Bundling Guidelines

Description

Professional services are identified with Current Procedure Terminology (CPT®) codes, Healthcare Common Procedure Coding System (HCPCS Level II) codes, and International Classification of Diseases, 10th Revision, Clinical Modifications (ICD-10-CM). These codes enable the accurate identification of the service or procedure. All claims submitted by a provider must be in accordance with the reporting guidelines and instructions contained in the most current CPT®, HCPCS and ICD-10-CM publications.

Inclusion of a code in CPT ®, HCPCS, or ICD-10 does not represent endorsement of any given diagnostic or therapeutic procedure by the bodies that develop the codes (AMA, CMS, and the CDC). The inclusion of the code in CPT®, HCPCS, or ICD-10 does not imply that it is covered or reimbursed by any health insurance coverage.

Use of any CPT®, HCPCS, or ICD-10-CM code should be fully supported in the medical documentation.

Claims are reviewed to determine eligibility for payment. Blue Cross Blue Shield North Carolina (Blue Cross NC) uses several reference guidelines in developing its claims adjudication logic for services and procedures, including, but not limited to the American Medical Association’s Current Procedural Terminology (CPT®) manual, the CMS Correct Coding Initiative (CCI), and Medicare (CMS) guidelines. These reference guidelines were developed for varying populations and benefit structures and are not uniformly consistent with each other.

Services considered incidental, mutually exclusive, integral to the primary service rendered, or part of a global allowance, are not eligible for separate reimbursement. Definitions for incidental, mutually exclusive, integral, or global procedures or services are as follows:

1. Incidental Procedures
   An incidental procedure is carried out at the same time as a more complex primary procedure. These procedures require little additional provider resources and are generally not considered essential to the performance of the primary procedure. For example, the removal of an asymptomatic appendix is considered an incidental procedure when done during hysterectomy surgery. An incidental procedure is not reimbursed separately.
2. Mutually Exclusive Procedures
   Mutually exclusive procedures are two or more procedures that are usually not performed on the same patient on the same date of service. Mutually exclusive rules may also include different procedure code descriptions for the same type of procedures for which the provider should be submitting only one of the procedure codes. Only the most clinically intense procedure will be allowed. Generally, an open procedure and a closed procedure in the same anatomic site are not both reimbursed. If both codes accomplish the same result, the clinically more intense procedure supersedes, and the comparative code is denied as mutually exclusive.
3. Integral Procedures
   Procedures considered integral occur in multiple surgery situations when one or more of the procedures are included in the major or principal procedure. Integral procedures are those commonly carried out as part of a total service and do not meet all the criteria listed under the policy “Multiple Surgical Procedure Guidelines.” Some of the procedures or services listed in the CPT® manual that are commonly carried out as an integral component of a total service or procedure have been identified by the term “separate procedure.” These codes should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.
4. Global Allowance
   Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work. Reimbursement for these services is based on a global allowance. Claims for services considered to be directly related to pre-procedure, intra-procedure, and post-procedure work are included in the global reimbursement and will not be paid separately.
   The pre- and post-operative global days are based on CMS standards. The global period is defined as the period of time during which claims for related services will be denied as an unbundled component of the total surgical package. Major procedures have a global period of 90 days. Minor procedures have a global period of 10 or 0 days.
   The global surgical package includes all necessary services normally furnished by the surgeon before, during and after a surgical procedure. The global period also includes Evaluation and Management services that are related to the procedure. Payment for related medical or surgical services performed the day prior to, the day of, or within 90 days of a major surgical procedure is included in global allowance. Payment for related medical or surgical services performed the same day as a minor surgical procedure, as well as medical or surgical services performed within 10 days of a 10-day procedure, is included in the global allowance. Global surgery guidelines also apply to facility claims.
   See related policy, “Guidelines for Global Maternity Reimbursement.”
   Claims may be processed according to the same provider or same group practice. Same group practice is defined as a physician and/or other qualified health care professional of the same specialty with the same Federal Tax ID number.

Policy

Services Blue Cross NC considers to be mutually exclusive, incidental to, integral to, or within the global period of the primary service rendered are not allowed additional reimbursement. Participating providers cannot balance bill members for these services. Claims editing for bundling guidelines will apply to professional and facility claims unless otherwise stated.

Reimbursement Guidelines

The guidelines addressed in this policy are not an all-inclusive listing.

Administration Fee for injectable(s):

In accordance with CPT® guidelines the administration fee for injectable(s) 96372 – 96379 may be submitted in addition to the code for the drug(s) or substance(s). For 96372 – 96379 to be considered reimbursable, an allowable drug or substance service code must be filed on the same claim. If the administered drug or substance was not supplied by the professional provider, the drug or substance service line should still be attached to the claim with a $.01 charge.

CPT® codes 96372-96379 are considered incidental to evaluation & management services, regardless of modifier usage, when performed in the following places of service (POS): 19, 21, 22, 23, 24, 26, 51, 52, and 61.

Allergen Immunotherapy:

Office visit (99202-99215) reported with allergen immunotherapy (95115-95117) is not eligible for separate reimbursement unless the service is significant and separately identifiable.

Office visit (99211) is considered mutually exclusive to 95115-95117 (allergen immunotherapy) and not eligible for separate reimbursement. Modifiers do not apply.

Anesthesia:

Anesthesia provided by the operating physician is considered incidental to the surgical procedure. This includes sedation given for endoscopic procedures including, but not limited to, colonoscopy.

Anesthesia complicated by emergency conditions:

(Add-on code 99140) is considered incidental to the procedure/administration of anesthesia.

Anticoagulant management:

Anticoagulant management for a patient taking warfarin (93793) is not eligible for separate reimbursement.

Balloon Sinuplasty:

Balloon sinuplasty (codes 31295, 31296, 31297, 31298) performed in conjunction with functional endoscopic sinus surgery (FESS) within the same sinus cavity, is considered incidental to the major service and not eligible for separate reimbursement. Modifiers 58, 59, 78 and 79 (or XE, XS, XP, XU) will not allow additional payment when appended to these codes. Refer to policy “Surgical Treatment of Sinus Disease.”

Bone Marrow or Stem Cell Services/Procedures:

Codes 38204, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214 and 38215 are considered incidental to 38240, 38241 and 38242.

Cardiac Stress Test:

A stress test may require the administration of pharmacological agents. An IV injection of a pharmacological agent is considered an integral component of the stress test and does not warrant separate reimbursement.

