CurrentEmblemHealthPolicy RP2O210017

Coding Edit Rules (Commercial, Medicare & Medicaid)

Defines EmblemHealth's claims coding edits applied to professional and outpatient facility claims (including ambulance, DMEPOS, drugs) across Commercial, Medicare and Medicaid products; describes many specific edit rules, limits and modifier requirements that affect payability.

Policy Summary

PayerEmblemHealth

PolicyCoding Edit Rules (Commercial, Medicare & Medicaid)

Policy CodePolicy RP2O210017

Change TypeRevisions & code updates (2021–2025)

Effective Date

Next Review Date

Key ActionReview and apply the updated coding edit rules and modifier requirements to claims submissions; ensure supporting diagnoses, modifiers, and documentation are present to avoid denials.

SourceLink

POLICY UPDATE CHANGES

Multiple edits and effective dates updated across the policy catalog (edits added, updated, terminated) with revision history entries from 2021 through 2025.

Clarified billing rules for laterality diagnosis codes: when a bilateral code exists, reporting separate left and right codes is not appropriate (excludes breast malignancy codes).

Specific code deletions and terminations noted (e.g., deletion of codes 0240U and 0241U from Laboratory-Pathology edits effective 7/01/2025).

Numerousdistinct coding edit rules listed (by topic)

2025-09-02

2021-2025revision history range showing active maintenance

modifier requirementsMany rules require key modifiers

88304–88309surgical pathology CPT codes repeatedly referenced

Policy Scope & Summary

This policy defines EmblemHealth's procedure and diagnosis coding edits that are applied to professional and outpatient facility claims (including ambulance, DMEPOS and drugs) across Commercial, Medicare and Medicaid lines of business. It details conditions under which lines will be not payable — for example, missing requisite diagnosis codes, missing or disallowed modifiers, duplicate/mutually exclusive services, frequency and unit limits, place-of-service constraints, and CMS-derived NCCI/MUE/NCD packaging rules — and establishes the scope for claims editing and adjudication across provider types and settings.

Policy metadata

PayerEmblemHealth

Policy numberRP2O210017

StatusCURRENT

Last review2025-09-02

Effective

Applicable statesCT, MA, NY

General Denial and Edit Logic (Criteria Trees)

General pattern: not payable when requisite diagnosis/modifier/procedure absent or conflicting

Many rules deny payment if a required diagnosis, modifier, supporting procedure or code combination is not present; or when mutually exclusive/duplicate billing is detected.

ANY of the following

Service not payable when billed without a requisite diagnosis on the claim (multiple specific CPT/HCPCS examples throughout).
Service not payable when required modifier is not appended (e.g., EA/EB/EC for J0881/J0885; KX for TENS E0720/E0730; JW/JZ handling for single-dose drugs).
Service not payable when billed beyond specified frequency limits (e.g., lipid testing >6x/year; behavioral obesity counseling >22x/year; certain DME/rental limits).
Service not payable when duplicate or mutually exclusive services are billed (duplicate professional/technical components; identical codes same date by multiple providers).

Grouped Codes, Coverage Status & Examples

Allergy testing limitsCPTCovered

86003	Allergen specific IgE — limited units per year (30 units per year previously; updated limits described)
95024	Intradermal tests with allergenic extracts — limited to 40 units in a five-year period
95027	Intradermal tests — limits (137 units within one year referenced)
95028	Intradermal tests with allergenic extracts — limited to 40 units in a five-year period
95044	Patch tests — limited to 40 units in a five-year period
95004	Percutaneous tests — limited to 60 units in a five-year period
95017	Allergy testing — limited to 60 units in a five-year period
95018	Allergy testing — limited to 60 units in a five-year period
95165	Supervision of preparation and provision of antigens for immunotherapy — limit 137 units per year

Anesthesia service rulesCPT|Modifier|RevenueNot Covered

00100-01999	Anesthesia services — multiple general anesthesia codes limited to highest submitted charge; require appropriate modifiers (AA, QX, QZ); CRNA billing rules; supervision modifiers interactions
01996	Daily hospital management of continuous epidural/subarachnoid drug administration — not payable when billed with qualifying circumstance codes and without an anesthesia procedure code
99100-99140	Anesthesia qualifying circumstance codes — interact with 01996
Revenue Code 0964	CRNA revenue code — used in limitation of multiple anesthesia codes

Ambulance rulesHCPCS|ModifierNot Covered

A0427	Ambulance service — not payable when destination modifier not H or X as specified
A0429	Ambulance service — same restriction
A0433	Ambulance service — same restriction

Bilateral procedures and modifiersCPT|Modifier

50	Modifier 50 (bilateral) billing rules — line quantity rules and bilateral indicators (CMS Bilateral Indicators 1,2,3,9) guidance
LT	Left side modifier — interactions with modifier 50
RT	Right side modifier — interactions with modifier 50
76519	Ophthalmic biometry A-scan — not payable when billed twice same date or with conflicting modifiers
92136	Ophthalmic biometry partial coherence — not payable when billed twice or with conflicting modifiers

