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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® or HCPCS code; consistent with CMS, Uniform Billing Editor (UBE), and the UB-04 manual. Blue Cross NC enforces the revenue code list found within the most recent CMS OCE edit. Please refer to the Reference section for the current revenue code list.
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.
Related policy
References
Centers for Medicare and Medicaid Services and CMS Manual System
Healthcare Common Procedure Coding System, HCPCS Release and Code Sets
National Uniform Billing Committee (NUBC)
https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs
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. (cjw)
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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