| Anesthesia Information | Policy Number | Effective Date | End Date |
| Anesthesia Information | CPCP010 | 01/01/2025 | 10/31/2025 |
| Anesthesia Information | CPCP010 | 03/22/2023 | 12/31/2024 |
| Applied Behavioral Analysis | Policy Number | Effective Date | End Date |
| Applied Behavioral Analysis | CPCP011 | 10/28/2024 | 03/19/2026 |
| Applied Behavioral Analysis | CPCP011 | 05/30/2023 | 10/27/2024 |
| Chiropractic Care Services | Policy Number | Effective Date | End Date |
| Chiropractic Care Services | CPCP016 | 01/22/2024 | 06/19/2025 |
| Chiropractic Care Services | CPCP016 | 03/22/2023 | 01/21/2024 |
| Corrected Claim Submissions | Policy Number | Effective Date | End Date |
| Corrected Claim Submissions | CPCP025 | 01/22/2025 | 11/30/2025 |
| Corrected Claim Submissions | CPCP025 | 07/01/2024 | 01/21/2025 |
| Corrected Claim Submissions | CPCP025 | 07/01/2020 | 06/30/2024 |
| Co-Surgeon/Team Surgeon Policy - Professional Provider | Policy Number | Effective Date | End Date |
| Co-Surgeon/Team Surgeon Policy - Professional Provider | CPCP009 | 04/18/2025 | 04/09/2026 |
| Co-Surgeon/Team Surgeon Policy - Professional Provider | CPCP009 | 01/22/2024 | 04/17/2025 |
| Co-Surgeon/Team Surgeon Policy - Professional Provider | CPCP009 | 09/12/2023 | 01/21/2024 |
| Drug Testing CPCP | Policy Number | Effective Date | End Date |
| Drug Testing CPCP | CPCP020 | 11/18/2024 | 03/19/2026 |
| Drug Testing CPCP | CPCP020 | 12/07/2023 | 11/17/2024 |
| Emergency Department Services Evaluation and Management: E/M Coding – Facility Services | Policy Number | Effective Date | End Date |
| Emergency Department Services Evaluation and Management: E/M Coding – Facility Services | CPCP003 | 07/29/2024 | 10/05/2025 |
| Emergency Department Services Evaluation and Management: E/M Coding – Facility Services | CPCP003 | 08/01/2023 | 07/28/2024 |
| Emergency Department Services Evaluation and Management - E/M Coding – Professional Services | Policy Number | Effective Date | End Date |
| Emergency Department Services Evaluation and Management - E/M Coding – Professional Services | CPCP042 | 10/03/2024 | 11/13/2025 |
| Emergency Department Evaluation and Management (E/M) Services Coding – Professional Services | CPCP042 | 08/01/2023 | 10/02/2024 |
| Evaluation and Management Coding – Professional Provider Services | Policy Number | Effective Date | End Date |
| Evaluation and Management Coding – Professional Provider Services | CPCP024 | 11/18/2024 | 02/22/2026 |
| Evaluation and Management Coding – Professional Provider Services | CPCP024 | 12/07/2023 | 11/17/2024 |
| Global Obstetrical/OB Maternity Services Policy | Policy Number | Effective Date | End Date |
| Global Obstetrical/OB Maternity Services Policy | CPCP044 | 08/19/2025 | 05/21/2026 |
| Global Surgical Package - Professional Providers | Policy Number | Effective Date | End Date |
| Global Surgical Package - Professional Providers | CPCP014 | 04/15/2025 | 04/09/2026 |
| Global Surgical Package - Professional Providers | CPCP014 | 01/22/2024 | 04/14/2024 |
| Global Surgical Package - Professional Providers | CPCP014 | 06/27/2023 | 01/21/2024 |
| Hernia Repair | Policy Number | Effective Date | End Date |
| Hernia Repair | CPCP012 | 11/25/2025 | 07/09/2026 |
| Hernia Repair | CPCP012 | 07/16/2024 | 11/24/2025 |
| Hernia Repair | CPCP012 | 05/15/2023 | 07/15/2024 |