Assistant surgeon rulesCPT|Modifier|Bill Type|RevenueNot Covered

59510	Global obstetrical care, Cesarean delivery — not payable with assistant surgeon modifier
59618	Global obstetrical care, Cesarean delivery following failed VBAC — not payable with assistant surgeon modifier
59514	Cesarean delivery only — report for assistant surgeon when applicable
59622	Cesarean delivery following failed VBAC — not payable with assistant surgeon modifier
59515	Cesarean delivery only including postpartum care — not payable with assistant surgeon modifier
Modifiers 80,81,82,AS	Assistant surgeon modifiers — not payable unless same procedure was billed by different Provider ID as primary surgeon (policy dated 4/15/2024)
Bill Types 0850-0852	Critical Access Hospital bill types interact with assistant surgeon indicators and revenue codes 0960-0989

Bundled services / packaging (OPPS/APC)HCPCS|Status IndicatorNot Covered

Q4	Laboratory services subject to conditional packaging — denied when billed with non-lab services on certain hospital outpatient bill types
N	HCPCS with status indicator N — packaged into APC rates; not separately reimbursable when billed by outpatient hospital
T	T-packaged services — denied when billed with services with APC status indicator T
S/$/V	STV-Packaged service logic — certain packaged services deny when reported with specific APC status codes

Cardiology frequency and pairing rulesCPT

93970-93971	Venous studies — not payable when billed with arterial studies (93922-93931) without supporting diagnosis
93922-93931	Arterial studies — not payable when billed with venous studies without supporting diagnosis
78451-78454, 78466-78469, 78472-78473, 78483, 78494	Myocardial perfusion/cardiac blood imaging — duplicate low-allowed procedure on same date not payable
93260-93261, 93282-93284, 93289, 93292	Implantable cardiac device programming/interrogation — limited frequency (e.g., once per 3 months for certain diagnoses)

Chemistry/Panel unbundlingCPT|HCPCSNot Covered

Chemistry panels

Unbundled individual components of a disease-oriented or chemistry panel are not payable when submitted same date by same provider; must bill comprehensive panel code

CPAP/BIPAP supply frequency and modifier rulesHCPCS|Modifier

Supply codes (CPAP/BIPAP)

Denial when supply codes submitted exceed usual/customary frequency or when required modifiers not present (-KX) or disallowed modifiers used (~EY, ~GA, ~GZ)

Vaccination frequencyCPTNot Covered

90670	Pneumococcal vaccine — not payable if billed previously in patient lifetime or within prior 12 months (per context)
90732	Pneumococcal vaccine — same restriction

FQHC billingHCPCS|Bill Type|Condition Code

G0467	FQHC established patient — not payable for PPS payment without qualifying visit code on claim
G0466-G0469	FQHC visit codes — required when reporting PPS payment with certain condition codes
Bill Types 0771-0772	FQHC bill types — require Condition Code 65 and FQHC visit codes for PPS payment

Examples of procedure and vaccine codes not payable under specified conditionsCPT/HCPCSNot Covered

00812	Anesthesia for lower intestinal endoscopic procedures (screening colonoscopy) - not payable with modifier 33 unless screening colonoscopy billed
G0439	Annual wellness visit - not payable if another annual wellness visit billed within previous 11 months
G0438	Annual wellness visit; initial - one per lifetime (not payable if billed more than once)
93797	Outpatient cardiac rehabilitation - limited to 36 units in 36-week period unless modifier KX
93798	Outpatient cardiac rehabilitation - see 93797
G0372	Physician service to establish need for power mobility device - requires face-to-face E/M billed on same claim
J1642	Heparin lock flush (per 10 units) - not payable in some contexts
G0424	Pulmonary rehabilitation - limits and billing constraints (e.g., units, bill types)
17311	Mohs micrographic surgery - separate reporting/payment rules when surgical pathology by different providers
11713	Mohs micrographic surgery - see 17311

Examples of modifiers and billing constructs required or restrictedModifier

33	Modifier 33 (preventive) — anesthesia for screening colonoscopy not payable with modifier 33 unless screening colonoscopy billed
KX	Modifier KX — may be used to exceed cardiac rehab unit limits when requirements met
EA, EB, EC	Modifiers required for certain J0881/J0885/J0888 billing; specific rules when ESRD diagnosis present
80,81,82,AS	Modifiers required when major surgical procedures billed by NPPs

Revenue code and bill type constraintsRevenueNot Covered

0637	Revenue code for pharmacy self-administered drugs - not payable without HCPCS code
0360-0369,0490-0499	Operating room revenue codes required for certain vitrectomy CPT codes
0948	Pulmonary rehab revenue code requirement

Examples of CPT/HCPCS codes with conditional payment rules (partial list from this part)mixed

A4595	Supplies for electrical stimulation — not payable when only diagnosis is Bell's palsy
36522	Photopheresis, extracorporeal — not payable except for specified diagnoses (CTCL, acute cardiac allograft rejection, chronic GVHD, bronchiolitis obliterans syndrome) and other modifiers/conditions
J0881	Drug — not payable without modifier EA/EB/EC
G0281	Electrical stimulation unattended for chronic ulcers — not payable without approved ulcer diagnosis
67028	Intravitreal injection of pharmacologic agent — modifier requirements when billed with certain drug HCPCS

