New and Updated Reimbursement Policies

Highmark regularly issues new or updated reimbursement policies. Keep an eye on this newsletter and the Provider Resource Center (PRC) homepage for announcements regarding upcoming policy changes. As specific policy changes go into effect, the updated policies can be found on the Reimbursement Policy page of the PRC.

Below is a list of recent and upcoming updates to reimbursement policies (RPs):


January 1, 2024

MRP-006 Wrong Surgery
Effective Dec. 31, 2023, this policy was archived. The direction of this policy was merged into a new version of RP-036 (see below), which went into effect Jan. 1, 2024.

RP-006 Multiple Endoscopy Procedures
Codes 31242, 31243, 0781T, 0782T, 0813T, and 52284 were added to this policy in their respective groupings.

RP-007 Multiple Procedure Payment Reduction (MPPR) for Certain Diagnostic Imaging Procedures
Codes 0826T and 0865T were added.

RP-011 Procedure Codes Not Applicable to Commercial Products
Code G0137 was added.

RP-036 Preventable Serious Adverse Events
This policy was updated to include a Medicare Advantage section containing direction merged from MRP-006 (see above).

RP-041 Services Not Separately Reimbursed
Code G2211 was removed and is now a separately payable service when eligible.

RP-042 Global Surgery and Subsequent Services
Codes 0784T, 0785T, 0786T, 0787T, 0790T, 0816T – 0819T, 0823T – 0825T, and 0861T – 0863T were added to the global YYY codes sections for Medicare Advantage and Commercial.

RP-057 Evaluation & Management Services
The note included under “Level based on Medical Decision Making (MDM)” was updated.

RP-072 Injection and Infusion Services
Effective Jan. 1, 2024, Highmark applied a system enhancement to identify when chemotherapy administration codes are billed and to enforce the direction defined on RP-072. For providers, this enhancement reduces administrative costs associated with claim audits and adjustments by supporting the correct adjudication of claims before the finalization of initial claim processing.

In addition, the description for code 96361 was updated.

January 15, 2024

RP-037 Emergency Evaluation and Management Coding Guidelines
Outpatient surgery will be removed from the exclusion criteria.

RP-057 Evaluation & Management Services
The RP-041 policy cross reference note for code G2211 was removed.


April 1, 2024

RP-034 Prolonged Detention or Critical Care
Code 93598 will be added to the “Prolonged Detention or Critical Care” section of this policy.

April 29, 2024

RP-041 Services Not Separately Reimbursed
Code 76140 will be added and will no longer be a separately reimbursed service.

May 1, 2024

RP-026 Portable Radiography and ECG Services – Modifiers UN, UP, UQ, UR, US
Direction for “U” modifier reductions reported with code R0075 will be made applicable for Commercial.