Care Management Services:

Care Management Services which include complex chronic care management (99487, 99489, G2211), chronic care management (99439, 99490, 99491, G0506), transitional care management (99495, 99496), cognitive assessment and care plan services (99483, 99484), principal care management services (99424, 99425, 99426, 99427, 99437), care management services for behavioral health conditions (G0323), chronic pain management and treatment (G3002, G3003) are not eligible for separate reimbursement. Psychiatric collaborative care management (99492, 99493, 99494, G2214) are not eligible for reimbursement when performed by behavioral health provider(s).

Care Plan Oversight and Coordination Services:

Care plan oversight and care coordination services are not eligible for separate reimbursement when billed within the same calendar month of a monthly ESRD service.

Casting Application and Strapping:

Casting/strapping services 29000-29799 are considered integral to surgical procedures. Codes for fracture treatment include the application and removal of the first cast. Do not submit separate charges for these casting services or materials. The professional component for the reapplication of a cast or splint is eligible for separate reimbursement from the Evaluation and Management code unless the reapplication of a cast or splint follows a surgical procedure or fracture care. In which case the professional component is considered part of the surgical fee and is not eligible for separate reimbursement.

Separate reimbursement may be allowed for an Evaluation and Management code when billed with a casting/strapping code. In a situation where a separate, identifiable evaluation and management service is provided in addition to the casting/strapping service, such as treatment of an acute/chronic illness, modifier 25 should be used when billing. In these cases, further review of the claim and supporting documentation may be necessary to make the appropriate reimbursement decision.

Chemotherapy:

Evaluation and Management services will generally be denied when submitted on the same date of service as a chemotherapy administration code. If a significant, separately identifiable service is performed, Modifier 25 is used. Office notes must document the significant, separately identifiable service.

Intravenous infusion codes are not allowed in addition to intravenous chemotherapy administration services unless the intravenous infusion represents a treatment apart from chemotherapy administration. The reason for a separate intravenous infusion should be noted in the medical record, and the service code modifier for a distinct procedure appended to the procedure code for intravenous infusion.

Clinical photography:

Clinical photography for documentation/record-keeping purposes is considered to be an integral part of an evaluation and management (E/M) service or procedure and not eligible for separate reimbursement consideration.

Critical Care Services:

Codes 36000, 36410, 36415, 36591, 36600, 43752, 43753, 71010, 71015, 71020, 92953, 93561, 93562, 94002, 94003, 94004, 94660, 94662, 94760, 94761, and 94762, are considered incidental to 99291 and 99292 (Critical Care Services). Critical care service procedures will be denied as incidental when submitted with Neonatal and Pediatric Critical Care services (99466, 99467, 99468, 99469, 99471, 99472, 99475, 99476). The critical care service procedures are included in the pediatric and neonatal critical care codes.

Continuous intraoperative neurophysiology monitoring:

Continuous intraoperative neurophysiology monitoring (IONM) in the operating room (95940, 95941, G0453) is considered incidental to the surgeon’s or anesthesiologist’s primary service. IONM services billed by a facility are not eligible for separate reimbursement. Professional services are only eligible for separate reimbursement when performed and billed by an eligible provider other than the surgeon or anesthesiologist. HCPCS Code G0453 will not be allowed when billed during the same operative session as 95940 or 95941. See also Corporate Medical Policy titled, “Intraoperative Neurophysiologic Monitoring”.

Diagnostic Radiopharmaceuticals and Contrast Materials:

Diagnostic radiopharmaceuticals and contrast materials billed by a facility or in a facility place of service (POS) are not eligible for separate reimbursement. Diagnostic radiopharmaceuticals and contrast materials are considered incidental to the related imaging procedure. Blue Cross NC references CMS’s Ambulatory Surgical Center Fee Schedule (ASCFS) Addendum BB code list in determining incidental diagnostic radiopharmaceutical and contrast material.

Dialysis Routine Supplies and Services:

Routine laboratory services, drugs and biologicals, equipment, and supplies are included in the dialysis inclusive rate and are not eligible for separate reimbursement. Please refer to provider contract, provider manual, and CMS' consolidated billing list for code specifics.

Medical Nutrition Therapy is not eligible for separate reimbursement when dialysis services are reimbursed in the same month.

DME Bundling:

The items listed in the CMS DME Unbundled Column I/Column II document are considered incidental to/included in the allowance for the item listed in Column I, therefore separate reimbursement will not be provided for the items in Column II when provided in association with the item(s) in Column I.

Electrical Stimulation Electrodes:

The supply of electrodes is considered incidental to electrical stimulation. Separate reimbursement is not allowed for incidental supplies.

Electrocardiogram:

Electrocardiograms are considered incidental to a stress test, a cardiac test which includes an ECG as part of the test, and as part of initial hospital care. A 3 lead ECG is considered incidental to a 12 lead ECG.

An ECG is considered mutually exclusive to provider services for cardiac rehabilitation (93797, 93798). Separate reimbursement is not provided for ECGs which are considered mutually exclusive. See also policy titled, “ECG Reimbursement.”

Electromyography, Nerve Conduction Tests and Reflex Tests with Evaluation and Management Services:

Evaluation and Management service will be denied when billed on the same date as electromyography, nerve conduction tests or reflex tests, unless the evaluation and management service consisted of a significant, separately identifiable service.

Endoscopy:

Modifier 59 (or XE, XS, XP, XU) will not allow additional payment when a diagnostic endoscopic base code is submitted with a surgical endoscopic code from the same endoscopic family. The endoscopic family is defined by the Medicare physician fee schedule.

Hernia Repair:

Hernia repair is considered an incidental procedure when performed during the same operative session as bariatric surgery. Modifiers will not allow additional payment when appended. An incidental procedure is not eligible for separate reimbursement. See also corporate medical policy “Surgery for Morbid Obesity”.

Hospital Mandated On Call Service:

Hospital mandated on call service; in hospital, each hour (99026) and hospital mandated on call service; out of hospital, each hour (99027) will be considered incidental to Evaluation and Management services, Surgical services and Laboratory services. Separate reimbursement is not allowed for 99026 and 99027.

“Incident to” Services:

CMS defines “incident to” services as those services furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of a condition. A physician may be reimbursed directly for “incident to” services performed by auxiliary personnel only when an employer relationship exists between the physician and the auxiliary personnel, and when the place of service code indicates the service was performed at a location typical for such an employer relationship (typically a physician office or other non-facility clinic). When the place of service code indicates the service was performed at a location not typical of a physician employer relationship (such as, but not limited to, inpatient or outpatient hospital), the service is considered an “incident to” service and is not eligible for separate reimbursement. In the unusual circumstance when an employer relationship exists between the physician and auxiliary personnel performing a service in an inpatient or outpatient facility, documentation of this arrangement could be submitted for reconsideration.