Diabetic footwear and insertsHCPCS

A5500-A5514	Therapeutic shoes/inserts/modifications for diabetics; limits and modifier requirements noted
L3215-L3253	Orthopedic footwear — not payable with therapeutic diabetic inserts

Oxygen and respiratory equipmentHCPCS

E0424,E0425,E0430,E0431,E0433,E0434,E0435,E0440	Oxygen systems/rentals/purchase and portable delivery systems — various non-payable conditions
E0441-E0444,E0447	Oxygen contents — not payable with system rental in same month

Catheters and urological suppliesHCPCS

A4310-A4360,A5102-A5114	Indwelling/intermittent/external urinary catheters and supplies — frequency and modifier requirements
A4351-A4353	Intermittent urinary catheters — limit 600 units per 3 months

Prosthetics and orthoticsHCPCS

L5000-L6999	Various prosthesis/orthosis codes — modifier, frequency, and bundling rules (including KO-K4, RA/RB, test sockets, repair labor L7520)
L3250	Custom molded shoes — not payable with leg prostheses L5010-L5600

Infusion and pump suppliesHCPCS|CPT

E0776,E0779-E0781,E0784,E0791,K0455	IV and ambulatory infusion pumps — location and billing restrictions; battery and replacement parts rules
A4222,A4224,A4230,A4231,K0552,A4225	Insulin/infusion supplies — limits when billed with infusion pump supplies

E/M and observation rulesCPT|HCPCS

99218-99220,99234-99236,99221-99223,99231-99233,99238-99239	Observation, initial and hospital care, discharge — restrictions when billed within specific timeframes or with other services
99441-99443,G2010,G2012,G2252	Telephone E/M — not payable when E/M billed within previous 7 days or following same diagnosis
99495-99496	Transitional Care Management — not payable within 29 days of another TCM under same conditions; facility E/M rules apply

Pharmacy dispensing feesHCPCS

Q0513,Q0514,G0333

30-day and 90-day dispensing fees — frequency limits (not payable if within 83 days or more than once per month) and requirement to be billed with corresponding drug

Glucose monitors and suppliesHCPCSNot Covered

E0607,E2100,E2101,A9275-A9279

Home blood glucose monitors and related equipment — subsequent monitors not payable more than once per year; glucose monitor equipment does not meet DME definition

Miscellaneous high-frequency limitsHCPCS

B4081-B4083	Nasogastric tubes — not payable more frequently than three tubes every three months
B4034-B4036	Enteral feeding kits — limit 31 per month

E/M and related codes referencedCPT|HCPCS

99201-99215	Office/outpatient E/M codes referenced in multiple rules
99446-99449, 99451	Interprofessional telephone/internet consultation codes

COVID-19 specificHCPCSNot Covered

G2023, G2024

COVID specimen collection — integral to testing; not separately reimbursed (effective 3/1/2020)

Laboratory/pathologyCPT|HCPCS

88305, 88307, 88309	Surgical pathology gross & microscopic exam — denied for certain solitary diagnoses (hemorrhoid, hydrocele, polyp of stomach/duodenum, cornea, ganglion cyst, appendix, gallbladder)
G0452	Molecular pathology interpretation — not payable without modifier 26

Global obstetrical/surgeryCPT

59400, 59425, 59426, 59463, 59510-59515, 59610, 59618-59622	Global obstetrical/delivery and antepartum codes — various bundling/timeframe/duplicate-billing rules; Category II reporting required for NYS Medicaid (OS00F, 0502F, 0503F) as of 4/15/2025
01996	Epidural daily management — not payable when billed with 0/10/90-day surgical procedures

Surgical pathology gross & microscopic exam codesCPTNot Covered

88304	Surgical pathology gross & microscopic exam (listed where applicable)
88305	Surgical pathology gross & microscopic exam
88307	Surgical pathology gross & microscopic exam
88309	Surgical pathology gross & microscopic exam

COVID-19 / SARS-CoV-2 test codes and editsCPT|HCPCS|mixed

86769	Antibody; SARS-CoV-2
0224U	Antibody; SARS-CoV-2, includes titer(s)
U0003	SARS-CoV-2 viral test (nucleic acid) high throughput
87635	COVID-19 infectious agent detection by nucleic acid
U0002	COVID-19 lab test non-CDC
U0004	COVID-19 lab test non-CDC high throughput

Laboratory specimen / travel / supplies / specimen collectionHCPCS|CPT

P9603	Travel allowance one way for medically necessary laboratory specimen
P9604	Travel allowance one way for medically necessary laboratory specimen
90476-90750	Vaccine administration and vaccine codes referenced for modifier SL rules (range)

MUE/CMS/NCCI/Coding policy referencesmixed

Various

Many CPT/HCPCS codes subject to MUE, NCCI, NCD, and other policy edits described in text (not exhaustively enumerated in this excerpt)

Examples of specific non-payable CPT/HCPCS codes and groups mentionedmixedNot Covered

01996	Epidural or subarachnoid continuous administration — limited to one unit per date of service
80305-80307	Presumptive drug screen tests — conflict with other lab codes per rules
95957	Digital EEG analysis — not payable with long-term EEG monitoring 95700-95726
95700-95726	Long-term EEG monitoring — conflicts with 95957
92201-92202	Extended ophthalmoscopy — diagnosis and frequency constraints; not payable with 92250

