Effective for dates of service beginning Jan. 1, 2026, in support of correct coding practices, we’re implementing the following billing and reimbursement updates for our Harvard Pilgrim Health Care Commercial plans: 

  • Claims billed with procedure codes 64561, 64581, or A4290 will be denied when a diagnosis of urinary incontinence or fecal incontinence is not also submitted.
  • When reporting CPT codes 93784-93790 (ambulatory blood pressure monitoring; recording; analysis or review/report blood pressure recording), the claim will deny if it is billed for a reason other than elevated blood pressure reading without diagnosis of hypertension. 

For more information, please refer to Point32Health’s General Coding and Claims Editing Payment Policy in the Payment Policies section of our provider website, which has been updated to reflect these requirements. 

(Consistent with Maine regulations, a redlined version of this policy is also posted temporarily.)