Revenue Codes Requiring Procedure Codes, Facility

Description

This policy defines revenue codes that Blue Cross Blue Shield North Carolina (Blue Cross NC) require a CPT® or HCPCS procedure code be reported. This policy applies to UB-04 and 837-institutional claim forms.

Policy

Blue Cross NC will reimburse revenue codes according to the criteria outlined in this policy.

Reimbursement Guidelines

Blue Cross NC requires certain revenue codes be submitted with an appropriate corresponding CPT® /HCPCS code; consistent with CMS, Uniform Billing Editor, and the UB-04 manual.

Blue Cross NC enforces the revenue code list requiring a corresponding CPT® /HCPCS found within the most recent CMS OCE edit. Please refer to the Reference section for the current revenue code list from CMS.

In addition to the revenue codes from CMS, Blue Cross NC requires the additional revenue codes listed in the Billing and Coding section to be submitted with a corresponding CPT® /HCPCS.

Bill Types requiring revenue codes with a corresponding CPT® /HCPCS include 012x, 013x, 014x, 074x, 075x, 076x and 083x.

Multiple lines of the same revenue codes are required to represent different CPT® or HCPCS.

Revenue codes with modifiers are not reimbursable when a HCPCS or CPT® code is not submitted.

Rationale

Based on CMS, Uniform Billing Editor, and the UB-04 manual guidelines; Blue Cross NC enforces revenue code to CPT/HCPCS requirements.

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 . Please refer to the current OCE release for CMS’s list of revenue codes requiring CPT® /HCPCS. 

Additional Revenue Codes Requiring CPT®/HCPCS

Related policy

Facility Billing

References

Centers for Medicare and Medicaid Services, CMS Manual System

Healthcare Common Procedure Coding System (HCPCS)

American Medical Association, Current Procedural Terminology (CPT® ) National Uniform Billing Committee (NUBC)

Outpatient Code Editor (OCE) Outpatient Code Editor (OCE) | CMS History

History

6/1/2022 New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel) 

12/31/2022 Routine policy review. Minor revisions only. (ckb)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans 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 or supplies described herein. Please refer to the 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.