New Policy Updates - Clinical Payment Coding and Policy Changes effective January 1, 2026

By December 31, 2025: Billing team must implement the following claim validation rules in billing software for all Aetna Better Health Virginia Medicaid claims: (1) Cerumen removal codes (69209, 69210, G0268) require diagnosis of impacted cerumen or claim will be denied; (2) Outpatient consultation codes (99242-99245, 99446-99449, 99451, S0285) require documentation that a prior evaluation by a different provider occurred on same date or within previous year or claim will be denied; (3) Non-invasive FFR code (75580) requires approved diagnosis or claim will be denied; (4) Immunization administration codes (90460, 90471, 90473) cannot be billed with SARS-CoV-2 vaccines (91304-91322) unless vaccine/toxoid codes (90476-90477, 90581-90759) are also reported; (5) Vaccine/toxoid codes (90476-90477, 90581-90759) cannot be billed with COVID-19 administration code (90480) unless SARS-CoV-2 vaccine code (91304-91322) is also reported; (6) SDOH risk assessment code (G0136) limited to once every six months per patient per provider or claim will be denied; (7) Thyroid test codes (84480, 84481) require diagnosis other than hypothyroidism alone or claim will be denied; (8) Serum iron study codes (82728, 83540, 83550, 84466) cannot be billed for asymptomatic patients over age 5 with screening/examination diagnosis only or claim will be denied. Update encounter forms and provider documentation templates to capture required information. Communicate requirements to all providers submitting Virginia Medicaid claims. Claims submitted without compliance will face denial.