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Facility Billing Guidelines
Description
Blue Cross NC utilizes the guiding principles outlined below for outpatient facility claims editing. These principles may help practitioners anticipate and understand the likely outcome of claims submissions. Blue Cross NC follows coding edits that are based on industry sources, including, but not limited to; CPT® guidelines from the American Medical Association, specialty society organizations, and CMS including NCCI, OCE, and MUE.
Blue Cross NC follows the instruction and guidance of code and claim form issuers, including but not limited to CPT, HCPCS, UB-04, and ICD-10.
Policy
Blue Cross Blue Shield North Carolina (Blue Cross NC) will reimburse facility billing according to the criteria outlined in this policy.
Reimbursement Guidelines
The following scenarios are not reimbursable:
| Service Descriptions | Reimbursement Guidance |
|---|---|
| All Services | For services provided to prisoners or members in state or local custody (defined as Condition Code 63), reimbursement will not occur unless modifier QJ is also appended to the codes, indicating that certain exception criteria have been met. This also applies to any member discharged with a discharge status of 21 or 87. Bill types must be reflective of the services received and align with the location where the services were rendered. |
| Self-Administered Drugs | Revenue code 0637 (Pharmacy - self-administered drugs) is not reimbursable when submitted without a HCPCS code. |
| Outpatient Services During Inpatient Admission | Services, other than ambulance, that are rendered by an outpatient hospital and the date of service is after the inpatient admission date and prior to the discharge date, by any provider. |
| Ambulance Services During Inpatient Admission | Ambulance services for date of service that is after the admission date and prior to the discharge date for any inpatient admission. |
| Home Health | Home health services for date of service that is after the admission and prior to the discharge for any inpatient, skilled nursing facility, or swing bed hospital admission. |
| Hospital at Home (CMS Acute Hospital Care at Home) | Hospital at Home services are not eligible for reimbursement. If these services are provided, Blue Cross NC requires they be submitted with Revenue code 161 and Occurrence Span Code 82. |
| Hospital Observation Service and Hospital Emergency Department Visit | Reimbursement will not occur if either of these codes are billed with Revenue codes 0960-0989 (professional fee) or modifier 26 as the codes are exclusive to facility billing only. |
| Donor Services | Revenue code 0815 (Allogeneic stem cell acquisition/donor services) is only reimbursable when submitted with inpatient hospital, outpatient hospital or Special facilities-critical access hospital bill types. |
| ESRD-related erythropoiesis stimulating agents | When provided during an unscheduled or emergency dialysis treatment in the outpatient hospital setting, G0257 must also be included on the claim for the same date of service. |
| Pharmacogenomic Testing for Warfarin Responsiveness | For this to be eligible for reimbursement, the member must be in an approved clinical trial. This will only be eligible for reimbursement once per lifetime. |
| Audiology Services, including: audiologic function test, evaluation and therapeutic services, and special diagnostic procedures | Reimbursement will not occur when these services are performed in an outpatient rehabilitation facility. |
| Cardiac and Pulmonary Rehabilitation | Cardiac and pulmonary rehabilitation services will only be eligible for reimbursement when submitted with bill types representing hospital outpatient or critical access center |
| Rural health clinic (RHC) services | RHCs are required to bill the appropriate revenue code representing a free standing clinic or behavioral health treatment/service and applicable HCPCS/ CPT® code for each qualifying preventive health, behavioral health, or medical service provided. Additional services provided in an RHC will not be eligible for reimbursement when billed with revenue codes other than the ones previously addressed. Only one qualifying medical visit is allowed per date of service (unless modifiers appropriately appended) and, only one qualifying mental health visit is allowed per date of service. Additional medical or behavioral health services will not be eligible for reimbursement. Additionally, a qualifying preventive health service, other than an initial preventive exam (G0402) is not allowed in addition to an RHC qualifying medical service, on the same date of service |
