Healthcare providers are familiar with periodic policy updates from the Centers for Medicare and Medicaid Services (CMS) but private health plans are increasingly developing their own rules. That trend requires ongoing diligence to identify and monitor changes related to documentation and reimbursement, since failure to do so can result in a negative revenue impact for pathology practices.
Cigna
Cigna implemented a new Medically Unlikely Edit (MUE) policy effective December 21, 2023. The rules apply frequency limitations, as defined by CMS, for a range of CPT codes, including those for COVID-19 laboratory services.
Cigna’s announcement of the policy stated it is “guided by comprehensive criteria such as clinical judgment, anatomic considerations and code descriptors” and involves claims submitted on CMS 1500 claim forms as well as outpatient services reported on UB-04 claim forms.
United Healthcare (UHC)
The January 2024 UHC Reimbursement Policy Update Bulletin announced implementation of the Molecular Pathology Policy, Professional and Facility for dates of service on or after April 1, 2024. That policy was originally announced on May 1, 2023 but delayed in September 2023 to allow additional time for providers to complete molecular pathology test registrations for Z-codes on tests.
The policy requires submission of a DEX-Z code® for molecular pathology claims to be considered for reimbursement. The codes can be obtained from the Palmetto DEX Registry at www.dexzcodes.com and claims will be denied if that information is missing, invalid or doesn’t match the service represented by the CPT code reported on the claim.