Injection and Infusion:

Infusion supplies and equipment, such as standard tubing and syringes, are included in the payment for infusion and injection services and will be denied as not separately reimbursed when billed with therapeutic, prophylactic, and diagnostic injection and infusion services by the same provider or same specialty.

Interactive complexity:

(90785) is an add-on code reported in conjunction with codes for diagnostic psychiatric evaluation and psychotherapy. It is considered incidental to the main service and is not eligible for separate reimbursement.

Interfacility transport care:

Supervision by a control physician of interfacility transport care of the critically ill/injured pediatric patient (99485, 99486) is considered incidental to the professional services provided on that day and is not eligible for separate reimbursement.

Intraoperative Use of Kinetic Balance Sensor:

Intraoperative use of kinetic balance sensor or implant stability during knee replacement arthroplasty (27599) is considered incidental to the primary procedure being performed and is not eligible for separate reimbursement.

Intraoperative visual axis identification using patient fixation (0514T) is considered incidental to the primary procedure being performed and is not eligible for separate reimbursement.

Lab Tests:

Lab codes 80047 – 80081 are lab panels that were developed for coding purposes. When the lab tests performed on a particular patient constitute one of the listed panels, the panel should be reported. The individual lab tests are rebundled into the lab panel code for reimbursement. Individual lab codes which constitute a panel are considered mutually exclusive to the lab panel.

Specimen validity testing is integral to the presumptive and definitive drug testing. Modifiers will not allow additional reimbursement.

Lesion Biopsy:

Lesion biopsy of separate anatomical sites will be allowed in addition to surgical procedures such as removal of skin tags/ lesions and closure.

Lesion Excision and Closure:

Separate reimbursement is allowed for the excision of lesion procedures when submitted with intermediate, complex, or reconstructive closures; 12031-12057, 13100-13160, 14000-14350, 15002 – 15261, and 15570-15770. Simple wound repair procedures, 12001 through 12021, will be found incidental to excision of lesions, unless the excision is a Mohs’ procedure.

Lumbar Laminectomy, Facetectomy or Foraminotomy reported with a Lumbar Spinal Fusion:

When a lumbar laminectomy, facetectomy or foraminotomy is performed in conjunction with a posterior approach for a lumbar spinal fusion procedure, the laminectomy, facetectomy or foraminotomy is generally incidental, and should be bundled with the fusion. Modifiers 58, 59, 78 and 79 (or XE, XS, XP, XU) will not allow additional payment when appended to CPT® codes 63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047, and 63048 and when performed in conjunction with 22630, 22632, 22633, and/or 22634. Based on the most common clinical scenario, it is expected that when a lumbar laminectomy, facetectomy, and/or foraminotomy is billed with a lumbar arthrodesis, posterior interbody technique, the procedures are being performed on the same level. In the unusual clinical circumstance when the procedures are performed at different vertebral levels, clinical information will be required to be submitted on appeal.

Medical Home Program:

Medical home program, comprehensive care coordination and planning, initial plan (S0280) and medical home program, comprehensive care coordination and planning, maintenance of plan (S0281) are not covered services. Separate reimbursement is not allowed for S0280 and S0281.

Medical Nutrition Therapy:

Medical nutrition therapy services are not reimbursable when billed by a provider other than a registered dietician, nutritional professional, or hospital. Other specialty providers performing medical nutrition therapy services are not eligible for reimbursement.

Moderate (Conscious) Sedation:

(99151, 99152, 99153): moderate sedation services (other than those services described by codes 00100-01999) provided by the same provider performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status is considered incidental to Evaluation and Management services (99091-99499), Surgical services (10004-69990), and Laboratory services (0001U-89398) and is not eligible for separate reimbursement.

G0500 (Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopy service) will be denied when a gastrointestinal endoscopic procedure has not been reported by the same physician for the same date of service.

Monitoring Feature/Device:

Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified (A9279) is considered incidental to all monitoring systems and not eligible for separate reimbursement.

Obstetrical Ultrasound:

Ultrasound add-on codes indicating multiple gestation will be denied when the diagnosis code does not specify multiple gestation.

First trimester obstetrical ultrasound (76801) is considered to be incidental to obstetrical ultrasound with first trimester fetal nuchal translucency measurement (76813) unless there is a separate medical necessity indication for 76801.

Outpatient Therapies Comprehensive Outpatient Rehabilitation Facilities (CORF) or Outpatient Physical Therapy Providers (OPT):

All services other than Q4001-Q4051 billed with the revenue code 0270 (supplies and device) will be denied when the bill type is 0740-075Z (CORF/ORF). Any supplies billed with revenue code 0270 by a CORF/OPT are considered packaged and therefore will not be separately reimbursed.

Pelvic Exams and Pap Smears:

Pelvic Examination (99459) is eligible for reimbursement of supplies and chaperoning.

Obtaining a pap smear is integral to the office visit. This includes both preventive and routine office visits. Separate reimbursement is not allowed for Q0091.

Pediatric and Neonatal Critical Care:

Codes 36000, 36140, 36620, 36510, 36555, 36400, 36405, 36406, 36420, 36600, 31500, 94002, 94003, 94004, 94375, 94610, 94660, 94760, 94761, 94762, 36430, 36440, 43752, 51100, 51701, 51702 and 62270 are considered incidental to 99468, 99471 and 99475 (Inpatient Neonatal and Pediatric Critical Care). The critical care procedure codes listed as a part of 99291 and 99292 are included in the Pediatric Neonatal Critical care and are considered incidental. Separate reimbursement is not allowed for incidental services.

Pharmacologic Management:

(90863) including prescription and review of medication, when performed with psychotherapy services is considered incidental and is not eligible for separate reimbursement.

Pulse Oximetry:

Non-invasive ear or pulse oximetry is considered an incidental service and not eligible for separate reimbursement.

Respiratory Treatments:

Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB devise is considered mutually exclusive to an office visit and is not eligible for separate reimbursement.

Robotic Surgical Systems:

Surgical techniques requiring use of robotics surgical system (S2900) are considered incidental to surgical services. Payment for new technology is based on the outcome of the treatment rather than the “technology” involved in the procedure. Additional reimbursement is not provided for the robotic surgical technique.

Shoulder Surgery:

Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. Arthroscopic debridement (29822, 29823), when performed at the same time as a more complex primary procedure is considered integral to the primary procedure and not eligible for separate reimbursement.