Examples of specific CPT/HCPCS codes referenced (non-payable contexts)mixedNot Covered

99406	Smoking and tobacco use cessation counseling visit — not payable without tobacco/nicotine dependence diagnosis
36415	Venipuncture — incidental when billed with laboratory procedure codes
81002	Urinalysis dipstick — incidental with E/M unless modifier appended
76140	X-ray evaluation by consultant — considered integral to E/M, not separately reimbursable
90476-90750,90756	Vaccine/toxoid codes (required with immunization admin codes)

Examples of explicitly mentioned CPT/HCPCS codes and rulesmixedNot Covered

11042	Debridement — not payable when billed with pressure ulcer stage 1 or 2 unless stage 3/4 or non-pressure chronic ulcer also reported
36522	Photopheresis — additional rule: when billed with chronic GVHD must also include complications of transplanted organ
A4466	Elastic garment/covering — not payable without requisite diagnosis/support
J0881	Drug — not payable without modifier EA/EB/EC
G0447	Face-to-face behavioral counseling for obesity — limited to 22 times/year and requires BMI >=30 diagnosis

All other referenced codes & groups (policy-wide examples)mixed

Various

Many additional CPT/HCPCS codes and ranges are included throughout the policy with specific conditions, frequencies, modifiers, POS and diagnosis requirements as detailed in the policy text

What Providers Must Do

Documentation Required

Assistant surgeon documentation and eligibility

Clinical documentation is required for assistant surgeon services in accordance with CMS; assistant surgeon services are payable only when the code allows an assistant per CMS indicators. Primary surgeons may not bill for assistant surgeon reimbursement for the same procedure; verify CAH bill types and revenue codes when applicable.

59510
59618
59514
59622
59515
Modifiers 80,81,82,AS

Billing Rule

Anesthesia modifier and billing requirements

Numeric Limits and Unit Thresholds

Frequency and unit thresholds

Allergen specific IgE units (86003)Historically 30 units/year; updated to 40 units/year (policy changes/terminations noted)

Intradermal/patch tests (95024/95027/95028/95044)40 units per five-year period

Percutaneous/allergy testing (95004/95017-95018)60 units per five-year period

Allergen immunotherapy supervision (95165)137 units per year

Outpatient cardiac rehab (93797-93798)36 units in 36 weeks unless modifier KX present

Smoking cessation counseling (99406/99407)8 units per year

Lipid testing frequency (80061,82465,83718,83721,84478)

Clinical & Administrative Background

Background: EmblemHealth applies coding edits that largely mirror CMS guidance (NCCI, MUE, OPPS/APC and NCD/LCD rules) together with industry sources (AMA CPT, specialty guidance and third-party edit vendors) to ensure accurate claims processing, prevent duplicate or bundled payment, and enforce frequency/unit limits. The policy is maintained over time with numerous effective-date edits and revisions; it governs adjudication of professional and outpatient facility claims across affected states and products and instructs providers on when additional documentation, modifiers (for example KX, EA/EB/EC, JW/JZ, LT/RT/50), or place-of-service designations are necessary to support payment.

Defined Terms Used in This Policy

Definitions

Payable/Not payableLanguage used indicates whether a procedure or supply line will be reimbursed based on edit conditions; 'not payable' indicates denial or removal from payment.

Add-on codesProcedure codes designated as add-on are not payable with modifier -51 or when the primary code is absent/denied.

STV-PackagedServices considered packaged in presence of codes with APC status indicator S, T or V per CMS OPPS rules.

CMS-defined non-covered servicesServices identified by CMS as not payable under Medicare; EmblemHealth applies these rules to products as specified.

Modifier KXModifier indicating documentation supports medical necessity and allows exceeding certain payment limits (used to exceed cardiac rehab, DME, etc.).

JW modifierModifier indicating drug amount discarded/not administered to any patient; submission rules and per-drug unit thresholds apply.

Changes & Material Updates

2025-09-02revisionLatest

Updates highlighted in policy; multiple edits had previous effective dates updated (examples include edits with prior effective date 7/04/2025 moved to 9/26/2025) and deletion of codes 0240U and 0241U from Laboratory-Pathology edits was indicated.

2025-08 (as written)clarified

Added clarity to laterality/diagnosis reporting: when a bilateral diagnosis code is available, reporting separate left and right codes is not appropriate (excludes breast malignancy codes).

2025-06-19revision

Policy Summary

PayerEmblemHealth

PolicyCoding Edit Rules (Commercial, Medicare & Medicaid)

Policy CodePolicy RP2O210017

Change TypeRevisions & code updates (2021–2025)

Effective Date

Next Review Date

Key ActionReview and apply the updated coding edit rules and modifier requirements to claims submissions; ensure supporting diagnoses, modifiers, and documentation are present to avoid denials.

SourceLink

On This Page

Service not payable when laterality diagnosis conflicts with procedure/modifier codes.

Service not payable when clinical trial modifier Q0/Q1 present without required diagnosis indicating trial participation.

General denial/limitation logic for E/M services and related procedures

Payment is denied or limited when specific combinations, timing, modifiers, settings, or missing supporting elements occur.