| Home Health Care Policy | Policy Number | Effective Date | End Date |
| Home Health Care Policy | CPCP005 | 03/21/2025 | 03/08/2026 |
| Home Health Care/Private Duty Nursing Policy | CPCP005 | 11/03/2023 | 03/20/2025 |
| Implant, Device, and Tissue Policy | Policy Number | Effective Date | End Date |
| Implant, Device, and Tissue Policy | CPCP007 | 10/08/2024 | 01/18/2026 |
| Implant, Device, and Tissue Policy | CPCP007 | 02/27/2023 | 10/07/2024 |
| Increased Procedural Services, Modifier 22 - Professional Provider | Policy Number | Effective Date | End Date |
| Increased Procedural Services, Modifier 22 - Professional Provider | CPCP013 | 04/15/2025 | 04/09/2026 |
| Increased Procedural Services (Modifier 22) | CPCP013 | 01/22/2024 | 04/14/2025 |
| Increased Procedural Services (Modifier 22) | CPCP013 | 05/15/2023 | 01/21/2024 |
| Infusion Services | Policy Number | Effective Date | End Date |
| Infusion Services | CPCP019 | 07/18/2025 | 07/18/2025 |
| Home Infusion | CPCP019 | 11/03/2023 | 07/17/2025 |
| Inpatient Readmission | Policy Number | Effective Date | End Date |
| Inpatient Readmission | CPCP027 | 12/18/2024 | 12/18/2025 |
| Inpatient Readmission | CPCP027 | 10/13/2023 | 12/17/2024 |
| Inpatient/Outpatient Unbundling Policy - Facility | Policy Number | Effective Date | End Date |
| Inpatient/Outpatient Unbundling Policy - Facility | CPCP002 | 12/27/2023 | 03/12/2026 |
| Intraoperative Neurophysiology Monitoring (IONM) Coding and Reimbursement Policy | Policy Number | Effective Date | End Date |
| Intraoperative Neurophysiology Monitoring (IONM) Coding and Reimbursement Policy | CPCP032 | 10/03/2024 | 10/30/2025 |
| Intraoperative Neurophysiology Monitoring (IONM) Coding and Reimbursement Policy | CPCP032 | 09/12/2023 | 10/02/2024 |
| Laboratory Panel Billing | Policy Number | Effective Date | End Date |
| Laboratory Panel Billing | CPCP021 | 07/16/2024 | 09/21/2025 |
| Laboratory Panel Billing | CPCP021 | 06/27/2023 | 07/15/2024 |
| Medical Record Documentation | Policy Number | Effective Date | End Date |
| Medical Record Documentation | CPCP029 | 11/18/2024 | 10/30/2025 |
| Medical Record Documentation | CPCP029 | 11/03/2023 | 11/17/2024 |
| Modifier Reference Policy | Policy Number | Effective Date | End Date |
| Modifier Reference Policy | CPCP023 | 01/22/2024 | 10/30/2025 |
| Modifier Reference Policy | CPCP023 | 11/03/2023 | 01/21/2024 |
| Multiple Surgical Procedures - Professional Provider Services | Policy Number | Effective Date | End Date |
| Multiple Surgical Procedures - Professional Provider Services | CPCP015 | 04/23/2025 | 04/09/2026 |
| Multiple Surgical Procedures - Professional Provider Services | CPCP015 | 01/22/2024 | 04/22/2025 |
| Multiple Surgical Procedures - Professional Provider Services | CPCP015 | 09/12/2023 | 01/21/2024 |
| Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy | Policy Number | Effective Date | End Date |
| Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy | CPCP004 | 08/25/2025 | 05/21/2026 |
| Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy | CPCP004 | 07/29/2024 | 08/24/2025 |
| Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy | CPCP004 | 11/29/2023 | 07/28/2024 |
| Non-Reimbursable Experimental, Investigational and /or Unproven Services (EIU) | Policy Number | Effective Date | End Date |
| Non-Reimbursable Experimental, Investigational and /or Unproven Services (EIU) | CPCP028 | 05/15/2025 | 12/31/2025 |
