgery) are not payable. Claims with these modifiers will be denied in accordance with the Never Events policy.

Modifier PA = wrong body part, PB = wrong patient, PC = wrong surgery; any claim line with these modifiers is not payable.
Retain adequate documentation to prevent inappropriate use of these modifiers.

Denial Risk

Orthopedic intraoperative and arthroscopy edits

Orthopedic intraoperative services and certain arthroscopy combinations are not separately payable. Intraoperative services billed with an orthopedic procedure or specific arthroscopy debridement/meniscectomy combinations will be denied.

Intraoperative services are not payable when billed with an orthopedic procedure.
Knee arthroscopy with abrasion arthroplasty (29879) is not payable when billed with meniscectomy codes (29880‑29881).
Shoulder arthroscopy/debridement codes (29822, 29833) are not separately payable with a surgical arthroscopy on the same joint.

Billing Rule

Multiple procedure payment reduction - professional

Multiple procedure payment reductions apply to professional claims. Procedures are ranked by RVU; the highest‑ranked procedure receives full payment, the second ranked typically receives 50%, and lower ranked procedures may receive reduced or zero percent payment per plan rules.

Pay percent recommendations: Rank 1 = 100%; Rank 2 = 50%; Rank 3–5 = 0% (per plan configuration).
Adjustments consider bilateral, multiple quantity, and applicable modifiers.

Billing Rule

Place of Service billing restrictions

Place of Service (POS) restrictions are enforced for many codes. Verify the correct POS before billing—certain E/M, observation, consultation, cardiac rehabilitation, and other services are payable only in specified POS values and will be denied if billed outside those locations.

Outpatient cardiac rehab (93797‑93798, G0422‑G0423) payable only in POS 11, 19, or 22 for professional claims.
Home visit E/M (99341‑99350) payable only in POS 02 or 12.
Observation and inpatient E/M codes are restricted to specified POS values; review POS tables before submission.

Note

Place of Service restrictions (examples)

Examples of POS restrictions: New and established office/outpatient visit codes (99201‑99205, 99211‑99215) are not payable when billed in certain POS values (e.g., 01 Pharmacy is invalid for office visits). Outpatient cardiac rehabilitation requires POS 11, 19, or 22. Review the policy POS lists for code‑level constraints.

Office/outpatient visit CPTs are limited to approved POS values—do not bill in invalid POS such as pharmacy (01) or telehealth (02) unless allowed.
Cardiac rehab not payable outside POS 11, 19, 22 for professional claims.
Observation and inpatient consultation codes have explicit POS allowances—confirm before billing.

Denial Risk

Related Services to a Noncovered Procedure

Related services to a non‑covered procedure may be denied when performed within the related time window. If a non‑covered procedure was denied, related services billed within ten days prior, the same day, or within seven days after may also be recommended for denial when the diagnosis first three digits match.

This rule audits facility and professional claims and requires plan‑supplied mappings of related codes.
If the non‑covered procedure was paid, related services are not denied via this rule.
Examples include labs, anesthesia, radiology, revenue and E/M codes related to the non‑covered procedure.

Billing Rule

Revenue Codes Requiring CPT/HCPCS

Certain revenue codes require a CPT/HCPCS code to be payable. Claims submitted with revenue codes that CMS OPPS specifies must include a HCPCS/CPT code will be denied if no HCPCS/CPT is present. Include the appropriate HCPCS/CPT when billing revenue codes that require it.

OPPS Detailed Program Edits identify which revenue codes require a HCPCS/CPT code.
The edit only fires when no HCPCS/CPT is present on the claim line; OPPS does not prescribe the specific HCPCS to use.

Billing Rule

Modifiers for reduced/discontinued procedures

Use modifiers 52, 53, 73, and 74 per CMS guidance for reduced or discontinued procedures. When a procedure was not carried out or was reduced/discontinued for specified reasons, append the appropriate modifier and ensure documentation supports the reason to avoid denial.

Modifier 52 = Reduced or eliminated procedure; 53, 73, 74 = Discontinued procedures (inpatient/outpatient/emergency contexts).
Claims reporting procedures not carried out due to contraindication or patient decision should include the appropriate modifier (52/53/73/74) and supporting documentation.

Billing Rule

Drug/biological JW modifier guidance

JW/JZ modifier guidance: When reporting wastage from single‑use vials, append JW and submit a corresponding administered drug line. JW claims that report units equal to or exceeding the package insert units without an administered line may be denied. Use JZ when no wastage occurred and submit a single line with JZ and units administered.