ANY of the following

E/M code with the lower RVU price is not payable when multiple E/M services billed same date, same provider group and specialty, unless additional E/M has modifier 25.
Problem-oriented E/M services are not payable when billed with preventive medicine services unless the E/M service has modifier 25.
E/M services not payable when billed same date as electromyography, nerve conduction tests, or reflex tests.
E/M services not payable same date as specified cardiovascular services (listed codes).
E/M services (99201-99215, 99221-99223, 99231-99233, 99460) are not separately payable when billed with critical care (99291) at same place of service, except when appended with modifier 25.
New patient or initial care visit not payable in excess of one unit.
Observation care discharge (99217) not payable when certain observation/admission services not billed within prior three days.
Inpatient hospital consults (99251-99255) not payable if any inpatient visit billed in previous week for same place and no discharge billed.
Initial neonatal/pediatric critical care (99468, 99471, 99475) not payable if inpatient critical care services occurred previous day.
Initial neonatal intensive care (99477) not payable when reported within 24 hours of admission.
Combination of neonatal/pediatric critical care codes limited to one unit per date of service.
G0101 or Q0091 not payable when billed with S0610-S0612 by same physician.
E/M services with modifier 25 (same code) limited to one unit per provider ID.
Observation services (specified codes) limited to one unit per date of service across providers in specified inpatient/outpatient places of service.
Hospital discharge services (99238-99239) not payable when both 99238 and 99239 billed same date.
New patient visit by non-physician practitioner not payable if prior face-to-face by same group within 3 years with matching primary diagnosis.
Care management codes (99487, 99489-99491, 62058) not payable without a secondary diagnosis.
Medication therapy management initial (99605) not payable if billed within one year of prior 99605/99606.
Digital rectal exam (G0102) not payable when billed with preventive wellness visit codes G0438-G0439.
Interprofessional telephone/internet consult codes (99446-99449, 99451) not payable when a face-to-face service billed same date or within previous 14 days.
G2211 complexity add-on not payable when reported with outpatient/office E/M with modifier 25 (effective 1/1/2024) or with allowed preventive service without modifier 25 (effective 1/1/2025).
CPT 99459 not payable when billed with preventive medicine visits (99391-99397) or illness-related E/M (99211-99215) (effective 1/1/2024).
Procedures that are components of a comprehensive procedure are not payable when another component in same family billed/paid same date.
Frequency rules and many specialty-specific mutual-exclusion rules restrict separate payment for overlapping procedures or services.
Global surgery and obstetrical package rules: E/M and other services not payable within global periods or when billed by same Provider ID per CMS guidance.
COVID-19 specimen collection codes G2023/G2024 considered integral to testing—no separate reimbursement (effective 3/1/2020).
Procedure codes with CMS payment indicator 'B' are considered bundled and not separately payable.
Invalid HCPCS/CPT and Revenue code combinations are not payable (effective 10/1/2022).
CLIA/QW modifier rules and lab supply bundling rules: CLIA-waived modifier QW only payable if code designated waived; supplies inherent to lab service not separately payable.
Home health billed during inpatient stay not payable (exceptions for admission/discharge dates); readmission within 30 days subject to clinical review (effective 7/04/2025).
Inappropriate age or gender code use rules deny when member age/gender incompatible with procedure/diagnosis.
Modifier use rules: procedures submitted with modifiers 26, 50 or TC not permitted where concept does not apply; telehealth modifiers GO/GQ/GT/95 not permitted for non-designated services.
Incident-to services not payable when billed with specified place of service codes.

Non-payable surgical pathology when only diagnosis is listed

Surgical pathology gross & microscopic exam codes are denied when the only diagnosis on the claim line is a specified diagnosis.

ANY of the following

If the only diagnosis on the claim line is hydrocele or spermatocele, deny CPT 88305, 88307, 88309.
If the only diagnosis on the claim line is polyp of stomach and duodenum, deny CPT 88307 or 88309.
If the only diagnosis on the claim line is a cornea diagnosis code, deny CPT 88305, 88307, 88309.
If the only diagnosis on the claim line is ganglion cyst, deny CPT 88305, 88307, 88309.
If the only diagnosis on the claim line is an appendix diagnosis code, deny CPT 88305, 88307, 88309.
If the only diagnosis on the claim line is a gallbladder diagnosis code, deny CPT 88305, 88307, 88309.
If the only diagnosis on the claim line is a polyp diagnosis code, deny CPT 88305, 88307, 88309.
If the only diagnosis on the claim line is a hemorrhoid diagnosis code, deny CPT 88305, 88307, 88309.
If the only diagnosis on the claim line is an encounter for (unspecified in this excerpt), deny 88304, 88305, 88307, 88309 (effective 3/15/2023).

COVID-19 and SARS-CoV-2 test bundling/duplication rules

Rules limiting duplicates and unit counts for SARS-CoV-2/COVID-19 testing codes.

