Reimbursement Policy Update: Frequency Editing -- Professional*

The following changes will be made to Anthem Blue Cross and Blue Shield (Anthem)’s Frequency Editing policy effective September 1, 2019:

 

• In the February 2018 edition of Network Update, we advised that we were revising our Frequency Editing policy to remove the frequency limits of one (1) per date of service and 18 per 365 days for definitive drug testing for HCPCS codes G0482 and G0483. Please note we are adding the language back into our policy dated September 1, 2019 to reflect that we still limit the frequency for these two codes.

 

• Beginning with dates of service on or after September 1, 2019, we will add a frequency limit of one (1) per date of service not to exceed one every three (3) years for CPT code 81528 – Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result, such as Cologuard^®

 

• Beginning with dates of service on or after September 1, 2019, the following language will be removed:

The Health Plan will apply per day frequency maximums based on the CPT/HCPCS codes listed on the CMS Medically Unlikely Edit (MUE) listing that have a per day MUE Medicare Adjudication Indicator (MAI) 2.

The policy will apply frequency maximums based on CMS Medically Unlikely Edit (MUE), industry standards and/or code description.

 

For more information about this Frequency Editing policy, visit Anthem’s professional reimbursement policies on anthem.com for your state.

Indiana: Reimbursement Policies-Professional

Kentucky: Reimbursement Policies-Professional

Missouri: Reimbursement Policies-Professional

Ohio: Reimbursement Policies-Professional

Wisconsin: Reimbursement Policies-Professional