| Federally Qualified Health Center (FQHC) Services | Five visit codes (G0466-G0470) were established to be used by FQHC when submitting a claim for services under the prospective payment system (PPS). Only 1 unit of any FQHC visit or up to 3 units if providing a combination of FQHC visits will be eligible for reimbusement if reported on a single date of service. If billing for a combination of FQHC visits, the appropriate modifier must also be appended to the claim line. G0469 (FQHC visit, mental health, new patient) when reported for PPS payment will not be eligible for reimbursement if FQHC new patient visit code G0466 is also present on the claim. |
| Hospice Services | Hospice services (Q5003-Q5008, Q5010) must be billed with an appropriate bill type. Services completed under hospice care will not be eligibile for reimbursement if submitted on a hospice bill type indicating late charges. However, hospices may adjust finalized claims to add late charges within the normal timely filing period. |
| Skin Substitute Procedures and Products | Billing for skin substitute application procedures are required to also include the appropriate high cost or low cost skin substitute products. |
| Corneal Tissue Processing, Preserving and Transporting | Corneal tissue processing, preserving and transporting should only be reported when corneal tissue is used in a corneal transplant procedure. |
| Digital Breast Tomosynthesis (DBT) (G0279) | DBT is only eligible for reimbursement in the inpatient hospital, outpatient hospital, inpatient skilled nursing facilty (SNF), outpatient SNF, and outpatient critical access center. Bill types must be reflective of this. Additionally, DBT must be billed with the appropriate revenue codes. |
| Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) | Ultrasound screening for AAA is only eligible for reimbursement in the following settings: inpatient hospital, outpatient hospital, inpatient SNF, outpatient SNF, RHC, freestanding clinic, and outpatient critical a |
| Outpatient Hospital Packaged Services | Conditionally packaged laboratory service codes (Status indicator Q4) when billed with any nonlaboratory service and the bill type is 0130-013Z (hospital outpatient) will be denied. Packaged laboratory service codes (Status indicator N) and conditionally packaged laboratory service codes (Status indicator Q4) when billed with bill type 0120-012Z (Hospital inpatient Part B) and condition code W2 (Duplicate of original bill) is also present, will be denied. STV packaged services will be denied when billed on the same claim as a procedure or service that has an APC status with status indicator of S, T, or V. T- packaged services will be denied when billed with a procedure with an APC status indicator of T. Blue Cross NC enforces the CMS OPPS list of revenue codes that are considered packaged. Packaged revenue codes will be denied when billed without a HCPCS code. |
| 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. |
Rationale
Blue Cross NC enforces CMS guidance for purposes of this facility billing reimbursement policy and will provide reimbursement accordingly.
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.
References
Healthcare Common Procedure Coding System
American Medical Association, Current Procedural Terminology (CPT®)
Centers for Medicare & Medicaid Services, CMS Manual System, Medicare Claims Processing Manual 100- 04, OPPS, and OCE
CMS Hospital at Home
History
6/1/2022 - New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)
6/30/2022 - Clarification: “(CMS Acute Hospital Care at Home) Hospital at Home services are not eligible for reimbursement. If these services are provided, Blue Cross NC requires they be submitted with Revenue code 161 and Occurrence Span Code 82.” Added to Reimbursement Guidelines: Service Descriptions Section. Effective date 6/30/2022. (cjw)
12/31/2022 - Routine Policy Review. Minor revisions only. (cjw)
10/1/2024 - Moved “Devices, Implants, Blood Products, & Imaging Agents” section to Supply and Equipment reimbursement policy. Minor revision only. (ss)
Application
These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services.
This policy relates only to the services or supplies described herein. Please refer to the Member's Evidence of Coverage (EOC) 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.
Disclosures:
Reimbursement policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benefits are determined by the group contract and subscriber certificate that is in effect at the time services are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and Blue Cross NC reserves the right to review and revise its medical and reimbursement policies periodically.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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