Specimen Collection:

Specimen collection by any method (venipuncture, central venous access, nasal/throat swab, etc.) is considered incidental to Evaluation and Management services, Surgical services, and Laboratory services regardless of place of service. Separate reimbursement is not allowed for 36400, 36405, 36406, 36410, 36415, 36416, 36420, 36425, 36600, G2023, G2024, and S9529. Other Central Venous Access procedures for collection of blood specimens from a completely implantable venous access device (36591) and collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified (36592) will be considered incidental to Evaluation and Management , Surgical and Laboratory services.

STAT or After-Hours Laboratory Charges:

Additional charges for STAT or after-hours laboratory services are considered an integral part of the laboratory charge and not eligible for separate reimbursement.

Standby Services:

Standby services, such as 99360 will be considered incidental to Evaluation and Management services, Surgical services and Laboratory services. Separate reimbursement is not allowed for 99360.

Surgical Supplies:

Surgical supplies will be considered incidental to Surgical; Laboratory; Inpatient, Outpatient or Office Medical Evaluation and Management; and Consultation services.

Surgical dressings applied in the provider’s office are considered incidental to the professional services of the health care practitioner and are not separately payable. Surgical dressings billed in the provider’s office (place of service 11) will be denied.

Surgical trays and miscellaneous medical and/or surgical supplies are generally considered incidental to all medical, chemotherapy, surgery, and radiology services, including those performed in the office setting.

Supplies are considered components of the 0, 10, and 90-day global surgical package, and are not separately billable on the same date of service as the 0, 10, or 90-day procedure.

Supplies are not covered when they do not require a prescription and can be purchased by the member over the counter or when they are given to the member as take-home supplies. Medical and/or surgical supplies, such as dressings and packings, used during an office visit are generally considered incidental to the office visit.

Anti-embolism stockings (TED hose), elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered.

Supplies and Equipment Provided in the Facility Setting:

Supplies and equipment services billed in a facility setting are not reimbursable and will be denied when billed with inpatient or facility places of service.

Transvaginal Ultrasound:

Transvaginal ultrasound (76830) is considered mutually exclusive to a hysterosonography with or without color flow Doppler (76831).

Travel Allowance:

Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from home bound or nursing home bound patient; prorated miles actually travelled (P9603) or prorated trip charge (P9604) is considered incidental to Evaluation and Management services, Surgical and Laboratory services and not eligible for separate reimbursement.

Urgent Care Services:

Additional reimbursement will not be allowed for S9088 – Services provided in an urgent center (list in addition to code for service) or S9083 – Global fee urgent care centers. These codes are considered incidental to the primary service(s) rendered.

Vision Services:

Visual acuity screening (99173) is considered incidental to evaluation and management services. Separate reimbursement is not allowed.

Determination of refractive state (92015) performed incidental to a medical eye exam is permissible and may be reimbursable when performed outside of any global allowance and subject to member benefits.

X-Rays:

When the entire spine, survey study is billed (72082, 72083, 72084) with cervical spine films (72040, 72050, 72052), thoracic spine films (72070, 72072, 72074) or lumbosacral spine films (72100, 72110, 72114, 72120) only the entire spine, survey study code is allowed. When a single view X-Ray code is billed with a multiple view X-Ray code, only the multiple view X-Ray code is allowed (e.g., 72020 with 72040, 72070, or 72100). Only one professional and one technical component are allowed per X-Ray.

Rationale

The guidelines addressed in this policy are not an all-inclusive listing.

For global payment of diagnostic tests and radiology services, total payment will be based on no more than the equivalent global service regardless of whether the billing is from the same or different provider. If one provider bills for the global service and the same or different provider also bills for either the technical or professional component for the same test or service, then the first claim processed will be processed normally. The second claim processed will either be denied (if the first claim processed was for the global service) or will have the remaining component service appended to the global (if the first claim processed was for either the technical or professional component.

Out of Sequence claims are claims involving procedures where unique CPT® codes have been established for two or more components of a procedure as well as the more comprehensive procedure. In most situations, there are three separate codes, two each addressing distinct components of the procedure and a third addressing the comprehensive procedure. When all components are performed on the same date of service and are billed together, services are recoded into the more comprehensive procedure. When all components are performed on the same date of service and are billed on multiple claims at different times, the subsequent services will be denied if inclusive to the service already billed or recoded to the remaining portion of the service.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.

Related policy

Durable Medical Equipment (Medical Policy)

ECG Reimbursement

Evaluation and Management Services

Global Surgery

Guidelines for Global Maternity Reimbursement

Immunization Guidelines

Intraoperative Neurophysiologic Monitoring (Medical Policy)

Modifier Guidelines

Multiple Surgical Procedure Guidelines

NCCI

Outpatient Code Editor (OCE) Edits

Professional Pathology Billing Guidelines (Medical Policy)

Surgical Treatment of Sinus Disease (Medical Policy)

Wheelchairs (Manual and Power Operated) (Medical Policy)

References

Medical Policy Advisory Group – 10/2003

Medical Policy Advisory Group – 03/10/2005

Medical Policy Advisory Group – 03/24/2006

Senior Medical Director – 6/23/2010

Senior Medical Director Review – 5/26/2011

Medical Director review – 3/2012

Medical Director review 5/2013

Medical Director review 7/2015

RPOC review 5/2018

Healthcare Common Procedure Coding System

American Medical Association, Current Procedural Terminology (CPT®)

Centers for Disease Control and Prevention, International Classification of Diseases, 10th Revision

Centers for Medicare & Medicaid Services 100-04 | CMS

CMS’s Ambulatory Surgical Center Fee Schedule (ASCFS) Addendum BB

CMS National Correct Coding Initiative Medicare NCCI Procedure to Procedure (PTP) Edits

Centers for Medicare & Medicaid Services CMS Wheelchair Options/Accessories

History

3/00 Removed Blue Edge references.

5/00 Corrected specimen handling paragraph to state will be covered. Stipulation “when performed in the provider’s office and the independent laboratory (not the provider) submits claims for tests performed” has been deleted. Added to Policy Guideline section, “The guidelines addressed in this policy are not an all-inclusive listing.”

9/01 Medical Policy Advisory Group review. No change in policy.

11/01 Coding format change.

5/02Added the following codes: 87620, 87621, and 87622 (Human papillomavirus HPV) as eligible codes for pathologists. Removed the Starred procedures section from this policy. Corrected Ultrasonic Guidance for Needle Biopsy paragraph to state will be covered when services are rendered on the same day by the same provider.

12/02 Policy reformatted. Additional key words added. Additional information added regarding bundling guidelines. Coding changes.

