Payment Policy Updates

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June 4, 2026

The following policies received their annual review with no changes:

• Modifier 51
• Modifier 59
• Modifier 90
• Modifier SU
• Place of Service Codes
• Unlisted, Non-Specific and Miscellaneous Procedure Codes

The following policies received their annual review with the changes noted below:

Global Surgery

• In the policy section under XXX global codes:
  • A subset of XXX codes represents procedures that include pre-, intra-, and post-procedural work.
  • Because this work is already part of the procedure, the Evaluation and Management visits (E&M) should not be billed separately.
  • If documentation supports a separate and significant E&M service on the same day as the XXX procedure that goes beyond the routine work of the procedure, the E&M service may be billed with modifier 25
    • See the below section "Significant, Separately Identifiable E&M Service on the Same Day of a Procedure or Other Service: Modifier 25"
    • See the cross-reference policy: Modifier 25 – Significant, Separately Identifiable Evaluation and Management (E&M) Service on the Same Day of a Procedure or Other Service
    • See the National Correct Coding Initiative (NCCI) manual
  • Effective for dates of service September 4, 2026 and after, Evaluation and Management visits (E&M) billed on the same date as XXX procedures may be denied as inclusive to the XXX procedure.
  • XXX codes have no preoperative and no postoperative period
• In the Modifier 25 section: Added “XXX” to the list of procedures where an E&M with modifier 25 is not appropriate when the visit is solely for the performance of the procedure.

Modifier 25

• Added “XXX” procedures to the list in the policy section where modifier 25 is not appropriate solely for the performance of the procedure.

Modifier 26/TC

• Clarified the description of the NPFS indicator details for modifier 26 and TC details in the 1^st, 2^nd, and 3^rd paragraph of the policy section.

Modifier 33-Preventive Services

Updated Preventive Service recommendation organizations to mirror AMA guidelines and Preventive benefit guideline medical policy references:

• United States Preventive Services Task Force (USPSTF) grade A or B recommendations
• Advisory Committee on Immunization Practices (ACIP) recommendations adopted by the Director of the Center for Disease Control and Prevention (CDC)
• Health Resources and Services Administration (HRSA) supported comprehensive guidelines which are published by any of the following sources:
  • The Bright Futures Recommendations for Pediatric Preventive Health Care schedule of services
  • Uniform Panel of the Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children
  • Specific women’s health care services and guidelines adopted by HRSA

Multiple Modifiers

• To Policy section added reimbursement modifiers: CO, CQ, QZ.

Multiple Endoscopic procedure reductions

• Correction to statement regarding procedures billed on the same claim in policy section: removed “All diagnostic imaging procedures” and added “All endoscopic procedures rendered to a member by the same provider on the same date of service should be billed on a single claim.”