Clinical Payment and Coding Policies

This information does not apply to members who have Medicaid or Medicare plans.

Clinical payment and coding policies are based on criteria developed by specialized professional societies, national guidelines (e.g. Milliman Care Guidelines (MCG) and the CMS Provider Reimbursement Manual. Additional sources are used and can be provided upon request. The clinical payment and coding guidelines are not intended to provide billing or coding advice but to serve as a reference for facilities and providers. 

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern. 

In the event of conflict between a Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. Plan documents include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents. 

In the event of conflict between a Clinical Payment and Coding Policy and any provider contract pursuant to which a provider participates in and/or provides services to eligible member(s) and/or plans, the provider contract will govern. 

For CPCPLAB policies, refer to the Laboratory Benefit Management Program page.

For other policies, select the policy name below for more information.

Policy Name Policy Number Effective Date

Anesthesia Clinical Payment and Coding Information

CPCP010  9/2/2022

Applied Behavior Analysis

CPCP011  11/9/2021

Chiropractic Services

CPCP016  1/1/2022
Coordinated Home Care/Private Duty Nursing CPCP005  10/08/2021
Corrected Claim Submissions CPCP025  5/1/2020

Co-Surgeon/Team Surgeon Modifiers

CPCP009  10/5/2021

Drug Testing Clinical Payment and Coding Policy

CPCP020  12/29/2021
Evaluation and Management (E/M) Services Coding – Facility Services CPCP003  12/1/2021
Evaluation and Management (E/M) Coding – Professional Provider Services CPCP024  12/23/2021

Global Surgical Package

CPCP014  3/1/2022

Hernia Repair

CPCP012  4/22/2022

Home Infusion

CPCP019  9/7/2021

Implant Payment and Coding Policy

CPCP007  7/6/2020

Increased Procedural Services (Modifier 22)

CPCP013  2/24/2022
Inpatient Readmissions CPCP027  12/1/2021
Inpatient/Outpatient Unbundling Policy CPCP002  12/16/2021
Intraoperative Neurophysiology Monitoring Coding and Reimbursement Guideline CPCP032  4/22/2022

Laboratory Panel Billing Guideline

CPCP021  4/06/2022

Medical Record Documentation Guidelines

CPCP029  9/16/2022

Modifier Reference Guideline

CPCP023  5/13/2022

Multiple Surgical Procedures

CPCP015  6/24/2022

Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy



Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)

CPCP028  8/1/2022

Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)

CPCP028  4/1/2022
Observation Services Tool for Applying MCG Care Guidelines Clinical Payment and Coding Policy CPCP001  7/20/2021

Outpatient Facility and Hospital Claims: Revenue Codes Requiring CPT or HCPCS Codes

CPCP018  12/01/2021

Paravertebral Facet Injection Procedure Coding & Billing Policy

CPCP036  11/2/2021

Pneumatic Compression Devices

CPCP022  12/10/2021

Point-of-Care Ultrasound Examination Guideline

CPCP030  2/24/2022

Preventive Services Policy

CPCP006 9/1/2022

Psychological and Neuropsychological Testing

CPCP008  4/1/2021

Telemedicine and Telehealth Services

CPCP033  6/1/2022

Therapeutic, Prophylactic and Diagnostic Injection and Infusion Coding

CPCP026  9/7/2021

Trauma Activation - Facility Services

CPCP031  2/24/2022

Unbundling Professional

CPCP034  4/5/2022

Unlisted/Not Otherwise Classified (NOC) Coding

CPCP035  9/2/2022

Wasted/Discarded Drugs and Biologicals Guideline

CPCP017  12/21/2021