JW = units discarded; requires a separate administered claim line without JW.
JZ = zero drug amount discarded; submit one line with JZ and units given.
Avoid billing wastage in a manner inconsistent with FDA package sizing or CMS expectations to prevent denials.

ExampleWhen same code is reported once with RT and once with LT, report with modifier 50 for 1 unit and 150% payment adjustment applies for Bilateral Indicator 1 codes

Q4, N, S, T, V status indicators

Status indicatorsQ4, N, S, T, V — CMS OPPS packaging/conditional packaging indicators that determine when services are packaged/not separately payable

EffectCodes with these indicators may deny when billed with other payable services or on certain bill types (e.g., outpatient hospital) per OPPS rules

ExampleQ4 — conditionally packaged lab codes denied when billed with non-lab services on Bill Type 0130-013Z

Modifier KX

MeaningModifier KX indicates that requirements specified in the medical policy have been met, allowing certain service limits to be exceeded when present

Use caseRequired to exceed cardiac rehab 36-in-36 limit and used for some DME/pressure-reducing support surface claims

Claim effectAbsence of KX where required will result in denial for services exceeding policy limits

CMS National Coverage Determinations / Coverage Policies

Source examplesCMS National Coverage Determinations (NCD) and CMS-based coverage policies are used as coding edit sources to determine coverage and non-coverage pairs

PurposeMap procedure-to-diagnosis pairs and enforce CMS NCD inclusionary/exclusionary rules

ApplicationUsed to deny procedures when paired with non-covered diagnoses per NCD policy

LOPS — loss of protective sensation

DefinitionLOPS — loss of protective sensation (used in diabetic foot care coding rules)

Clinical relevanceUsed to determine eligibility for certain diabetic foot care and screening services per policy

Example codesG0245-G0247 related foot care codes reference LOPS requirements in policy entries

Diagnosis coding rules

RuleDiagnosis coding rules require ICD-10 codes to the highest specificity; manifestation/sequela codes cannot be sole diagnosis

LateralityWhen laterality exists, unspecified codes are inappropriate; do not report both left and right when bilateral code exists (breast malignancy excluded)

Claim validityClaim lines submitted without at least one valid diagnosis code are not payable

Status Indicator Codes

DefinitionStatus Indicator Codes — CMS status indicators that determine payability and review (e.g., I = not valid for Medicare)

EffectCodes with certain status indicators (I, C, etc.) may be non-reimbursable or subject to payment review per MPFS definitions

ReferenceUsed to identify codes subject to packaging or special payment treatment in OPPS/MPFS

JW — discarded drug amount (and related JW/JZ guidance)

JW modifierJW — indicates drug amount discarded/not administered to any patient (single‑dose vial wastage); requires separate administered drug claim line when used

JZ modifierJZ — indicates zero drug amount discarded/not administered to any patient (no wastage)

Billing requirementWhen reporting wastage with JW, submit one line for drug administered (no modifier) and one line for wasted units with JW per CMS guidance

JZ — no discarded drug amount

JZ modifierJZ — indicates no discarded amount from single‑dose vial; submit single claim line with JZ when no wastage

ContextUsed as alternative to JW when there is no wastage; effective policy examples revised in revision history

Effective date noteModifier JZ effective date correction noted in revision history (10/1/2024 update)

-NU, -NR, -UE, -RR — DME ownership/rental modifiers

-NUNew equipment (indicates ownership)

-NRNew when rented (indicates ownership)

-RR / -UE-RR = Rental; -UE = Used equipment (indicates ownership); ownership/rental modifiers determine payability and rental maximums

Duplicate professional component

DefinitionDuplicate professional component — only one professional component for same service is payable when billed by different providers

EffectDuplicate professional or technical component services billed by different providers will be denied

ExampleDuplicate lab/professional components subject to denial per Duplicate Services Policy

POS 81 restriction

POS 81Place of Service 81 = Independent laboratory — certain pathology/lab codes billed by outpatient hospital when same code billed by POS 81 will be denied

EffectPathology and lab codes 80000-89999 denied when outpatient hospital bills and same code billed by POS 81 exists

Effective datePolicy effective 10/15/2025 for POS 81 restriction entry

Modifier KX (definition duplicate entry)

DefinitionModifier KX — used to indicate that specified coverage criteria have been met and may be required to avoid denial for certain DME items or therapy limits