ALL of the following

CPT 86769 (SARS-CoV-2 antibody) is not payable when billed with 0224U (antibody with titer). Effective 2/01/2022.
CPT 0224U is not payable when previously billed and paid same date with 86769. Effective 2/01/2022.
Nucleic-acid based SARS-CoV-2 tests (U0003) limited to one unit per day unless reported with modifier 59. Effective 2/01/2022.
U0003 not payable when billed with 87635 (COVID-19 NAAT) if duplication/pairing conflicts exist. Effective 2/01/2022.
Various mutual-exclusion and duplication rules between U-codes and CPT 87635/U0003/U0002/U0004; several edits effective 2/01/2022.

Modifier and unit-related denial logic

Rules deny services when inappropriate modifiers, missing required modifiers, or excess units are billed.

ALL of the following

Modifier QW (CLIA waived) not payable when billed with procedure code not designated as CLIA waived on fee schedule.
Travel allowance HCPCS P9603/P9604 not payable when billed without specimen collection code.
Supplies inherent to a laboratory service are not separately payable.
Units exceeding allowed MUE or provider/unit limits will be denied per Maximum Units and MUE policies.
Various modifier-specific denials: SJ, SH, 92 incompatibilities, anatomical modifier requirements, invalid CMS/AMA modifiers, repeat modifiers (76,77,78,79) denial conditions, telehealth modifiers GQ/95 restrictions, modifier SL vaccine rules, AX limited to specific HCPCS, CS not allowed per CMS, and others.

General mutually exclusive / comprehensive component / NCCI edits

Procedures categorized as Column II, mutually exclusive, or comprehensive component codes are not payable when billed with their associated comprehensive codes by the same provider on the same date.

ALL of the following

Same provider
Same date of service
Column II vs associated comprehensive or mutually exclusive Column I code present

NCD Procedure-to-Diagnosis inclusionary/exclusionary rules

Lab and procedure codes may be denied based on pairing with ICD-10 diagnoses per CMS NCD lists (inclusionary/exclusionary/non-covered).

ANY of the following

Procedure submitted with an ICD-10 code on CMS non-payable list → deny
Procedure submitted without an ICD-10 on the payable list (inclusionary) → deny
Procedure submitted with diagnosis specifically defined as non-covered in NCD → deny

Place of Service (POS) constraints

Many codes are non-payable when billed in inappropriate places of service or require specific POS to be payable.

ALL of the following

If procedure code is billed in a POS not listed as allowable for that code → not payable
Some services require hospital POS (21/22/19/24 etc.) or are limited to office (11) or facility-specific POS

Frequency / unit limits

Certain CPT/HCPCS codes have per-day, per-period, or lifetime frequency/unit limits.

ANY of the following

01996 (epidural/subarachnoid continuous administration) — not payable beyond one unit per date of service.
95937 (neuromuscular junction testing) — not payable beyond 3 units/day for myoneural disorders; 2 units/day for motor neuron disease/myopathies when higher-frequency diagnosis not present.
Polysomnography codes 95782/95783/95808/95810/95811 — not payable more than one unit per date of service (historical; some rules terminated).
EEG digital analysis 95957 — not payable when billed same day as long-term EEG monitoring 95700-95726.
Scanning computerized ophthalmic imaging (92134, 92132, 92133) — frequency and diagnosis constraints (e.g., 92134 not payable more than once within 28 days for retinal disease).
Fundus photography 92250 — not payable more than two units within one year except specific diagnoses.
Once-per-lifetime services — subsequent claims after initial reimbursement are not payable.

Place-of-service restrictions for specific E/M and other CPT codes

Lists codes that are not payable when billed in specific POS values (allowed POS enumerated where applicable).

ANY of the following

E/M add-on codes (99026, 99050, 99051, 99053, 99056, 99058, 99060) not payable with POS 20 (Urgent care) or when provider specialty = urgent care.
E/M add-on codes not payable with ED visit codes when provider specialty = emergency medicine and POS = 23 or 20.
Office/outpatient visit codes (99202-99205, 99211-99215) not payable unless billed in allowed POS list (examples enumerated in policy).
Inpatient neonatal/pediatric critical care (99468-99476) and intensive care (99477-99480) payable only in POS 02 or 21.
Domiciliary/rest home E/M (99324-99340) allowable only in specified POS (13,14,33,55,99) except POS 02 telehealth exceptions.
Emergency department visits (99281-99285, G0380-G0384) only payable in POS 23 (or 02 Telehealth for some ED codes).
Home visit E/M (99341-99350) only payable in POS 02 or 12 (Patient's home).
Initial hospital care (99221-99223), subsequent (99231-99233), discharge (99238-99239) payable only in enumerated inpatient POS (with POS 02 exceptions).
Nursing facility E/M (99304-99310, 99315-99316, 99318) payable only in POS 31,32,34,54,56 (telehealth exception POS 02).
Initial inpatient consultation (99251-99255) payable only in specified POS list.
Outpatient consultation services (99241-99245) not payable in POS 21 (Inpatient hospital).

Procedure/age and procedure-definition consistency rules

Procedures inconsistent with patient age or code definition are not payable; codes billed out of sequence or not meeting CPT/HCPCS criteria denied.

ALL of the following

Procedures inconsistent with patient's age based on code definition are not payable.
Procedures billed out of sequence are not payable.
Services that do not meet specific CPT/HCPCS code descriptive criteria are not payable (examples provided).
Procedures designated as bundled/packaged per CMS NPFS/OPPS/APC are not separately payable.

