New and Updated Reimbursement Policies

April 3

RP-072 Injection and Infusion Services
This policy is being updated with the addition of codes Q5127 and Q5130.

June 5

RP-045 Purchased Services
This policy is being updated to clarify pass-through billing direction for independent laboratories. A provider may not report a professional service that is performed by another entity.

REMINDER: Here are additional upcoming RP changes that were announced in the February 2023 issue of Provider News:

May 1

RP-037 Emergency Evaluation and Management Coding Guidelines
This policy is being updated to provide direction on the Plan’s analysis of evaluation and management codes for accuracy.

May 29

RP-003 Convenience Kits, Drug and Biological Wastage
This policy is being updated regarding the use of JZ and JW modifier, as well as skin substitute wastage documentation.

RP-019N Drugs and Biologicals
This policy is being updated with direction on the New York market’s reimbursement of Drugs and Biologicals. This tiered reimbursement structure has been in place for many years, and it is being documented in a policy for provider advisement. To access this reimbursement policy, log into NaviNet^® and select Resource Center from the left menu. Once redirected to the Provider Resource Center, choose CLAIMS, PAYMENT & REIMBURSEMENT from the left menu then Reimbursement Policy.

RP-041 Services Not Separately Reimbursed
This policy is being updated for Commercial products to add codes 38204, 90889, 92605, 92606, 92618, 93740, and R0076. These codes will be considered not separately reimbursed and rejected as non-billable to the member.

RP-057 Evaluation and Management Services
The policy is being updated to align with recent changes to Centers for Medicare and Medicaid Services (CMS) guidance for selecting the level of a reported Evaluation and Management (E/M) service and the eligibility for E/M reimbursement based on the fulfillment of the required criteria. As of January 1, 2023, all Evaluation and Management services are now selected and scored based on medical decision-making (MDM) or time.

NEW: RP-075 Appropriate Use Criteria for Advanced Diagnostic Imaging
Highmark has created RP-075 to provide direction to practitioners on how to successfully increase the rate of advanced diagnostic imaging services based on Appropriate Use Criteria. For more information about this RP, click to read the Special Bulletin .