Description

All codes published on the National Physician Fee Schedule (NPFS) by the Centers for Medicare and Medicaid Services (CMS) are assigned a status code. The status code indicates whether the code is separately payable if the service is covered.

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

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will reimburse status indicator codes according to the criteria outlined in this policy.

Reimbursement Guidelines

Status “B” codes

Payment for these services is always included in payment for other services not specified, whether billed alone or with another service. Status B code edits are applied to professional and outpatient facility claims. Status B codes are bundled. Certain benefit allowances may apply.

Status “I” codes

Status I codes are not eligible for reimbursement. Medicare uses other codes for reporting and payment of services with a status code I.

Status “N” codes

Status N codes are ancillary HCPCS codes that are integral to the delivery of other procedures and services. Payment for this code type is “packaged” (bundled) into the payment for other services and therefore are not separately reimbursable.

Status “P” codes

Payment for these services is considered bundled/excluded. The services are incidental to other payable services when performed by the same Tax ID/Provider ID on the same date of service and are therefore not separately payable.

Status “T” codes

Status T codes bundle into services assigned a status indicator of A (Active) or R (Restricted Cover age) provided on the same date of service by the same group practice, for which payment is made. This code type is only paid if there are no other services payable under the physician fee schedule on the same date by the same provider. Modifier overrides will not prevent codes with a status indicator of T from bundling into other services. 

Rationale

Status indicator codes will be reimbursed consistent with CMS and in accordance with correct coding guidelines.

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.

Each status code list is accessible using the PFS link within the References section.

Related policy

Bundling Guidelines

Evaluation and Management Services

Outpatient Code Editor Edits

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 and Medicaid Services, Physician Fee Schedule (PFS)

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-ValueFiles

History

6/1/2022 - New policy developed. Medical Director approved. Notification on 3/31/2022 for effectivemdate 6/1/2022. (eel)

12/31/2022 - Routine Policy Review. Minor revisions only. (cjw)

7/18/2023 - Added Status Code “I” to Reimbursement Guidelines. Medical Director approved. Notification on 7/18/2023 for effective date 9/18/2023. (tlc)

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.