Modifier and component (26/TC) rules

Rules for use of modifier 26 and TC and PC/TC/global-only codes applicable to professional and facility billing.

ALL of the following

Modifier 26 or TC not payable when appended to codes where professional/technical component concept does not apply.
Modifiers 26 and TC cannot be appended to the same claim line.
Technical component only procedures are not payable to professional providers in inpatient/outpatient facility settings.
Global-only codes with PC/TC status '4' are not payable when billed by inappropriate entity (facility vs professional) — only applicable component payable and appropriate code must be used.
Immunization administration codes (90460-90461, 90471-90474) not payable without corresponding vaccine/toxoid code on same date.

Procedure-diagnosis incompatibility and related-service rules

Denials when diagnosis is incompatible or when procedures are related to non-covered services.

ANY of the following

Procedures with diagnosis codes not compatible with CMS NCD/LCD are not payable.
Related services to a non-covered procedure may be denied if the linked non-covered procedure was denied (rule checks timing and diagnosis match).
Procedure codes or services received with a secondary diagnosis used as principal are not payable.

Revenue code / HCPCS matching rules

Require matching HCPCS codes for certain revenue codes and bill types; mismatches are not payable.

ALL of the following

Home health/hospice visits not payable when HCPCS code and revenue code do not match.
Revenue codes that require HCPCS codes per CMS OPPS are not payable when HCPCS is missing.
Claims with bill type 0140-014Z without revenue code 0300-0319 are not payable.
Revenue code 0452 not payable without 0451.
Evaluation and Management lines reported with Revenue Code 0450 are not payable when billed with another E/M with revenue 0451 or 0452.

Vaccination and immunization frequency/age limits

Rules restricting repeat vaccinations by time, age or lifetime counts.

ALL of the following

Influenza vaccines not payable when same/different vaccine billed and paid within previous 3 months for patients >=9 years.
Influenza vaccine not payable when paid more than twice in same calendar year for patients >=9 years.
HPV vaccines (90649, 90650, 90651) not payable for patients <9 years; 90651 not payable for patients >=46 years; HPV vaccines not payable when billed more than three times in lifetime.

Service scope / provider specialty limitations

Denials when providers perform services outside their scope or when certain specialties bill restricted codes.

ANY of the following

E/M services are not considered within scope of Clinical Psychologists or Clinical Social Workers — E/M billed by CP/CSW are not payable per CMS guidance.
Deny procedures billed by audiologists, physical therapists, pathologists, podiatrists, chiropractors when outside their scope of practice as specified (examples provided).
Manipulation of spine requiring anesthesia (CPT 22505) not payable under Chiropractor specialty.

General nonpayable/edit conditions

Rules that render a line nonpayable when specified conditions are met (examples summarized).

ANY of the following

Add-on CPT codes are not payable when the primary (parent) code has not been billed and paid on the same date of service by the same provider.
Services designated as bundled/incidental/packaged per CMS NPFSRVF, OPPS, or APC are not payable when billed separately.
CPT 99406 and 99407 (smoking cessation counseling) are not payable without a diagnosis of tobacco or nicotine dependence.
Fracture/dislocation care codes billed in office within 10 days (or two weeks for some edits) of same or different fracture/dislocation care code by any provider are not payable.
Procedures billed with modifiers 54, 55, or 56 are not payable when another provider has billed the same code globally without those modifiers.
Physician visits or services are not payable when billed by the operative provider with a related diagnosis within the postoperative global period as defined by CMS NPFSRVF.
CPT codes not allowed for Team Surgery are not payable when billed with modifier 66; and team surgery rules reverse-pay when duplicates exist with/without modifier 66.
Telehealth modifier rules: GQ or GO billed when POS or revenue codes do not match telehealth expectations are not payable; modifier 95 not payable when used with non-approved telemedicine codes.
Unbundled/incidental services (e.g., venipuncture CPT 36415, urinalysis CPT 81002) are not separately reimbursable with related higher-level services unless appropriate modifiers apply.
Intraoperative neurophysiological monitoring is not reimbursed separately when performed by the operating surgeon or anesthesiologist; only reimbursed when performed as a diagnostic service by a separate provider.
Specific CPT/HCPCS pairings detailed as nonpayable in specialty policies (examples: ophthalmology imaging frequency limits, urology ultrasound/uroflowmetry pairings, etc.).

Anesthesia procedure codes (00100–01999) must be billed with appropriate anesthesia modifiers (AA, QX, QZ) and follow CRNA billing rules; multiple general anesthesia codes billed same day are limited to the code with the highest submitted charge and CRNA lines without proper modifiers are not payable.

00100-01999
QX
QZ
AA
Revenue Code 0964

Billing Rule

Ambulance origin/destination modifiers and place of service

Ambulance claims must include valid origin and destination modifiers and be billed to allowed ambulance places of service; certain ambulance HCPCS (A0427, A0429, A0433) are denied when the destination modifier is not H or X, and transport services require POS 41 or 42 where specified.

A0427
A0429
A0433
Modifiers QM, QN, QL
Place of Service 41,42

Documentation Required

Diagnosis support for vascular studies

When arterial (93922–93931) and venous (93970–93971) duplex studies are billed on the same date, include a supporting diagnosis for each study; if the counterpart study lacks a supporting diagnosis it will be denied.

