Five New Claims Editing Rules will be Implemented November 2025

Missing Modifier 54

This rule identifies claim lines that should have a reduction in payment for surgical services provided in an emergency room where the follow-up care isn’t done by the same provider and Modifier 54 wasn’t billed.

This rule is appropriate for professional claims submitted with an emergency room place of service.

This rule identifies codes billed for the same member for the same date of service for rebundling to a more comprehensive code:

• When any two or more CPT test codes (87491, 87591 and/or 87661) are billed separately for the same member, provider and the same date of service, the payment policy recommendation would be based on the rate for 87801, which is the more comprehensive code for multiple organisms.
• If the comprehensive procedure code (87801) has been billed by the same provider for the same date of service, then the separate single test codes (87491, 87591 and/or 87661) are disallowed.

This rule is appropriate for professional and outpatient facility claims. 

This rule identifies intensity modulated radiation therapy procedure codes submitted on an outpatient facility or professional claim when planning procedure 77301 is found within 30 days before or on the same date of service for the same provider.

This rule is appropriate for professional and outpatient facility claims.

Trauma Activation

This rule identifies claim lines with revenue code 068X and procedure code G0390 when submitted on an outpatient facility claim with no critical care procedure code 99291 on the same date of service.

This rule is appropriate for outpatient facility claims. 

This rule identifies technical component only procedure codes that should not be billed on a professional claim in a facility setting. These codes are identified by the Centers for Medicare & Medicaid Services’ PC/TC Indicator of 3.

This rule is appropriate for professional claims.