02/03 The following statements were added “Bone Marrow or Stem Cell Services/Procedures – Codes 38204, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, G0265, G0266 and G0267 are considered incidental to 38240, 38241 and 38242. Separate reimbursement is not allowed for incidental services.” Added the new 2003 cpt code 36416 to the Venipuncture section of the policy. Added new 2003 HCPCS code G0268 to Ear Wax Removal section of the policy.

4/03 This policy applies to Blue Care, Blue Choice, Blue Options, and Classic Blue products only. Clarified this point in the policy.

11/03 Medical Policy Advisory Group review. Policy updated with bundling edits.

02/04 Reference to HCFA revised to CMS.

3/04 The following statement added to the Injection Procedures section of the policy “Injection procedure 90782 and 90784 is considered incidental to 99211. Separate reimbursement is not allowed for incidental services.” New Visit Frequency was added to this policy under the Topic of Frequent Interest section.

6/10/04 Removed bundling guideline for Venipuncture. Please see new policy entitled: Code Bundling Rules Not Addressed in Claim Check, Policy ADM9028 with an effective date of 6/10/04.

6/11/04 Effective 07/01/04. Revisions under the “Topic of Frequent Interest” section of the policy, Fluoroscopic Guidance “Fluoroscopic Guidance- In general, fluoroscopic guidance is considered incidental to the procedure being done. However, code 76005 will be allowed separately when reported with 27096, 62270-62282, 62310-62319, 64470-64484, 64622-64627. 76005 will be considered incidental to 72275 – Epidurography, radiological supervision and interpretation.”

Ear Wax Removal- Ear wax removal (69210 and G0268) is considered incidental to medical or surgical services. Separate reimbursement is not provided for ear wax removal. Notification date 04/ 22/04. Effective date 07/01/04.

4/07/05 Medical Policy Advisory Group reviewed policy on 03/10/2005. Removed the following statements as they no longer apply: “Starred Procedures- Established patient Evaluation and Management services will not be allowed unless submitted with a -25 modifier, indicating a significant, separately identifiable service. As always, office notes should document the additional services.”

5/19/05 Revised “Voiding Pressure Studies” to “Voiding pressure (VP) (51795) studies any technique are considered incidental to intra-abdominal voiding pressure (AP) (51797) studies.

12/15/05 Added “Robotic Surgical Systems” to indicate that payment for new technology is based on the outcome of the treatment rather than the “technology” involved in the procedure. Additional reimbursement is not provided for the robotic surgical technique.

02/02/06 Removed the bundling guidelines for Anesthesia complicated by emergency conditions. See policy entitled Code Bundling Rules Not Addressed in Claim Check, Policy Number ADM9028.

02/16/06 Added the following statements under Injection Procedures: December 31, 2005 CPT deleted code 90782, 90783, 90784 and 90788. New January 1, 2006, CPT codes are reference in policy “Code Bundling Rules Not Addressed in Claim Check”.

Removed the following statements from Injection Procedures: Injection procedure 90788 is allowed in addition to all other medical, surgical, and chemotherapy services. Injection procedures 90782 and 90784 will be considered incidental to surgery, radiology, and anesthesia services. Injection procedures 90782 and 90784 are considered incidental to 99211. Separate reimbursement is not allowed for incidental services. Injection procedure 90783 will be considered incidental to anesthesia services. A therapeutic, prophylactic or diagnostic injection (90782) is considered mutually exclusive to professional services for allergen immunotherapy (95115-95134).

Added the following information to Introduction of Needle or Intracatheter into a Vein: Removed December 31, 2005 deleted CPT codes 90780, 90781, 90782, and 90784. Added new 2006 CPT codes 90760, 90761, 90765, 90766, 90767, 90768, 90772, 90773, 90774, and 90775.

3/30/06 Added section for Allergen Immunotherapy. Added to the section Ultrasonic Guidance for Needle Biopsy – “Separate reimbursement is allowed for 76942 (Ultrasonic Guidance for Needle Biopsy) when submitted with 76645 (Ultrasound, Breast(s) (unilateral or bilateral), B-scan and or real time with image documentation). Removed the bundling guidelines for Hot or Cold Packs. Removed the bundling guidelines for Introduction of Needle or Intracatheter. Section contained information for CPT codes effective January 1, 2006. Removed the bundling guidelines under Casting Application and Strapping – “A4580, ‘cast supplies (e.g., plaster),’ will be considered incidental to casting/strapping codes 29000-29799. The cost of the cast or splint is included in the basic value of the application and its corresponding code and does not provide separate reimbursement.”

5/8/06 Medical Policy Advisory Group review 3/24/06 including revisions noted above. No additional changes required to policy criteria. Policy number added to the Key Words Section.

6/5/06 Revised guidelines to be consistent with Medicare for reimbursement to pathologists for interpretation of clinical labs with an effective date of August 18, 2006.

8/21/06 Removed statement “Injection Procedures – December 31, 2005 CPT deleted code 90782, 90783, 90784 and 90788. New January 1, 2006, CPT codes are reference in policy “Code Bundling Rules Not Addressed in Claim Check”. Removed the following CPT codes from “Pathologists” statement; 80500, 80502,85060,85097, 86077, 86078, 86079, 86499, 86510, 86580, 86585, 87620, 87621, and 87622. Added CPT codes 84166 and 86355 to “Pathologists” statement.

10/16/06 “Specimen Handling and/or Conveyance or Implementation of Orders for Devices” to “Specimen Handling and/or Conveyance.” And clarified reimbursement policy for 99000.

11/05/07 In the Pathologist section added code 85060 to the list of codes eligible for clinical interpretation. Changed the wording from “Pathology interpretation of all other codes in the 80002-87999 range is considered an integral service.” To “Pathology interpretation of all other codes in the 80002-87999 range is considered an integral to the laboratory test.” Changed the words “mutually exclusive” to “incidental” in the Cardiac Stress Test section. Removed code 93000 and 93040 because the incidental logic no longer applies to 99291 and 99292 in the Critical Care section. Code 93798 removed from the Electrocardiograms section. Removed code 82800, 82805, 82810, 93000, 93040 and 94640 because the incidental logic no longer applies to codes 99296, 99294, 99295, 99296 and 99298 in the Neonatal Intensive Care Services. Changed the word from “incidental” to “mutually exclusive” in the Transvaginal Ultrasound section. Removed the Maldistribution of Inspired Gas, Chlamydia Testing by Direct or Amplified Probe Technique, Fluoroscopic Guidance and Voiding Pressure Studies section. Removed any deleted codes. Policy reviewed 10/26/07 by Senior Medical Director of Provider Partnerships, Medical and Reimbursement Policy.

