UnitedHealthcare Commercial Reimbursement Policy Update Bulletin: January 2024

Policy Title:

Popular pathology policy, professional and facility

Effective Date:

January 1, 2024

Policy Summary:

• The molecular pathology policy, professional and facility was previously announced on May 1, 2023, but delayed in September of 2023 to allow additional time for providers to complete their molecular pathology test registrations for Z-codes on tests. The policy will now be effective for dates of service on or after April 1, 2024
• The policy will require the submission of a DEX Z-code® which would be obtained from the Palmetto DEX registry for claims to be considered for reimbursement. The registry can be found on www.dexzcodes.com
• Claims for molecular pathology services will be denied if the DEX Z-code® information is missing, invalid, or does not match the service represented by the CPT code reported on the claim.
• Claims denied for missing or invalid information may be resubmitted with the required information.
• The Palmetto DEX Z-code® should be reported in Loop 2400 or SV-101-7 for professional electronic claims and inbox 19 for paper claims. Facility claims should be reported and loop 2400 or SV-202-7.

Policy Title:

Diagnosis code requirement policy, professional and facility

Effective Date:

May 1, 2024

Policy Summary:

• Effective with dates of service May 1, 2024, United Healthcare will introduce a comprehensive diagnosis could requirement policy for both professional and facility services. This new policy will integrate the existing ICD-10-CM guidelines covered by the inpatient unacceptable principal diagnosis policy (facility), the outpatient hospital inappropriate primary diagnosis code policy (facility), and the inappropriate primary diagnosis codes policy (professional).

• • Additionally, the policy will address excludes one coding with the ICD-10-CM framework. Excludes one guidelines denote mutually exclusive codes, representing two conditions that cannot be reported together-such as congenital form versus an acquired form of the same condition. All providers should align to coding with the excludes 1 guidelines when submitting claims; however, at this time, the applications guidelines is specifically for inpatient claims.
• Providers are expected to accurately submit diagnosis codes in alignment with ICD-10-CM requirements.

Source: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-reimbursement/rpub/UHC-COMM-RPUB-January-2024.pdf