Reimbursement policy update: Frequency Editing — Professional

Beginning with dates of service on or after October 1, 2024, Anthem will update the Related Coding section of the Frequency Editing — Professional reimbursement policy.

This policy identifies reimbursement for a procedure or service that is billed for a single member, on a single date of service by the same provider and/or provider group, up to the maximum number of units allowed. In addition to using claims processing logic to determine when the use of multiple units is appropriate, we use the nomenclature for a particular CPT^® or HCPCS level II code, the CMS’s medically unlikely edits (MUEs) designation, industry standards, or the ability to clinically perform or report a specific service more than one time on a single date of service or within a specific date span per member, per provider in making these determinations.

In the Related Coding section of the policy, the following updates will be made:

CPT maximum frequency code list:

• Remove 36415 and 36416 (refer to laboratory and venipuncture C-10001)
• Remove 96158-96159, 96164-96165 (refer to health and behavioral assessment/intervention C-11003)
• Delete 76942, 77002, 77003, 77012, 77021, 77338, 77600, 77605, 80320-80377, 81479, 86160, 87483, 87491, 87591, 88305, 87529, 90378, 92250, 92273, 92274, 92326, 93325, 95925, 95926, 95938, 95927, 95928, 95929, 95939, 96900, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 93792, 93793

HCPCS maximum frequency code list:

• Remove S9529 (refer to laboratory and venipuncture C-10001)
• Remove G0480, G0481, G0482, and G0483 (refer to drug screen testing-professional C-12004)
• Remove C9257, G0480, G0481, G0482, G0483
• Add A4238, A4239, A6520-A6529, A6552-A6589, A6593-A6610, Q0509

For specific policy details, refer to the Maine reimbursement policy page at tinyurl.com/4efrmynn or visit anthem.com/provider.

Through our efforts, we are committed to reducing administrative burden and ensuring timely payments because we value you, our care provider partners.