12/03/07 Preoperative and Postoperative section was removed from “Topics of Frequent Interest Related to Blue Care, Blue Choice, Blue Options, and Classic Blue Products” and added to “Discussion Related to Blue Care, Blue Choice, Blue Options, and Classic Blue Products.” Added “Administration Fee for Injectable(s): In accordance with CPT guidelines the administration fee for injectable(s) (90772 – 90775) will be covered in additional to the cost of the drug(s), which are eligible for coverage. Removed “an” from “Pathology interpretation of all other codes in the 80002-87999 range is considered an integral to the laboratory test. Added “for” to “Separate reimbursement is not allowed integral services.” Reference added to clarify that “Blue Advantage” applies to this policy.

05/05/08 Added BCBSNC does not automatically reassign or reduce the code level of evaluation and management codes billed for covered services, with the exception of the new visit frequency editing as described below. Removed any key words or deleted codes which are no longer relevant to this policy. Policy reviewed 4/4/2008 by Vice President and Senior Medical Director of Provider Partnerships, Medical and Reimbursement Policy.

6/22/10 Policy Number(s) removed (amw)

7/1/10 Added guidelines for Balloon Sinuplasty. If Balloon Sinuplasty is performed in conjunction with FESS it will be considered incidental to the major service and not eligible for separate reimbursement. Refer to policy titled, “Balloon Sinuplasty for Treatment of Chronic Sinusitis”.

Added “Clinical photography – for documentation/record-keeping purposes is considered to be an integral part of an evaluation and management (E&M) service or procedure and is, therefore, not eligible for separate reimbursement consideration.”

Removed the following statement;“Ear Wax Removal – Ear wax removal (69210 and G0268) is considered incidental to medical or surgical services. Separate reimbursement is not provided for ear wax removal.” Refer to policy, Removal of Impacted Cerumen. Senior Medical Director review 6/23/2010. (btw)

1/18/2011 Added CPT codes 31295, 31296 and 31297 to Balloon Sinuplasty in the section “Topics of Frequent Interest.” (and)

3/15/2011 Lumbar Laminectomy, Facetectomy or Foraminotomy reported with a Lumbar Spinal Fusion – When a lumbar laminectomy, facetectomy or foraminotomy is performed with a posterior approach for a lumbar spinal fusion procedure, the laminectomy is generally incidental, and should be bundled with the fusion. When a claim is submitted reporting a posterior lumbar spinal fusion (22630/ 22632) and one of the following laminectomy procedures, 63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047 and 63048, the laminectomy will be denied as incidental to the primary procedure, even if the 59 modifier is appended. New 2011 CPT codes added to Critical Care Services and Neonatal Intensive Care sections. Allergen Immunotherapy and Ultrasonic Guidance for Needle Biopsy sections were removed as they do not apply to this policy any longer. Notification 3/15/2011 with an Effective date of 6/19/2011. (dpe)

6/7/2011 Further defined “When a lumbar laminectomy, facetectomy or foraminotomy is performed in conjunction with a lumbar spinal fusion procedure, the lumbar laminectomy, facetectomy or foraminotomy will be considered incidental to the lumbar spinal fusion.” Notification 3/15/2011 with an Effective date of 6/19/2011. (dpe)

Policy implementation information from 3/30/2006-05/05/2008 restored.

Added information regarding After Hours Care and Specimen Handling. “After Hours Care – Reimbursement is not provided for CPT codes 99050 and 99051 for a facility credentialed and contracted as an urgent care center” and “CPT codes 99000 and 99001, the handling and/or conveyance of specimen, are eligible for payment to the provider’s office when the laboratory service is not performed in the provider’s office and the independent laboratory bills BCBSNC directly for the test. The independent laboratory/reference laboratory will not be reimbursed for 99000 and 99001.” Removed the following information from Topics of Frequent Interest Related to Blue Care, Blue Choice, Blue Options, and Classic Blue Products as no longer applicable: “Visual Acuity Screening – Visual acuity screening (99173) is considered incidental to routine office visits and preventive health visits. Separate reimbursement is not allowed for incidental services.” Notification given 6/7/2011 for effective date of 9/1/2011. (and)

3/30/12 Added information to the Discussion section, Item D, regarding Global Allowance. The global surgical package includes all necessary services normally furnished by the surgeon before, during, and after a surgical procedure. The following was noticed and will be effective 5/29/2012: Supplies (except those related to splinting and casting) are considered components of the 0, 10, and 90-day global surgical package, and are not separately billable on the same date of service as the 0, 10, or 90-day procedure. For global payment of diagnostic tests and radiology services, total payment will be based on no more than the equivalent global service regardless of whether the billing is from the same or different provider. If one provider bills for the global service and the same or different provider also bills for either the technical or professional component for the same test or service, then the first claim processed will be processed normally. The second claim processed will either be denied (if the first claim processed was for the global service), or will have the remaining component service appended to the global (if the first claim processed was for either the technical or professional component). Claims for surgical dressings billed in the provider’s office (place of service 11) will be denied, because they are considered part of the professional/procedural service. Supplies and materials furnished by the provider (drugs, trays, and materials) above and beyond those usually included with the procedure(s) performed should be separately reported by the provider. Professional radiology services in the inpatient or outpatient hospital setting are not eligible for payment unless the provider is an anesthesiologist, neurologist, obstetrician/gynecologist, emergency medicine specialist, physical medicine specialist, radiologist, or radiation oncologist. The intent of this edit is to avoid duplicate payment for services that were performed by another provider. Normally, the radiology group associated with the hospital will bill these procedures because they performed the official interpretation; an additional allowance for a second provider’s interpretation of the test results will not be allowed. (A specific exception to this policy is made for supervision and interpretation of angiography). In the unusual situation where a provider not included among the above specialties furnishes the sole interpretation of the professional radiology service, documentation of this circumstance could be submitted for reconsideration.

In the Topics of Frequent Interest section, the following statement was added under subtitle for Chemotherapy: Intravenous infusion codes are not allowed in addition to intravenous chemotherapy administration services unless the intravenous infusion represents a treatment apart from chemotherapy administration. The reason for a separate intravenous infusion should be noted in the medical record, and the service code modifier for a distinct procedure appended to the procedure code for intravenous infusion. Added description of “out of sequence” claims to Policy Guidelines section.

