Overuse
Description
The Choosing Wisely® and Practicing WiselyTM initiatives evaluate usage of health care services with a goal of reducing excessive tests and procedures that result in unnecessary medical spend. Subject matter experts and specialty societies provide recommendations for preventing overuse of health care services having a potentially negative impact on both the quality and/or cost of health care.
Policy
Blue Cross North Carolina (Blue Cross NC) does not reimburse for overuse of services according to the guidelines in this policy.
Reimbursement Guidelines
| Overuse Category | Reimbursement Guidance |
|---|---|
| Lower Back Pain (LBP) Imaging | Imaging services (X-ray, CT scan, or MRI) billed within 28 days of a principal diagnosis of uncomplicated LBP are not eligible for reimbursement. Imaging services may be appended with a KX modifier to indicate NCQA HEDIS™ exclusionary criteria was met. |
Rationale
Based on Choosing Wisely® and Practicing WiselyTM guidance, Blue Cross NC will limit reimbursement for services deemed overuse.
Billing and Coding
Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross NC web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.
Related policy
Bundling Guidelines
References
https://choosingwisely.org
https://motivepw.com
https://www.ncqa.org/hedis/measures/use-of-imaging-studies-for-low-back-pain
History
04/18/2023 New policy developed. MD Approval. Notification on 4/18/2023 for effective date 6/18/2023. (eel)
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.
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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