Payment Policy Updates
In consideration of current industry standards and to align with CareFirst’s mission to provide affordable healthcare, CareFirst has made an update to the following Payment Policies in the online Payment Policy Reference Manual:
The following will impact Government Programs lines of business effective October 1, 2026:
- PP GP 002.01 Diagnosis Guidelines – this is a new policy that will outline billing requirements and outcomes related to diagnosis, manifestation and etiology codes. Details can be found within the policy which will be publicly available by July 1.
- Policy PP CC 002.04 Claims During an Inpatient Admission – this policy was previously named Policy PP CO 002.04 Claims During an Inpatient Admission. The logic outlined in the policy was applicable to Commercial but will now expand across Government Programs lines of business as of the effective date listed.
- Policy PP CC 400.05 MPPR Well Problem Visit E/M Pay Percent - this policy was previously named Policy PP CO 400.05 MPPR Well Problem Visit E/M Pay Percent. The logic outlined in the policy was applicable to Commercial but will now expand across Government Programs lines of business as of the effective date listed.
- Policy PP CC 017.02 Outpatient Services prior to Admission - this policy was previously named Policy PP CO 017.02 Outpatient Services prior to Admission. The logic outlined in the policy was applicable to Commercial but will now expand across Government Programs lines of business as of the effective date listed.
The following will impact Commercial lines of business effective July 1, 2026:
- PP CO 500.01 Status Codes – clarifying details and examples have been updated. Detailed information can be found in the History Section of the policy. No changes to existing logic.
- PP CO 012.01 Hair Removal Services Gender Dysphoria - clarifying details have been added to the policy. Detailed information can be found in the History Section of the policy. This update does not change existing logic.
- PP CO 016.01 Critical Care – information previously found in the Medical Provider Manual, Chapter 9, have been added to the policy. Detailed information can be found in the History Section of the policy. This update does not change existing logic.
- PP CO 080.02 Doula Services – additional detail was adding to policy to define attendance during delivery. This update does not change existing logic.
- As reminder, in alignment with correct coding guidelines CareFirst will deny claim lines for services when;
- billing multiple units or using modifier 59 is not appropriate when the code descriptor specifically includes phrases such as ‘Initial, up to, up to and including,’ or is stated in plural form. These descriptors indicate that one unit covers the number of services described. For example, code 11901 (Inject skin lesions >7) should be billed with one unit, as the descriptor clearly states it applies to more than 7 lesions.
- using inappropriate code to modifier combinations. We have seen an increase in claims for modifier 91denials. The following link will provide helpful information when considering if the modifier is appropriate to include - Modifier 91 Fact Sheet. References may be found with existing Payment Policies: PP CO 600.01 Modifier 59, PP CO 600.02 Modifier 90, PP CO 600.05 Modifier Policy, PP CO 600.06 Modifier 33 and PP CO 090.01 NCCI Editing.
- Inappropriate ICD-CM coding - Not following ICD 10 conventions, general coding and chapter specific guidelines can result in claims denials.
- IE.M54.5 – Low back pain has an Excludes 1 Note of M54.4- Lumbago with sciatica; if M54.50 is billed with M54.41, the claim line(s) will be denied
- Laterality denials will be issued when the RT/LT modifier conflicts with the diagnosis associated with the claim line(s) and/or diagnosis conflicting with each other.
- IE.Procedure billed with RT modifier, but diagnosis is for the left side.
- Secondary Only Diagnosis Codes – These codes should not be coded as the primary diagnosis. Claim line(s) billed with secondary diagnosis codes as the primary will be denied. These diagnosis codes are to be listed following ‘Use additional code’ note
- IE.Z3A.01 ‘Less than 8 weeks gestation of pregnancy’ billed as the primary DX when the obstetric condition or encounter of delivery is not coded first.