ExamplesRequired for exceeding cardiac rehab limits and for certain infusion/pressure support devices and DME claims

Claim effectAbsence of KX where required will cause denial for items/services exceeding policy limits

Place of Service restrictions — DMEPOS examples

POS restrictionsCertain DMEPOS items billed by DMEMAC providers payable only when reported with specific POS codes (examples: 01 Pharmacy, 12 Home, 65 ESRD facility)

EffectIf billed in disallowed POS, DMEPOS claim lines are not payable

Policy noteApplies to infusion supplies, pumps, and other DME items per Durable Medical Equipment and Supplies Policy

Global period — definition and examples

DefinitionGlobal period — postoperative global periods (0-, 10-, 90-day) that determine when E/M services are included and not separately payable

ExamplesE/M services within postoperative global periods are generally not payable; certain care management and transitional services excluded within 10-day window

Claim effectModifier 25/24 exceptions and provider relationship rules may apply per Global Surgery Policy

Integral service — example

Integral serviceService considered integral (not separately reimbursable) — example: COVID-19 specimen collection (G2023/G2024) when a COVID test is rendered

Policy impactSuch integral services should not be billed separately for reimbursement when paired with the primary test/service

Effective dateG2023/G2024 integral rule effective 3/1/2020

MUE adjudication indicator (MAI) categories 1-3

MAI categoriesMAI (MUE adjudication indicator) categories 1–3 determine MUE adjudication behavior: MAI=1 claim-line deny if exceeded; MAI=2 date-of-service edits with no modifier override; MAI=3 date-of-service edits not overridden by modifier 59 (clinical documentation for appeal)

ApplicationUsed to enforce CMS MUE values on claim lines and dates of service

Effective dateMUE policy effective 10/01/2021

NCCI column designation

NCCI columnsNCCI Column one/column two designation — column two procedure codes are not payable when billed with associated column one codes; applies across providers when billed by same Provider ID

ScopeIncludes mutually exclusive and non-mutually exclusive edits and DME-specific column edits

Effective dateNCCI edits effective 1/01/2018 (with later supplemental updates)

Column I/II edits

Column I/II editsColumn I/Column II edits prevent payment of column II codes when billed with associated column I codes; temporary pandemic-related variations noted in supplemental policy

Claim behaviorApplies regardless of Tax ID or Specialty when billed by same Provider ID; facility claim effects updated in revisions

ReferenceSupplemental policy revisions updated facility claim effect on 12/01/2021

NCD procedure-to-diagnosis

DefinitionNCD procedure-to-diagnosis — CMS National Coverage Determinations map procedure and diagnosis pairs to determine covered vs non-covered services

PurposeIdentifies procedure lines not payable when paired with non-covered diagnoses per CMS NCD lists

Application dateNCD mapping entries effective 10/01/2021 for many policies

PA/PB/PC (never event modifiers)

ModifiersPA, PB, PC — never event modifiers indicating wrong body part/patient/surgery

EffectAny procedure billed with PA/PB/PC is not payable as a never event

Policy noteNever event rule updated and applicable to facility and professional claims per policy

Pay percent recommendation

DefinitionPay percent recommendation — ranking-based payment adjustment applied when a well visit/preventive exam and other E/M codes are billed same patient/provider/date; Rank1=100%, Rank2=50%, Rank3-5=0%

UseApplied to professional multiple-procedure scenarios to determine percent payable to lower-ranked lines

ExampleSame provider defined by same FTIN and primary specialty; ranking by RVU value per CMS file

Place of Service (POS)

DefinitionPlace of Service (POS) — two-digit POS codes that designate where a service was provided; many CPT codes limited to specific POS values and will not be payable if billed with inappropriate POS

EffectNumerous POS restrictions in policy (examples include telehealth POS 02 exceptions and POS lists for E/M codes)

ReferenceSee Place of Service Policy entries for code-specific allowed POS lists

Procedure Code Definition

DefinitionProcedure Code Definition — procedure codes and related guidelines contain descriptive criteria for use; services not meeting code criteria are not payable

ImplicationClaims billed without meeting code descriptive criteria may be denied

ExampleCPT 17004 example in policy highlighting improper diagnosis pairing

PC/TC and Global Only codes

PC/TCProfessional/Technical component rules — modifier 26 (professional) and TC (technical) usage differ between professional and facility providers; global-only codes handled per MPFS

Global-onlyGlobal-only codes (PC/TC status 4) are not payable when billed by incorrect provider type in facility settings

