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Clinical payment and coding policy changes


We regularly adjust our clinical payment and coding policy positions as part of our ongoing policy review processes. Our standard payment policies identify services that may be incidental to other services and, therefore, ineligible for payment. In developing our policies, we may consult with external professional organizations, medical societies and the independent Physician Advisory Board, which advises us on issues of importance to physicians. The chart below outlines coding and policy changes.



Effective date

What’s changed

Application of prefabricated splints*


March 1, 2019

We will deny CPT codes 29105 – 29131 and 29505 – 29515, application of casts or splints, when billed for the same date of service as HCPCS codes for prefabricated collars, orthosis and splints.

National Correct Coding Initiative (NCCI) and Outpatient Code Editor (OCE)*


March 1, 2019

Our existing Incidental Claim Edits policy includes recommendations provided by the Centers for Medicare & Medicaid Services (CMS) OCE and the American Medical Association Current Procedural Terminology codes manual. For dates of service on or after March 1, 2019, we will apply this policy to claims for:


  • Skilled nursing facilities (SNFs)
  • Comprehensive outpatient rehabilitation facilities (CORFs)
  • Outpatient physical therapy and speech-language pathology providers
  • Certain home health agencies (HHAs)


This language is consistent with CMS’s NCCI.

Definitive drug testing*









March 1, 2019

We are updating our policy on definitive drug testing to allow testing of up to eight definitive drug classes per date of service. 

  • We’ll continue to allow eight definitive drug test encounters per rolling 12-month period across all providers. 
  • Drug testing procedure codes received for an allowable encounter of more than eight definitive drug classes per day will be considered at the rate for G0481 and reimbursed accordingly.


Daily limits for lab codes*



March 1, 2019

We currently allow a daily limit of one unit for many lab codes for professional claims. Starting March 1, 2019, we’re expanding these edits to include facility claims.

Duplex scans*

March 1, 2019

We will no longer allow payment for physiologic studies of upper or lower extremities (CPT codes 93922, 93923 and 93924) when performed on the same day as a duplex scan (CPT codes 93925, 93926, 93880 and 93882). We consider physiologic studies services and duplex scans to be mutually exclusive.

Billable-times limitation on nursing care in the home*

March 1, 2019

We will limit any combination of the following HCPCS codes to 24 units per date of service:

  • S9123 — Nursing care in the home; by registered nurse, per hour
  • S9124 — Nursing care in the home; by licensed practical nurse, per hour


Both of these codes, by definition, represent one hour of service.

Prepayment coding reviews for Coventry Medicare claims

March 1, 2019

For admission dates on or after March 1, 2019, we’ll expand our prepayment coding reviews for specific diagnosis-related group (DRG) claims. This will affect all Coventry Medicare claims.


As always, we want to ensure that the claims correctly show the services you give to our members. We will review DRG facility claims based on case history.


To make sure we review your claims quickly and accurately, please make sure all necessary clinical information is provided up front. If we need more information, we may ask you for medical records.


This program does not impact providers in the following states: Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island, Texas and Vermont.


*Washington state providers: This item is subject to regulatory review and separate notification.