| Non-Reimbursable Experimental, Investigational and /or Unproven Services (EIU) | CPCP028 | 10/01/2024 | 05/14/2025 |
| Non-Reimbursable Experimental, Investigational and /or Unproven Services (EIU) | CPCP028 | 07/01/2024 | 09/30/2024 |
| Non-Reimbursable Experimental, Investigational and /or Unproven Services (EIU) | CPCP028 | 05/15/2024 | 06/30/2024 |
| Non-Reimbursable Experimental, Investigational and /or Unproven Services (EIU) | CPCP028 | 04/01/2024 | 05/14/2024 |
| Non-Reimbursable Experimental, Investigational and /or Unproven Services (EIU) | CPCP028 | 01/15/2024 | 03/31/2024 |
| Non-Reimbursable Experimental, Investigational and /or Unproven Services (EIU) | CPCP028 | 12/01/2023 | 01/14/2024 |
| Observation Services Policy | Policy Number | Effective Date | End Date |
| Observation Services Policy | CPCP001 | 08/08/2024 | 12/21/2025 |
| Observation Services Policy | CPCP001 | 07/14/2023 | 08/07/2024 |
| Outpatient Facility Service(s) Overlapping During an Inpatient Stay | Policy Number | Effective Date | End Date |
| Outpatient Facility Service(s) Overlapping During an Inpatient Stay | CPCP039 | 06/20/2025 | 06/07/2026 |
| Outpatient Facility Service(s) Overlapping During an Inpatient Stay | CPCP039 | 07/16/2024 | 06/19/2025 |
| Outpatient Facility Service(s) Overlapping During an Inpatient Stay | CPCP039 | 07/01/2023 | 07/15/2024 |
| Outpatient Services Prior to an Inpatient Admission | Policy Number | Effective Date | End Date |
| Outpatient Services Prior to an Inpatient Admission | CPCP038 | 06/20/2025 | 05/21/2026 |
| Outpatient Services Prior to an Inpatient Admission | CPCP038 | 03/01/2024 | 06/19/2025 |
| Outpatient Services Prior to an Inpatient Admission | CPCP038 | 06/01/2023 | 02/29/2024 |
| Paravertebral Facet Injection Procedure Coding & Billing Policy | Policy Number | Effective Date | End Date |
| Paravertebral Facet Injection Procedure Coding & Billing Policy | CPCP036 | 11/18/2024 | 11/20/2025 |
| Paravertebral Facet Injection Procedure Coding & Billing Policy | CPCP036 | 11/03/2023 | 11/17/2024 |
| Physical Medicine and Rehabilitation Services | Policy Number | Effective Date | End Date |
| Physical Medicine and Rehabilitation Services | CPCP040 | 09/22/2025 | 11/06/2025 |
| Physical Medicine and Rehabilitation Services | CPCP040 | 01/22/2024 | 09/21/2025 |
| Physical Medicine and Rehabilitation Services | CPCP040 | 03/22/2023 | 01/21/2024 |
| Pneumatic Compression Devices | Policy Number | Effective Date | End Date |
| Pneumatic Compression Devices | CPCP022 | 10/31/2025 | 07/16/2026 |
| Pneumatic Compression Devices – Outpatient Use | CPCP022 | 03/01/2024 | 10/30/2025 |
| Pneumatic Compression Devices – Outpatient Use | CPCP022 | 02/01/2023 | 02/29/2024 |
| Point-of-Care Ultrasound (POCUS) Examination Policy | Policy Number | Effective Date | End Date |
| Point-of-Care Ultrasound - POCUS Examination Policy | CPCP030 | 01/07/2025 | 12/18/2025 |
| Point-of-Care Ultrasound (POCUS) Examination Policy | CPCP030 | 09/12/2023 | 01/06/2025 |
| Preventive Services Policy | Policy Number | Effective Date | End Date |
| Preventive Services Policy | RP006 | 04/01/2026 | 06/30/2026 |
| Preventive Services Policy | CPCP006 | 01/01/2026 | 03/31/2026 |
| Preventive Services Policy | CPCP006 | 10/01/2025 | 12/31/2025 |
| Preventive Services Policy | CPCP006 | 07/01/2025 | 09/30/2025 |
