ICD-10 diagnosis coding requirements for ST/PT/OT effective February 15, 2026
Effective February 15, 2026, professional claims for physical therapy (PT), speech therapy (ST), and occupational therapy (OT) services that include an ICD-10 diagnosis code, requiring the seventh character “A”, in any position will be denied.
If a modality procedure code is submitted on the same date of service, by the same provider, and with the same diagnosis code as the therapy procedure code, the modality claim line will also be denied. We have updated our policies with this information:
Dental Providers Filing Evaluation and Management for Medical Reasons
This policy is being updated to allow payment for E&M services by all dental specialties (other than an Oral Maxillofacial Surgeon -OMS) when the encounter is in preparation for kidney transplantation or heart valve replacement surgery ONLY. This policy has been updated to instruct “other dental providers” (General Dentist, Periodontist, Endodontist, Orthodontist, Prosthodontist, and Pedodontist) to file the E&M claim with ICD-10 code Z01.818 Encounter for other pre procedure in the primary position. For additional details related to this policy, please click here.
Preventive Services for Commercial Members Policy
Effective January 1, 2026, 2026 HRSA (health resource services administration) preventive Mandate has a new requirement to cover follow-up imaging (including mammography, ultrasound, and MRI) needed to complete the screening for malignancies. CPT Codes 76641, 76642, 77049 are to process as a preventive benefit when filed with the screening Diagnosis Code Z12.31 and/or Z12.39 only. Member costs are to apply $0 cost share for Commercial in network members only. For additional details related to this policy, please click here.
Pharmacy Post Claim Review Medications
BCBSRI is implementing a change in the way we manage certain drugs that fall under the medical and specialty benefit. This policy is a tool for providers to use to manage medications that will be subject to post service claims editing.
Medicare Advantage Plans and Commercial Products - Effective May 1, 2026, the following listed medications will be subject to post service claims editing.
Please see drug lists for both Commercial and Medicare Advantage plans that do not require Prior Authorization but will be subject to the post service claims edit.
Grids included within the policy:
For additional details related to this policy, please click here.
Provider New and Recredentialing Process
Office hours information has been updated related to this policy:
Office Hours – For PCPs only, office hours of twenty (20) hours per week or three days per week with appropriate coverage arrangements are required. Requests not meeting this criteria will be reviewed as an exception. **
** signifies a required element for set up in the BCBSRI system to support claims participating claims adjudication.
RECREDENTIALING PROCESS
Office Hours – For PCPs only, office hours of twenty (20) hours per week or three days per week with appropriate coverage arrangements are required. Requests not meeting this criteria will be reviewed as an exception.
For additional details related to this policy, please click here.
2026 Radiopharmaceuticals
Effective January 1, 2026 new code C9176 has been added to this policy.
For additional details related to this policy, please click here.
2026 Oral Surgeons Filing for Anesthesia Services in the Office Setting
Two new codes were added to replace one deleted code; the codes still are non-covered services.
The following CDT codes are not covered and are considered a member liability:
D9248* Non-intravenous conscious sedation *(HCPCS code deleted as of 12/31/2025)
D9246 Moderate sedation-non-IV parenteral (first 15 minutes)
D9247 Moderate sedation-non-IV parenteral (subsequent 15 minutes
For additional details related to this policy, please click here.
2026 Hearing Aid Coverage
The crossed-out codes below have been deleted as of December 31, 2025 and replaced with a more detailed list of codes (still non-covered services for Commercial and Medicare Advantage offers coverage for some of these services.) effective January 1, 2026.
The following CPT and HCPCS codes are non-covered for Commercial products.
Medicare Advantage offers coverage for some of these services. Please refer to the Evidence of Coverage for additional information.
92628 Evaluation for hearing aid candidacy…; first 30 minutes
92629 Evaluation for hearing aid candidacy…; each additional 15 minutes
92631 Hearing aid selection services…; discussion of device recommendations with report; first 30 minutes
92632 Hearing aid selection services…; each additional 15 minutes
92634 Hearing aid fitting services…; fitting services; first 60 minutes
92635 Hearing aid fitting services…; fitting services; each additional 15 minutes
92636 Hearing aid post-fitting follow-up services…; fitting services; first 30 minutes
92637 Hearing aid post-fitting follow-up services…; fitting services; each additional 15 minutes
92638 Behavioral verifications of amplification including aided thresholds… when performed
92639 Hearing-aid measurement, verification with probe-microphone
92641 Hearing device verification, electroacoustic analysis
92642 Hearing assistive device, supplemental technology fitting services
For additional details related to this policy, please click here.