Payment Policy Changes Effective 11/1/2026

Policy Number

Policy Name

Policy Description

Lines of Business

CP.PP.071

E&M Services Billed with Treatment Room Revenue Codes

Treatment room and specialty services revenue codes characterize services performed in a facility setting that are represented by a specific procedure reportable in a treatment room setting.  The patient receiving these services must be registered through the hospital business office for outpatient services on a hospital campus.

Policy/Criteria
The health plan does not reimburse facility evaluation and management (E/M) charges billed in conjunction with a treatment room revenue code as these services do not represent a specific procedure performed in a treatment room.  Billing treatment room revenue codes is incorrect coding when reported for office-based evaluation and management services. The health plan will reimburse facility treatment room services directly related to the procedure(s) that are provided on the same day in which the treatment is rendered.

Applies to: Type of Bill 13X

Reimbursement Guidelines
The health plan’s code editing software will evaluate claims billed with revenue codes 760, 761 and 769 that are billed in conjunction with an evaluation and management service according to the application criteria mentioned in this policy.

Any service line reported incorrectly will be denied for reimbursement

Marketplace

Medicaid

CC.PP.013

Clinical Validation of Modifier 25

The misuse of modifiers that override correct coding edits represents challenges for payors. Centene will institute a prepayment clinical claims review on all procedures billed with modifier -25. A registered nurse will review the information billed on the claim, along with the member and provider’s claim history to determine whether or not it is likely that the modifier was used correctly for the circumstances of the patient on the date of service. The Health Plan, and its vendors, will use nationally published guidelines from CPT and CMS when determining whether or not the modifier was used correctly.

Medicaid

CP.PP.145

Malnutrition*

Acute care hospitalizations for malnutrition require the most appropriate and most specific level of diagnosis coding. The medical record documentation supporting the diagnosis should be clearly documented by the physician or a licensed independent practitioner.

The cost difference between a Diagnosis Related Group (DRG) billed with malnutrition as a major complication or comorbidity (MCC) (in a position other than as the primary diagnosis code position) and a DRG billed without malnutrition as an MCC (in a position other than as the primary diagnosis code position) will be denied reimbursement unless meeting the documentation requirements described in this policy.

The purpose of this policy is to support a retrospective review of inpatient claims billed with the diagnosis of malnutrition.

Medicaid

Marketplace

HIDE
D-SNP