| Preventive Services Policy | CPCP006 | 04/01/2025 | 06/30/2025 |
| Preventive Services Policy | CPCP006 | 02/01/2025 | 03/31/2025 |
| Preventive Services Policy | CPCP006 | 01/01/2025 | 01/31/2025 |
| Preventive Services Policy | CPCP006 | 10/01/2024 | 12/31/2024 |
| Preventive Services Policy | CPCP006 | 07/01/2024 | 09/30/2024 |
| Preventive Services Policy | CPCP006 | 04/01/2024 | 06/30/2024 |
| Preventive Services Policy | CPCP006 | 01/01/2024 | 03/31/2024 |
| Psychological and Neuropsychological Testing | Policy Number | Effective Date | End Date |
| Psychological and Neuropsychological Testing | CPCP008 | 11/18/2024 | 03/01/2026 |
| Psychological and Neuropsychological Testing | CPCP008 | 11/16/2023 | 11/17/2024 |
| Revenue Codes Requiring Supporting CPT, HCPCS and/or NDC Codes - Outpatient Facility Claims | Policy Number | Effective Date | End Date |
| Revenue Codes Requiring Supporting CPT, HCPCS and/or NDC Codes - Outpatient Facility Claims | CPCP018 | 04/14/2025 | 10/30/2025 |
| Outpatient Facility and Hospital Claims: Revenue Codes Requiring Supporting CPT, HCPCS and/or NDC Codes | CPCP018 | 11/03/2023 | 04/13/2025 |
| Sepsis Policy | Policy Number | Effective Date | End Date |
| Sepsis Policy | CPCP041 | 01/07/2025 | 04/29/2026 |
| Sepsis Policy | CPCP041 | 07/16/2024 | 01/06/2025 |
| Sepsis Policy | CPCP041 | 05/30/2023 | 07/15/2024 |
| Telemedicine and Telehealth/Virtual Health Care Services Policy | Policy Number | Effective Date | End Date |
| Telemedicine and Telehealth/Virtual Health Care Services Policy | CPCP033 | 09/26/2025 | 03/26/2026 |
| Telemedicine and Telehealth/Virtual Health Care Services Policy | CPCP033 | 01/01/2025 | 09/25/2025 |
| Telemedicine and Telehealth/Virtual Health Care Services Policy | CPCP033 | 03/01/2024 | 12/31/2024 |
| Telemedicine and Telehealth/Virtual Health Care Services Policy | CPCP033 | 12/07/2023 | 02/29/2024 |
| Therapeutic, Prophylactic, Diagnostic, Injection and Infusion Administration Coding | Policy Number | Effective Date | End Date |
| Therapeutic, Prophylactic, Diagnostic, Injection and Infusion Administration Coding | CPCP026 | 08/08/2024 | 09/25/2025 |
| Therapeutic, Prophylactic and Diagnostic Injection and Infusion Coding | CPCP026 | 05/15/2023 | 08/07/2024 |
| Trauma Activation – Facility Services | Policy Number | Effective Date | End Date |
| Trauma Activation – Facility Services | CPCP031 | 07/29/2024 | 01/05/2026 |
| Trauma Activation – Facility Services | CPCP031 | 07/14/2023 | 07/28/2024 |
| Unbundling Policy-Professional Providers | Policy Number | Effective Date | End Date |
| Unbundling Policy-Professional Providers | CPCP034 | 06/25/2024 | 01/18/2026 |
| Unbundling Policy-Professional Providers | CPCP034 | 05/15/2023 | 06/24/2024 |
| Unlisted/Not Otherwise Classified (NOC) Coding Policy | Policy Number | Effective Date | End Date |
| Unlisted/Not Otherwise Classified (NOC) Coding Policy | CPCP035 | 09/13/2024 | 10/16/2025 |
| Unlisted/Not Otherwise Classified (NOC) Coding Policy | CPCP035 | 09/08/2022 | 09/12/2024 |
| Wasted/Discarded Drugs and Biologicals Policy | Policy Number | Effective Date | End Date |
| Wasted/Discarded Drugs and Biologicals Policy | CPCP017 | 03/01/2024 | 11/24/2025 |
| Wasted/Discarded Drugs and Biologicals Policy | CPCP017 | 02/01/2023 | 02/29/2024 |
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