ExampleDiagnostic tests/radiology services require modifier 26 when billed by professional in facility setting

Unbundled Pair

Unbundled PairUnbundled Pair / Incidental service — services considered integral or incidental to a primary procedure are not separately payable

ExamplesIntraoperative monitoring performed by operating surgeon/anesthesiologist is integral; other listed procedures deemed integral per CPT/CMS guidance

Policy effectSuch services will be denied when billed separately unless specific diagnostic exception applies

Telehealth modifiers

Telehealth modifiersG0, GQ, 95 — indicate telehealth modalities and must be used with permitted codes and POS; inappropriate use leads to denial

ApplicationGQ/95 use limited to approved telemedicine codes and appropriate POS (02) per policy

ExampleG0 for acute stroke telehealth services; misuse results in non-payable edit

Intraoperative monitoring

DefinitionIntraoperative monitoring — monitoring by operating surgeon/anesthesiologist is considered integral to primary procedure and not separately reportable unless performed as diagnostic service

Policy impactIONM professional services reported by operating surgeon/anesthesiologist will be denied when billed separately

ReferenceCPT/CMS guidance and Unbundled Pair policy examples

Modifier 50 — bilateral reporting

Modifier 50Modifier 50 — bilateral reporting; when same code reported once with RT and once with LT, report with modifier 50 and quantity 1 with 150% payment adjustment for Bilateral Indicator 1 codes

Billing ruleCertain 'pair' codes are not payable when billed with RT/LT instead of 50 per DME/paired code guidance

Policy noteSee bilateral indicator policy for code-specific guidance (indicators 0–3,9)

JW / JZ modifiers — definitions and guidance

JWModifier JW — indicates discarded drug amount from single‑dose vial; requires separate claim line for administered drug and wasted units or may trigger JW-specific unit threshold edits (see drug/biological policy)

JZModifier JZ — indicates zero discarded amount (used when no wastage); submit single claim line with JZ

Policy revisionsRevision history corrected JZ effective date and clarified JW/JZ examples; see 12/5/2025 and other revision entries

Drug and Biological Policy clarified for JW/JZ usage and modifier examples; corrections to JW examples and modifier dates were recorded.

7/04/2025effective_date_update

3D rendering CPT codes 76376 and 76377 originally effective 7/04/2025 had their effective date updated to 9/26/2025 and are specified as integral to the primary imaging service (not separately reimbursable).

9/2/2025revisionLatest

Revision log records 10 edits with previous effective date of 7/04/2025 updated to new effective date 9/26/2025, including 3D rendering bundling clarification.

9/1/2023revision

Allergen-specific IgE (CPT 86003) unit limit edited: prior per-year limit changes recorded (terming of a 30-per-year limit and addition of a 40-per-year limit effective 3/1/2023).

10/15/2025effective_date_updateLatest

NY Medicaid edit for CPT 86003 (Allergen-specific IgE) updated to include Facility claim type effective 10/15/2025.

3/1/2023effective_date_update

An edit adding CPT 86003 limited to 40 units per year when billed by any provider became effective 3/1/2023 (replacing prior 30-unit language).

9/1/2023revisionLatest

Revision history notes termination of an earlier 30-units-per-year 86003 edit as of 2/28/2023 and publication of the 40-units-per-year limit effective 3/1/2023; subsequent revisions later adjusted facility inclusion and other timing.

9/2/2025revisionLatest

Updated Laboratory-Pathology edits: nucleic-acid based SARS-CoV-2 tests (listed CPTs/U-codes) limited to one unit per day unless modifier 59 is reported; deletion of codes 0240U/0241U noted as effective 7/01/2025.

2/01/2022effective_date

Laboratory-Pathology policy effective dates for certain lab edits recorded (policy segment shows various effective dates including 2/01/2022 for specimen rules).

12/5/2025revisionLatest

Correction to a prior revision entry (3/14/2025) and updates to modifier JZ effective-date reporting along with typographical corrections across Drug and Biological Policy entries.

5/13/2025revision

Clarification added to Post-Operative Nasal Endoscopies edit and CMS Coverage Policy modifier guidance (modifiers 52, 53, 73, 74) with effective dates and examples.

9/1/2023revision

Allergy testing (CPT 86003) unit-limit history amended: prior terminations and replacements recorded, reflecting changes between 30 and 40 unit limits and noting terminated edits effective 3/1/2024 for select items.