Description

Based on human anatomy some procedures can only be performed once in a member’s lifetime. This policy will describe procedures that are only possible to perform once in a member’s lifetime and therefore only reimbursed once in a member’s lifetime.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will limit reimbursement for each “Once in a Lifetime” procedure group to only once during a member’s lifetime according to the criteria outlined in this policy.

Reimbursement Guidelines

Each “Once in a Lifetime” procedure group will only be reimbursed once per member. “Once in a Lifetime” procedure groups may consist of one or more codes.

There may be times when a “Once in a Lifetime” procedure is reported more than once, including, but not limited to, co-surgeons, team surgery, discontinued procedures, surgeries that require an assistant surgeon, laterality, or split surgical care. When it is appropriate to report a “Once in a Lifetime” code more than once, the “Once in a Lifetime” code must be reported with the appropriate modifier.

When a “Once in a Lifetime” procedure is reported, subsequent services specific to that removed body part or organ will not be reimbursable.

Rationale

Blue Cross NC enforces a once in a lifetime limit on some procedures based on typical human anatomy.

Billing and Coding

Applicable codes are for reference only and are not 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.

The following table identifies by code or code group some examples of “Once in a Lifetime” procedures described above. The inclusion or exclusion of a specific code does not indicate eligibility for reimbursement under all circumstances. This table is provided as an informational tool only, to help identify some of the procedures described above.

Related policy

Bundling Guidelines

Consistency Guidelines

Co-surgeon, Assistant Surgeons, and Assistant-at-Surgery Guidelines

Modifier Guidelines

References

Healthcare Common Procedure Coding System

American Medical Association, Current Procedural Terminology (CPT®)

Centers for Disease Control and Prevention, International Classification of Diseases, 10th Revision

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

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.