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Policy Bulletins

The Policy Bulletins listed below represent our catalogue of medical and claim payment policies. If you are looking for a specific type of policy, use the menu on the right to select a category and narrow your search.
  • For information about policy numbers click here.
  • For information about medical policies, the technology evaluation process, and claim payment policies click here.
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Policy #
Policy Bulletin Title
03.02.12b
Electrocardiogram (ECG/EKG) Reported with Single Photon Emission Computed Tomography (SPECT) for Myocardial Perfusion Imaging (MPI)
03.02.13b
Evaluation or Setup of a Cardiac Pacemaker Reported with an Electrocardiogram (ECG/EKG)
03.12.04b
Insertion or Application of Urinary Catheters and the Associated Supplies Provided in the Office Setting
03.00.15f
Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period
03.00.06f
Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
03.00.05g
Modifier 50: Bilateral Procedure
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03.00.29d
Modifier 51 Exempt
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03.00.07i
Modifier 51: Multiple Procedures
03.00.16f
Modifier 57: Decision for Surgery
03.00.08c
Modifier 59: Distinct Procedural Service
03.00.02a
Modifier 76: Repeat Procedure by Same Physician
03.00.11a
Modifier 77: Repeat Procedure by Another Physician
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03.00.12b
Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician Following the Initial Procedure for a Related Procedure During the Postoperative Period
03.00.12b
Attachment A
03.00.28g
Modifier 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period
03.00.17b
Modifier GC: This Service has been Performed in Part by a Resident Under the Direction of a Teaching Physician
03.00.20e
Modifiers 26 (Professional Component) and TC (Technical Component)
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03.00.31b
Modifiers for Split or Shared Surgical Services (Modifiers 54, 55, and 56)
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03.00.10e
Modifiers LT/RT: Left Side/Right Side Procedures


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