Retirement of Select Medicare Payment Policies - Effective December 31, 2026

Policy Update #: POLMEDPAY12312026
Effective Date: 12/31/2026
Current State: We are notifying providers that several Medicare payment policies are being formally retired. These policies are being retired to align with CMS standards and eliminate duplicative or potentially conflicting guidance. Providers should follow Centers for Medicare & Medicaid Services (CMS) guidance for appropriate billing and coding requirements for the Medicare line of business, including the Dual Special Needs Plan (also known as D-SNP).
Future State: Providers are expected to follow current CMS rules when submitting Medicare/D-SNP claims, including but not limited to.

• Medicare Claims Processing Manual
• Medicare Benefit Policy Manual
• National Correct Coding Initiative (NCCI) edits
• CMS transmittals and Medicare Learning Network (MLN) publications

Applicable Plan(s): Medicare
Applicable Policy: See below.
Business Owner: Cost of Care

The following payment policies will no longer include Medicare line of business:

• Add On Codes Professional (#3940)
• Advanced Practice Health Care Provider Payment Policy (#3932)
• Age to Diagnosis and Procedure Code Policy, Professional (#4030)
• Assistant Surgeon (#3819)
• Bilateral Procedure Payment Policy (#3998)
• Device Implant and Skin Substitute Payment Policy (#3983)
• Discontinued Procedure Payment Policy (#4001)
• Distinct Procedural Service Payment Policy (#3821)
• DRG Computation (#4556)
• Global Surgical Package (#3830)
• Inappropriate Primary Diagnosis Codes Policy, Professional (#4027)
• Increased Procedural Services Policy, Professional (#4028)
• Intensity Modulated Radiation Therapy, Professional and Facility (#3957)
• Moh's Micrographic Surgery (#3813)
• Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging-Facility (#4012)
• Multiple Procedure Payment Reduction (MPPR) Medical and Surgical (#4013)
• National Drug Code (NDC) Professional and Facility (#4035)
• New Patient Visit Policy-Professional (#4036)
• Observation -Professional (#3837)
• Once in a Lifetime (#3958)
• Outpatient Hospital Inappropriate Primary Diagnosis Code (#4031)
• Pain Management Payment Policy (#4021)
• Percutaneous Coronary Interventions-Modifier Requirements (#4349)
• Professional Technical Component Policy (PC/TC) (#3985)
• Prolonged Services Payment Policy (#4023)
• Site of Service Differential (#4056)
• Split Surgical Modifiers 54, 55, 56 (#3989)
• Time Spanned Codes (#3995)llergy Testing and Treatment Payment Policy (#4394)
• Ambulance-Medicare (#3818)
• CLIA Waiver Payment Policy (#4052)
• Collaborative Care Management and Behavioral Health Integration-Medicare (#4425)
• Contrast and Radiopharmaceutical Materials Policy (#4019)
• Durable Medical Equipment Payment Policy Medicare (#4003)
• Multiple Procedure Payment Reduction for Diagnostic
• Cardiovascular and Ophthalmology Professional (#4016) • NCCI Edits Payment Policy Medicare (#3966)
• Preventative Medicine and Screening Policy-Medicare (#4369)
• Psychological and Neuropsychological Testing Payment Policy Medicare (#4038)
• Telehealth (#3825)

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Retirement of Select Medicare Payment Policies - Effective December 31, 2026