New and Updated Reimbursement Policies

RECENTLY UPDATED

May 29

RP-003 Convenience Kits, Drug and Biological Wastage
Direction for modifier JZ and skin substitute wastage has been added. The name of the policy was changed, having formerly been Drug Wastage and Convenience Kits.

RP-026 Portable Radiography and ECG Services
A “Related Highmark Policies” section was added.

RP-041 Services Not Separately Reimbursed
Codes 38204, 90889, 92605, 92606, 92618, 93740, and R0076 were added for Commercial products. These codes will be considered not separately reimbursed and rejected as non-billable to the member.

RP-048 Independent Diagnostic Testing Facility (IDTF)
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-050 Inpatient Readmissions
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-051 Multiple Procedure Payment Reduction for Therapy Services
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-057 Evaluation & Management Services
The policy was 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.

RP-064 Government Supplied Vaccinations and Antibody Treatments
Direction was updated for the following codes that had the emergency use authorization rescinded: 0001A – 0004A, 0011A, 0012A, 0013A, 0051A, 0052A – 0054A, 0064A, 0071A – 0074A, 0081A – 0083A, 0091A – 0094A, 0111A – 0113A, 91300, 91301, 91305 – 91309, and 99311.

Codes 0121A, 0141A, 0142A, 0151A, 0171A, and 0172A were added.

REMINDER: RP-075 Appropriate Use Criteria for Advanced Diagnostic Imaging
This new policy — which was made available for review on the PRC on February 27, 2023 (click to read the Special Bulletin ) — is now in effect. Highmark 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. This policy follows CMS’ current suggested direction. CMS has not indicated when, or if, this direction will become mandatory. Providers are encouraged to follow the direction in this policy, but it is not mandatory.

June 5

RP-042 Global Surgery and Subsequent Services
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-043 Care Management
This policy was reviewed as part of our standard review process. No changes in direction were made.

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.

June 12

RP-055 Nominal Charges
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-056 Delivery Payment Equivalency
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-058 Acupuncture When Billed with Evaluation and Management Services
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-059 Associated Services
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-061 Implants and Implant Components
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-062 Durable Medical Equipment MUE Value
This policy was reviewed as part of our standard review process. No changes in direction were made.

RP-066 Sleep Study Supplies and Services
This policy was reviewed as part of our standard review process. No changes in direction were made.

UPCOMING

July 3

RP-007 Multiple Procedure Payment Reduction for Certain Diagnostic Imaging Procedures
Codes 0807T and 0808T will be added to the APPENDIX A – Procedure Codes Applicable To Professional And Technical Component Reduction section. Code 0804T will be added to the APPENDIX B – Applicable Cardiovascular Procedure Codes section.

RP-042 Global Surgery and Subsequent Services
Codes 0793T, 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0805T, 0809T, and 0810T will be added to the global YYY codes sections for Medicare Advantage and Commercial.

July 10

RP-015 Professional and Technical Components for Applicable Services
The Public Health Emergency (PHE) exception note will be removed. Codes 99000 and 99001 will return to pre-PHE policy direction. (The PHE ended on May 11, 2023.)

RP-016 Physician Laboratory and Pathology Services
The PHE exception note will be removed. Codes 99000 and 99001 will return to pre-PHE policy direction. (The PHE ended on May 11, 2023.)

RP-027 Hemodialysis and Peritoneal Dialysis
Policy exception notes pertaining to the PHE — which ended on May 11, 2023 — will be removed. A definitions section will be added.

RP-041 Services Not Separately Reimbursed
PHE exception notes and end-dated codes G2023, G2024, and U0005 will be removed. Codes 99000, 99001, 90887, 99024, 99374, 99377, 99378, 99379, 99380, and 99483 will return to pre-PHE direction. (The PHE ended on May 11, 2023.)

RP-046 Telemedicine and Telehealth Services
This policy will be updated with post-PHE direction. (The PHE ended on May 11, 2023.)

RP-054 Ambulance Services
The PHE exception note for destination requirements will be removed. (The PHE ended on May 11, 2023.)

RP-064 Government Supplied Vaccinations and Antibody Treatments
Direction will be updated for codes 91303, 0031A, and 0034A.

August 31 (Effective September 1):

RP-019N Drugs and Biologicals
An updated version of this policy will be available for review on the PRC on August 31, 2023, and will be effective beginning September 1, 2023. Drug tiering is being eliminated for Delaware, Pennsylvania, and West Virginia. To access this reimbursement policy, log into NaviNet^® and select Resource Center from the left menu. Once redirected to the PRC, select CLAIMS, PAYMENT & REIMBURSEMENT in the left menu and then click Reimbursement Policy.

Correction: RP-010 Update

RP-010 Incident To Billing Services and Advanced Practice Provider Reductions

For West Virginia: West Virginia was inadvertently checked as an applicable Commercial market in the current version of RP-010. This will be corrected in the updated policy. Highmark will continue to reimburse for these services for Medicare Advantage products, as well as for Mid-Level Practitioners and Advanced Practice Providers who have been enumerated and bill using their own provider ID.*

For Pennsylvania: Incident To services for Commercial products will no longer be recognized, effective January 1, 2024. Highmark will continue to reimburse for these services for Medicare Advantage products, as well as for Mid-Level Practitioners and Advanced Practice Providers.*

For Delaware: Only non-Primary Care Physician (PCP) Incident To services will no longer be applicable to the policy, effective January 1, 2024. PCP Incident To services will still be covered. Highmark will also continue to reimburse for these services for Medicare Advantage products, as well as for Mid-Level Practitioners and Advanced Practice Providers.*

For New York: New York was inadvertently checked as an applicable Commercial market in the current version of RP-010. This will be corrected in the updated policy. Highmark will continue to reimburse for these services for Medicare Advantage products, as well as for Mid-Level Practitioners and Advanced Practice Providers who have been enumerated and bill using their own provider ID.*

*Direction for continued reimbursement for Mid-Level Practitioners and Advanced Practice Providers will be published in a new policy, RP-068 (see NEW: RP-068 further down in this article), effective on September 25, 2023.

September 25

NEW: RP-068 Mid-Level Practitioners and Advanced Practice Providers
Highmark has created RP-068 to provide direction on reimbursement for Mid-Level Practitioners and Advanced Practice Providers. (NOTE: This policy will be available on the PRC on September 25, 2023.)