September 5, 2024
To support access to quality, cost-effective care for your patients with a medical plan administered by Cigna Healthcare, we routinely review clinical, reimbursement, and administrative policies for potential updates. As a reminder, reimbursement and modifier policies apply to all claims, including those for your patients with “G” ID cards.
Planned medical policy updates*
| Policy name | Update | Effective date |
| Revenue Code Billing Requirements (R41) | We will administratively deny revenue codes 960-989 for professional services when billed by facilities on Form UB-04. Professional services should be billed on Form CMS-1500. | April 14, 2024, for dates of service on or after this date. |
| Omnibus Reimbursement Policy (R24) | We will administratively deny Current Procedural Terminology (CPT®) code 76377 as incidental, consistent with the process in place for CPT code 76376. | April 14, 2024, for dates of service on or after this date. |
| Code Editing Policy & Guidelines | We will add 10 codes with a status B indicator: CPT codes 38204, 92921, 92925, 92929, 92934, 92938, 92944, and 97602, and Healthcare Common Procedure Coding System (HCPCS) codes A4262 and A4263. These codes will be administratively denied when billed with another service not indicated as bundled. | May 11, 2024, for dates of service on or after this date. |
| Omnibus Reimbursement Policy (R24) | We will administratively deny facility claims billed with CPT code 76376 as incidental, consistent with the process in place for professional claims. | June 16, 2024, for dates of service on or after this date. |
| Diagnosis Coding Requirements (R47) | We will administratively deny claims submitted with an unspecified laterality diagnosis code when it is the only code billed on the claim. | June 16, 2024, for dates of service on or after this date. |
| Unacceptable Primary/Principal Diagnosis (R38) | We will administratively deny claims when an unacceptable primary or principal diagnosis code is the only code billed. | June 16, 2024, for dates of service on or after this date. |
| Evaluation and Management (R30) | We will administratively deny the medical evaluation and management (E&M) code when billed with a preventive E&M code and only an International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Z diagnosis code on the claim. | July 14, 2024, for dates of service on or after this date. |
| Code Editing Policy & Guidelines | We will add 27 CPT Codes and four HCPCS codes for professional and outpatient facility services. These codes will be administratively denied when billed at a frequency greater than the medically unlikely edit set by the Centers for Medicare & Medicaid Services, by the same provider, for the same patient, on the same day. The CPT codes are 86000, 86161, 86235, 86255-86256, 86316, 86403, 86406, 90840, 90845-90847, 90849, 90853, 90863, 95012, 96146, 97151-97158, 0362T, and 0373T. The HCPCS codes are G0447, G0451, G0473, and Q4050. | July 14, 2024, for dates of service on or after this date. |
| Bilateral Procedures (M50) | We will administratively deny unilateral procedure codes when billed with modifier 50. | July 14, 2024, for dates of service on or after this date. |
| Serum Folate and Red Blood Cell Folate (0567) | We will administratively deny CPT code 82746 when billed with a diagnosis code that is not covered or considered medically useful. In addition, we will administratively deny CPT code 82747 regardless of the diagnosis, as it is not considered medically useful | August 17, 2024, for dates of service on or after this date. |
| Diagnosis Coding Guidelines (R47) | We will administratively deny claims when ICD-10-CM Z diagnosis codes Z02.0-Z02.6, Z02.71, Z02.79, Z02.82-Z02.83, Z02.89-Z02.9, Z13.9, Z56.1, Z62.21, or Z63.6 are the only codes on the claim. | August 17, 2024, for dates of service on or after this date. |
* Please note that the planned updates are subject to change. For the most up-to-date information, please visit CignaforHCP.com.
Additional information
For more information about our monthly policy updates, visit CignaforHCP.com > Resources > Coverage Policies > Policy Updates.
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