In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Company benefit contracts
Holden K, Orme N, eds. 2009 Ingenix Learning: Understanding Modifiers.West Valley City, UT: Ingenix, Inc.; 2008.
The American College of Obstetricians and Gynecologists (ACOG). [ACOG Website]. Available at: http://www.acog.org/ Accessed on 9/14/2010.
REFER TO POLICY ATTACHMENTS FOR EXAMPLES OF PROCEDURE AND MODIFIER CODING COMBINATION SCENARIOS FOR MULTIPLE BIRTHS
22: Unusual procedural services
59: Distinct procedural service
Policy: 00.10.01ab:Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
Policy: 00.10.18j:Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS
Policy: 03.00.08d:Modifiers XE, XS, XP, XU, 59
Policy: 11.00.10u:Multiple Surgical Reduction Guidelines (Independence)