Effective for dates of service beginning Oct. 1, 2024, Point32Health is making the updates outlined below to our General Coding and Claims Editing Payment Policy, to align with industry standard correct coding practices.
- Factors Influencing Health Status and Contact with Health Services Diagnoses and Non-Routine Examinations: Point32Health will deny any services billed with an ICD-10 diagnosis code in the Z53.1–Z53.20 range, indicating that the patient decided not to receive the procedure or treatment.
- Interprofessional Telephone/Internet Consultations: Any of the following services will be denied if an evaluation and management (E/M) service denoted by CPT codes 99202-99439, 99446-99499, or 99091 has also been billed with the same primary diagnosis on the same day, previous seven days, or following day:
- telephone E/M services 99441–99443
- remote evaluation of recorded video and/or image (G2010)
- brief check in by a physician or other qualified health care professional (G2012, G2252)
- Stem Cell Transplantation and Bone Marrow Transplantation: The procedure code CPT 38240 (Bone marrow or blood-derived peripheral stem-cell transplantation; allogeneic) will be reimbursed only when submitted with the ICD-10 diagnosis code Z00.6 to indicate that the patient is participating in an approved clinical trial.
- Transesophageal Echocardiography (TEE): Point32Health will deny any TEE service (CPT codes 93312–93318, 93355, or C8925–C8927) when they are billed with any of the following as the first listed or principal diagnosis:
- Encounter for aftercare following heart or lung transplant (ICD-10 Z48.21, Z48.280)
- Heart and lungs transplant status (ICD-10 Z94.1, Z94.3)
- Presence of prosthetic or other heart valve replacement (Z95.2–Z95.4)
These changes are documented in Point32Health’s updated General Coding and Claims Editing Payment Policy.
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