93922-93931
93970-93971

Billing Rule

Bundled services and OPPS packaging

Outpatient hospital claims must follow CMS OPPS packaging rules: HCPCS with status indicators N, Q4, T, or STV-packaged status are considered packaged into APC payments and will be denied when billed separately on outpatient hospital claims where packaging applies.

Status indicators N,Q4,T
HCPCS packaged lists

Billing Rule

Lab panel unbundling

Do not submit unbundled individual components of a disease-oriented or chemistry panel on the same date of service by the same provider; bill the appropriate comprehensive panel or automated multichannel test code instead.

Chemistry panels

Prior Authorization

Modifier KX usage for extended services

When outpatient cardiac rehabilitation (CPT 93797–93798) exceeds the standard unit/frequency limit (36 units in 36 weeks), report modifier KX to indicate the medical policy requirements have been met; without KX lines may deny.

93797-93798
Modifier KX

Documentation Required

Ensure required diagnoses and supporting services are present on claim

Ensure required diagnoses, supporting procedures, modifiers, place of service, and other companion services are present on the claim; lines lacking mandated clinical or billing elements (examples shown in policy) will be denied.

No more than 6 times per year (combined)

Intermittent urinary catheters (A4351-A4353)600 units per 3 months

Example drug JW unit thresholdsPer-drug thresholds (examples: J9035 >=10; J9041 >=35; J0585 >=100; J0587 >=25; J0588 >=50; J9171 >=20)

Operational note for Content Writer: several frequency and supply exceptions in this policy require use of modifier KX or prior authorization per EmblemHealth rules (for example, cardiac rehab beyond 36 units in 36 weeks, TENS device approvals, or DME modifiers). When drafting threshold rows, please cross-reference each threshold with provider_actions entries by index to indicate whether KX, other specific modifiers (EA/EB/EC, JW/JZ, LT/RT/50), or prior authorization/documentation are required — e.g., see provider_actions entries for cardiac rehab (index referencing 93797/93798) and DME modifier rules. Populate each threshold row with the corresponding provider_actions index(es) to guide billing teams on modifier and documentation obligations.

Q0/Q1 modifiersModifiers for clinical trial services (Q0 investigational; Q1 routine) and require appropriate trial diagnosis codes.

MUEMedically Unlikely Edit — identifies when allowed units for a code have been exceeded for a date of service/member/provider.

Place of Service (POS)Two-digit code indicating location (e.g., 11=Office, 21=Inpatient hospital, 23=ED, 02=Telehealth); many edits require specific POS values for reimbursement.

Multiple updates: new edits effective 1/01/2025 and 4/25/2025; NY Medicaid allergen-specific IgE (86003) updated to include Facility claim type effective 10/15/2025; several edits terminated effective 3/1/2024.

2025-05-13revision

Policy updated with new edit effective 1/01/2025 and clarified post-operative nasal endoscopy and CMS Coverage Policy modifier guidance.

2025-04 (as written)revision

Multiple edits scheduled for 2025 (including new and updated edits effective 7/04/2025 and 8/01/2025) and clarifications to JW/JZ single-dose container guidance.

2025-03-14revision

Clarified CMS Coverage Policy language on procedures not carried out due to patient decision and clarified Drug and Biological Policy content regarding JW/JZ and single-dose vials.

2025-01-27revision

Added two new edits effective 1/01/2025.

2024-10-23revision

Multiple new edits published (effective dates including 10/1/2024, 11/1/2024, and several in 2025) and Drugs and Biologicals Policy edits replaced effective 4/1/2024.

2024-07-30revision

New edit added effective 12/6/2024.

2024-06-18revision

Six new edits effective 10/15/2024 were added to the policy.

2024-06-06revision

New edit effective 1/1/2024 was added.

2024-04-29revision

Updated list of non-covered HCPCS (added A4553) and other supply edits.

2024-03-24revision

Updated colonoscopy/sigmoidoscopy coverage language with EmblemHealth policy hyperlink for clarification.

2024-03-08revision

Clarified bilateral procedures/ modifier 50 guidance to require modifier 50 (one unit) when same code reported LT and RT; 150% payment adjustment noted.

2023-12-11revision

Added multiple new edits effective 4/15/2024 and 1/1/2024 and other terminations/changes.

2023-10-23revision

Catalog updates and new edits added effective 1/01/2023.

2023-09-01revision

Allergy testing edit for CPT 86003 revised: terminated 2/28/2023 (30-unit limit) and replaced with 40-unit per year limit effective 3/1/2023.

2022-08-01revision

Edits updated to include additional lines of business (CNY, PPOC, PPOMR).

2022-03-01revision

New edits including COVID-19 and other updates with effective date 3/1/2022 (e.g., IONM outside OR rule).

Coding Edit Rules (Commercial, Medicare & Medicaid)

Policy Scope & Summary

General Denial and Edit Logic (Criteria Trees)

Grouped Codes, Coverage Status & Examples

What Providers Must Do

Numeric Limits and Unit Thresholds

Clinical & Administrative Background

Defined Terms Used in This Policy

Other Policies to Review

Changes & Material Updates