Added new CPT codes 22633 and 22634 to subtitled section on Lumbar Laminectomy. (and)

10/1/12 Topics of Frequent Interest. The following statement was deleted from the section regarding Surgical Supplies: “Supplies and materials furnished by the provider (drugs, trays, and materials) above and beyond those usually included with the procedure(s) performed are reported separately.” HCPCS codes removed from description. The remaining statements in that section are unchanged. (and)

11/13/12 Revisions made to “Surgical Supplies” section under Topics of Frequent Interest for clarity. The following statements were added: “Supplies are not covered when they do not require a prescription and can be purchased by the member over-the-counter or when they are given to the member as take-home supplies. Medical and/or surgical supplies, such as dressings and packings, used during the course of an office visit are generally considered incidental to the office visit. Compression/pressure garments, elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered.” (and)

12/11/12 Revision to Topics of Frequent Interest. Section regarding Balloon Sinuplasty deleted. Refer to corporate medical policy titled “Balloon Sinuplasty for Treatment of Chronic Sinusitis” for information on this procedure. (and)

2/26/13 CPT code removed from list in the section on “Pathologists.” CPT 83912 was deleted as of 12/31/12. (and)

5/14/13 Added the following to Topics of Frequent Interest: “Balloon Sinuplasty – Balloon sinuplasty (codes 31295, 31296, 31297) performed in conjunction with FESS is considered incidental to the major service and not eligible for separate reimbursement. Refer to policy “Balloon Sinuplasty for Treatment of Chronic Sinusitis.” (sk)

7/28/15 Description section updated. In the Topics of Frequent Interest section, codes in the “Lab Tests” were expanded to include all lab panels 80047 – 80076. The statement in the Policy Guidelines section regarding professional radiology services in the inpatient or outpatient hospital setting was removed. Information regarding National Correct Coding Initiative added to Policy Guidelines section. (and)

12/30/15 CPT Code 72010 deleted, replaced with 72082. New codes for January 2016 added: 0396T (intra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty) and 0399T (myocardial strain imaging) are considered incidental to the primary procedure being performed and are not eligible for separate reimbursement. Section related to specimen handling and conveyance was deleted. 99000 and 99001 are not a covered service. Refer to policy titled “Code Bundling Rules Not Addressed in ClaimCheck or Correct Coding Initiative.” (and)

2/29/16 Deleted information regarding Vision Services. Statement revised to read: please refer to CEC’s bundling guidelines related to routine vision services. Notification given 2/29/2016 for policy effective date 5/1/2016. (and)

12/30/16 In the Topics of Frequent Interest section, code range for Administration Fee for injectable(s) was expanded to include CPT code 96377. (an)

2/24/17 Deleted information regarding Vision Services. Statement revised to read: Determination of refractive state (92015) performed incidental to a medical eye exam is permissible and may be covered when performed outside of any global allowance and subject to member benefits. (an)

9/29/17 Added modifiers to section regarding Lumbar Laminectomy, Facetectomy or Foraminotomy reported with Lumbar Spinal Fusion. Modifiers 58, 59, 78 and 79 (or XE, XS, XP, XU) will not allow additional payment when appended to CPT codes 63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047 and 63048 and when performed in conjunction with 22630, 22632, 22633, and/or 22634. Chronic Care Management Services (99490, G0506) are considered incidental to other evaluation and management services and not eligible for separate reimbursement. Notification given 9/29/17 for policy effective date 11/28/17. (an)

12/29/17 Routine review. No change to current policy. (an)

1/12/18 Policy correction. Information for 9/29/17 update with notifications effective 11/28/17 was inadvertently left off the 12/29/17 version. (an)

5/25/18 Extensive revisions to policy. All guidelines listed in Corporate Reimbursement Policy titled “Code Bundling Rules Not Addressed in ClaimCheck or Correct Coding Initiative” have been combined with this policy and the Code Bundling Rules policy is being archived. Clarification to Balloon Sinuplasty, bundling occurs within the same sinus cavity. Codes updated throughout the policy where necessary. (an)

9/7/18 Added code 85097, 86077, 86078 and 88333 to the subsection titled “Pathologists.” These codes are allowed when submitted by pathologists for clinical interpretation of laboratory results. (an)

12/31/18 Pathologist specialty code corrected, replaced 29 with 22. Deleted code 99090. Added code 99491 (chronic care management). Added codes 99451, 99452 to section regarding Interprofessional Telephone/Internet Consultations. Added section regarding intraoperative visual axis identification (0514T). Added section regarding remote monitoring of physiologic parameters (99453, 99454, 99457). Removed statement regarding Medicare Status “B” from section on Prolonged Evaluation and Management Service. (an)

1/29/19 Clarified the section on Pulse Oximetry. Statement revised to read: non-invasive ear or pulse oximetry is considered an incidental service and not eligible for separate reimbursement. (an)

2/26/19 Added to “Topics of Frequent Interest” Shoulder Surgery: Certain procedures are commonly performed in conjunction with other procedures as a component of the overall service provided. Arthroscopic debridement (29822, 29823), when performed at the same time as a more complex primary procedure is considered integral to the primary procedure and not eligible for separate reimbursement. (an)

7/1/19 Added to “Topics of Frequent Interest” Hernia repair (43280, 43281, 43332, 43334, 43336) is considered an incidental procedure when performed during the same operative session as bariatric surgery (43644, 43645, 43770, 43775, 43842, 43843, 43845, 43846, 43847). MODIFIERS 58, 59, 78 AND 79 (OR XE, XS, XP, XU) WILL NOT ALLOW ADDITIONAL PAYMENT when appended to these codes. An incidental procedure is not eligible for separate reimbursement. See also corporate medical policy “Surgery for Morbid Obesity”. Notification 7/1/19 for effective date of 8/30/19. (an)

11/12/19 Revised information for Office Visit to read: (99211) is considered mutually exclusive to 95115-95117 (allergen immunotherapy) and not eligible for separate reimbursement. Modifiers are not allowed. Notification 11/12/2019 for effective date 1/14/2020. Medical Director review 12/2019. (an)

1/28/20 Inadvertently left code 31298 off the list of Balloon Sinuplasty codes. 31298 added back to list. (an)

2/25/20 Code 0399T for myocardial strain imaging deleted and replaced with code 93356. (an)

5/12/20 Added to Description section, item D: global surgery guidelines also apply to facility claims. Added Outpatient Code Editor (OCE) Edits to Related Policies section. Notification given 5/12/2020 for effective date 7/14/2020. (bb)

