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 Archive
Anesthesia Clinical Payment and Coding Information CPCP010 9/2/2022 View
Applied Behavior Analysis CPCP011 11/9/2021 View
Chiropractic Services CPCP016 1/1/2022 View
Coordinated Home Care/Private Duty Nursing CPCP005 10/8/2021 View
Corrected Claim Submissions CPCP025 5/1/2020 N/A
Co-Surgeon/Team Surgeon Modifiers CPCP009 10/27/2022 View
Drug Testing Clinical Payment and Coding Policy CPCP020 12/29/2021 View
Evaluation and Management (E/M) Services Coding – Facility Services CPCP003 12/1/2021 View
Evaluation and Management (E/M) Coding – Professional Provider Services CPCP024 12/23/2021 View
Global Surgical Package CPCP014 3/1/2022 View
Hernia Repair CPCP012 4/22/2022 View
Home Infusion CPCP019 9/7/2021 N/A
Implant Payment and Coding Policy CPCP007 7/6/2020 N/A
Increased Procedural Services (Modifier 22) CPCP013 2/24/2022 View
Inpatient Readmissions CPCP027 12/1/2021 View
Inpatient/Outpatient Unbundling Policy CPCP002 12/16/2021 View
Intraoperative Neurophysiology Monitoring Coding and Reimbursement Guideline CPCP032 4/22/2022 View
Laboratory Panel Billing Guideline CPCP021 4/6/2022 View
Medical Record Documentation Guidelines CPCP029 9/16/2022 View
Modifier Reference Guideline CPCP023 5/13/2022 View
Multiple Surgical Procedures CPCP015 6/24/2022 View
Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy CPCP004 12/13/2021 View
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) CPCP028 8/1/2022 View
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) CPCP028 1/1/2023 View
Observation Services Tool for Applying MCG Care Guidelines Clinical Payment and Coding Policy CPCP001 7/20/2021 View
Outpatient Facility and Hospital Claims: Revenue Codes Requiring CPT or HCPCS Codes CPCP018 10/27/2022 View
Paravertebral Facet Injection Procedure Coding & Billing Policy CPCP036 11/2/2021 View
Pneumatic Compression Devices CPCP022 12/10/2021 View
Point-of-Care Ultrasound Examination Guideline CPCP030 2/24/2022 View
Preventive Services Policy CPCP006 10/1/2022 View
Psychological and Neuropsychological Testing CPCP008 10/31/2022 View
Telemedicine and Telehealth Services CPCP033 6/1/2022 N/A
Therapeutic, Prophylactic and Diagnostic Injection and Infusion Coding CPCP026 9/7/2021 N/A
Trauma Activation - Facility Services CPCP031 2/24/2022 View
Unbundling Professional CPCP034 4/5/2022 View
Unlisted/Not Otherwise Classified (NOC) Coding CPCP035 9/2/2022 View
Wasted/Discarded Drugs and Biologicals Guideline CPCP017 12/21/2021 View