Description

Same group practice is defined as a physician and/or other qualified health care professional of the same specialty with the same Federal Tax ID number.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will reimburse same day nucleic acid testing according to the criteria outlined in this policy.

Reimbursement Guidelines

Two or more nucleic acid tests billed by the same group practice on the same date of service for the same member will be subject to a multiple procedure payment reduction. This will be applied to both multiple units billed for the same service and multiple individual services.

Reimbursement will be based on the following:

• 100% for the first unit/initial lab
• 50% for additional units and/or labs

Note: Reimbursement is not allowed for multiple testing methodologies for the same microorganism (i.e., direct, amplification, and quantitative testing).

Billing and Coding

Applicable codes noted throughout policy 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

Bundling Guidelines

NCCI Editing

Identification of Microorganisms using Nucleic Acid Probes (Medical Policy)

References

American Medical Association, Current Procedural Terminology (CPT^®)

Centers for Medicare & Medicaid Services, CMS Manual System, Medicare Claims Processing Manual 100-04, and NCCI Policy Manual

Healthcare Common Procedure Coding System

History

Application

These reimbursement requirements apply to all Blue Medicare HMO, Blue Medicare PPO, Blue Medicare Rx members, Healthy Blue + Medicare (HMO-POS D-SNP), 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.