8/25/20 Updated Policy section to include “Claims editing for bundling guidelines will apply to professional and facility claims unless otherwise stated”. Added “Wheelchairs (Manual and Power Operated)” and “Durable Medical Equipment” to Related Policies section. Added new topic Wheelchair Bundling to “Topics of Frequent Interest” section. Notification 8/25/2020 for effective date 10/27/2020. (bb)

10/27/20 In the “Topics of Frequent Interest” section Venipuncture and Other Central Venous Access changed to Specimen Collection, language updated, and added codes G2023 and G2024. Code 99072 added to “Topics of Frequent Interest” Status “B” codes section. CMS reference source for Wheelchair Options/Accessories added to Reference Sources. (bb)

11/24/20 Added related policy Professional Pathology Billing Guidelines. (eel)

12/31/20 Routine policy review. Medical Director approved 12/2020. No changes to policy statement. Deleted code 0396T was replaced with unlisted code 27599. New code 99439 and G2214 added to “Topics of Frequent Interest” section Care Management Services. Definition of new patient updated within New Frequency Visit section. Policy notification given 12/31/2020 for effective date 3/9/2021. (eel)

4/6/21 Effective 4/15/2021. 36600 added for clarity to “Topics of Frequent Interest” section Specimen Collection. No change to policy intent. Pathologist section removed from policy, see related Professional Pathology Billing Guidelines policy. (eel)

5/18/21 Policy format update. Added section Correct Coding Initiative. Clarified Casting Application /Strapping section. Updated Administration Fee for injectable(s) section to require drug or substance code be filed with administration. Added “CPT codes 96372-96379 are considered incidental to evaluation & management services, regardless of modifier usage, when performed in the following places of service (POS): 19, 21, 22, 23, 24, 26, 51, 52, and 61.” Policy notification given 5/18/2021 for effective date 7/28/2021. (eel)

6/1/21 The following sections were removed from policy and moved to new commercial reimbursement policy “Evaluation and Management Services”: New Visit Frequency, After Hours Care, Immunization Administration, Medical Records Copying Fee, Durable Medical Equipment Determination, Prolonged Evaluation and Management Service, and Resource Intensive Service. (eel)

7/1/21 Status B codes section was removed from policy and moved to new commercial reimbursement policy “Status Codes”. (eel)

7/27/21 Clarified Allergen Immunotherapy section to include all office visit codes (99202-99215). (eel)

10/1/21 Updated Balloon Sinuplasty section “Modifiers 58, 59, 78 and 79 (or XE, XS, XP, XU) will not allow additional payment when appended to these codes.” Policy notification given 10/1/2021 for effective date 11/30/2021. (eel)

12/30/21 Routine policy review. Grammatical errors corrected. Remote Monitoring of Physiologic Parameter(s) section renamed to Remote Physiologic and Therapeutic Monitoring, newly created codes 98975, 98976, 98977, 98980, and 98981 added. Newly created codes 63052 and 63053 added to Lumbar Spine section. Newly created codes 99424-99427 and 99437 added to Care Management Services section. Urgent Care Services section clarified to include S9083. Medical Director approved. (eel)

6/1/22 Policy language updated throughout. Added topics: Care Plan Oversight and Coordination Services, Injection and Infusion, and Outpatient Therapies. G0500 added to Moderate Sedation section. Removed topic Correct Coding Initiative, moved to new policy titled NCCI. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

7/26/22 Added Standby Services section. Medical Director approved. Notification on 5/17/2022 for effective date 7/26/2022. (eel)

11/1/2022 Moved Interprofessional Consults language from Bundling Guidelines Policy to Evaluation and Management Services Policy. (ckb)

12/31/2022 Routine policy review. Added new codes for 2023. Medical Director Approved. (ckb)

12/31/2022 Added Ambulance bullet under Reimbursement Guidelines section. Notification on 12/31/2022 for effective date 03/01/2023. (cjw)

4/1/2023 Added Dialysis Routine Services and Supplies Section. Updated Care Management Services “Psychiatric collaborative care management (99492, 99493, 99494, G2214) are not eligible for reimbursement when performed by behavioral health provider(s).” Medical Director Approved. Notification on 4/1/2023 for effective date 6/1/2023. (tlc)

4/18/23 Removed Remote Physiologic and Therapeutic Monitoring section and relocated to

Telehealth policy. Removed Myocardial Strain Imaging section, as it is now allowed as

add on code, and no longer incidental. (cjw)

6/13/2023 Updated Lab Tests section “Specimen validity testing is integral to the presumptive and definitive drug testing. Modifiers will not allow additional reimbursement.” Medical Director Approved. Notification on 6/13/2023 for effective date 8/15/2023. (tlc)

8/15/2023 Ambulance supplies moved from Reimbursement Guidelines to new Ambulance reimbursement policy. No change to policy intent. (tlc)

9/12/2023 Wheelchair Bundling renamed to “DME Bundling”. Medical Director Approved. Notification on 9/12/2023 for effective date 11/12/2023. Removed specific coding guidelines for Hernia Repair. Rationale language moved to Reimbursement Guidelines. (tlc)

11/1/2023 Added Medical Nutrition Therapy language to Dialysis Routine Supplies and Equipment. Medical Nutrition Therapy provider specialty language added in Reimbursement Guidelines. Medical Director approved. Notification on 11/1/2023 for effective date 1/1/2024. (tlc)

1/19/2024 Moved code G2211 from Status Codes policy to Care Management Services section. (tlc)

07/17/2024 63052 and 63053 removed from bundled services list for lumbar laminectomy, facetectomy and foraminotomy. (ss)

08/01/2024 Classified fiberglass casting materials as incidental to casting and strapping services. Clarified that visual acuity services are incidental to E&M visits. Incidental services are not separately reimbursable. Notification on 06/01/2024 for effective date 08/01/2024.

09/01/2024 Updated bundling rules for intraoperative neurophysiology monitoring. RPOC Approved. Notification on 07/01/2024 for effective date 09/01/2024 (ss)

10/01/2024 Updated radiology contrast bundling rules for facility and professional services. RPOC Approved. Notification on 08/01/2024 for effective date 10/01/2024 (ss)

10/01/2024 Added Pelvic Examination (99459) is eligible for reimbursement of supplies and chaperoning, effective 8/1/24. (eel)

11/1/2024 Clarification to the definition of same group practice. No change to policy intent. (tlc)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host Members (other Blue Cross and/or Blue Shield Plan Members who seek care from the NC service area). This policy does not apply to Blue Cross NC Members who seek care in other states.

This policy relates only to the services and/or supplies described herein. Please refer to the applicable Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore, Member benefit language should be reviewed before applying the terms of this policy.