Commercial Reimbursement Policy
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Origination: 08/2003
Last Review: 12/2022
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. Bill types must be reflective of the services received and align with the location where the services were rendered. |
| 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. |
| Annual Wellness Visit | Annual wellness visit (AWV) is considered a professional service, and there will be no separate reimbursement for a facility fee. If being provided in a facility setting, the bill type must be reflective of such. |
| 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. |
| Clinical Trial Services | Clinical trials that are performed in an outpatient facility, require three items to be included for proper processing of the claim: the appropriate clinical trial modifier (Q0 or Q1), condition code indicating qualifying clinical trial, and the appropriate bill type signifying outpatient hospital. |
| 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 facility (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. |
| 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. |
| Emergency Treatment and Labor Act (EMTALA) screening: | Reimbursement of revenue code 0452 requires the presence of 0451 on the same date of service. Evaluation and Management services using revenue code 0450 are not separately reimbursable when submitted with 0451 or 0452 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 reimbursement 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. |
| 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 services are billed with Revenue codes 0960-0989 (professional fee) or modifier 26 as the codes are exclusive to facility billing only. |
| Hospice Services | Hospice services (Q5003-Q5008, Q5010) must be billed with an appropriate bill type. Services completed under hospice care will not be eligible 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. |
| 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 |
| Physical Therapy Assistant (PTA) and Occupational Therapy Assistant (OTA) Services | Services administered in whole or in part by a PTA or OTA are only eligible for reimbursement when submitted with modifier CO or CQ. Services are reimbursed at 85% of the allowable amount. |
| Professional Services: | Revenue codes 0960-0989 representing professional services are not eligible for reimbursement on a facility claim. These services are to be submitted on a CMS-1500 professional claim form. |
| 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 reimbursed per date of service (unless modifiers are appropriately appended) and, only one qualifying mental health visit is reimbursed per date of service. Additional medical or behavioral health services will not be eligible for reimbursement. A qualifying preventive health service, other than an initial preventive exam (G0402) is not reimbursed in addition to an RHC qualifying medical service, on the same date of service. |
| Self-Administered Drugs | Revenue code 0637 (Pharmacy - self-administered drugs) is not reimbursable when submitted without a HCPCS code. |
| 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. |
| 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 access center. Bill types must be reflective of this. |
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 Blue Cross NC.
Related policy
Bundling Guidelines
Modifier Guidelines
Outpatient Code Editor (OCE) Edits
Pricing & Adjudication Principles
Revenue Codes Requiring Procedure Codes, Facility
References
Healthcare Common Procedure Coding System (HCPCS)
American Medical Association, Current Procedural Terminology (CPT®)
Centers for Medicare & Medicaid Services CMS Announces Comprehensive Strategy to Enhance Hospital Capacity Amid COVID-19 Surge | CMS: https://www.cms.gov/newsroom/press-releases/cms-announces-comprehensive-strategy-enhance-hospital-capacity-amid-covid-19-surge
Centers for Medicare & Medicaid Services NCDHHS COVID-19 Extension of Hospital at Home Program: https://medicaid.ncdhhs.gov/blog/2021/12/10/special-bulletin-covid-19-202-extension-hospital-home-program
Centers for Medicare & Medicaid Services CMS Manual Pub 100-20
https://www.cms.gov/files/document/r11191otn.pdf
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 added: (CMS Acute Hospital Care at Home) Service Descriptions for Reimbursement Guidance: 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. Effective date 6/30/2022. (ckb)
12/31/2022 Routine policy review. Alphabetized Service Descriptions. Minor revisions. (ckb)
10/01/2024 Removed “Devices, Implants, Blood Products, & Imaging Agents” section. Section can be found in Supply and Equipment reimbursement policy. Minor revision only. (ss)
2/01/2025 PTA and OTA Modifier CO and CQ reimbursement reduction added. Notification on 12/01/2024 for effective date 02/01/25 (ss)
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.
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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