updated december 30, 2021 - nebraska blue
TRANSCRIPT
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Updated May 31, 2022
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Dear Health Care Provider:
This manual is dedicated to keeping you and your staff informed about Blue Cross and Blue
Shield of Nebraska’s (BCBSNE) operational policies and procedures.
The contents of this manual are contractually binding for compliance, based on your provider
agreement with BCBSNE. Providers must follow all applicable BCBSNE policies and
procedures, as well as those applicable to the covered person. Contracting providers agree to
provide appropriate information to their employees, agents and representatives consistent with
this commitment.
It is important to familiarize yourself with the information provided in this manual and have it
readily available as a reference. For your convenience, the manual is available online at
NebraskaBlue.com/Providers/Policies-and-Procedures. The online version of the manual
contains the most current and updated information.
If you have any suggestions on how we can improve this manual as a comprehensive resource
for you, please let us know.
Sincerely,
Dwayne M. Asche, Vice President, Health Network Services
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Current Edition Updates
May 31, 2022 No updates April 29, 2022
• Section 2 – A9279 information added
• Section 2 – Breastfeeding Support Supplies and Lactation Counseling updated
• Section 3 – Place of Service for Home Versus Store updated March 31, 2022
• Section 2 – Casts and Strappings language updated
• Section 2 – Sepsis language updated
• Section 2 – Professional Surgery Guidelines added
• Section 2 – Surgery sections removed
• Section 4 – Intensive Outpatient/Day Treatment/Partial Care language update
• Section 5 – Injection Place of Service Restrictions language updated
Table of Contents
PREFACE ............................................................................................................................................................... 6
ABOUT BLUE CROSS AND BLUE SHIELD OF NEBRASKA ........................................................................... 7
WHO WE ARE ................................................................................................................................................................... 7 FINANCIAL STABILITY ....................................................................................................................................................... 7 OUR BOARD OF DIRECTORS ........................................................................................................................................... 8 OUR MISSION, VISION AND VALUES .................................................................................................................................. 8
ADVERTISING POLICY ........................................................................................................................................ 8
SECTION 1: FEDERAL EMPLOYEE HEALTH BENEFITS PROGRAM® ......................................................... 9
SECTION 2: PROVIDER REIMBURSEMENT AND BILLING GUIDELINES ................................................... 10
A9279 ............................................................................................................................................................................ 10 ADVANCED PRACTICE PROVIDER .................................................................................................................................. 10 AMBULANCE SERVICES .................................................................................................................................................. 11 AMBULATORY SURGERY CENTER (ASC) ...................................................................................................................... 12 ANESTHESIA GUIDELINES .............................................................................................................................................. 13 ANESTHESIA BILLING SITUATIONS, SPECIFIC ............................................................................................................... 15 BILATERAL PROCEDURES .............................................................................................................................................. 17 BIRTHING CENTERS ....................................................................................................................................................... 17 BLUE CARD AND MEDICARE .......................................................................................................................................... 17 BLOOD SUGAR MONITORING BILLING GUIDELINES ......................................................................................................... 18 BREASTFEEDING SUPPORT SUPPLIES AND LACTATION COUNSELING ......................................................................... 19
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CANCELLED PROCEDURE .............................................................................................................................................. 19 CASE MANAGEMENT/CARE PLAN OVERSIGHT SERVICES ............................................................................................ 19 CASTS AND STRAPPING ................................................................................................................................................. 19 CATHETERIZATION ......................................................................................................................................................... 20 CERUMEN (EAR WAX) REMOVAL .................................................................................................................................. 20 CHEMOTHERAPY ............................................................................................................................................................ 20 CONSULTATION CODES ................................................................................................................................................. 20 CONTRAST MEDIA .......................................................................................................................................................... 22 CRITICAL CARE CODES ................................................................................................................................................. 23 DEVELOPMENTAL TESTING ............................................................................................................................................ 23 DIABETES EDUCATION ................................................................................................................................................... 23 DIALYSIS ........................................................................................................................................................................ 23 DISCONTINUED SERVICES ............................................................................................................................................. 24 EMERGENCY ROOM SERVICES ..................................................................................................................................... 24 EVENING, WEEKEND OR HOLIDAY OFFICE HOURS ....................................................................................................... 24 FRACTURE CARE ........................................................................................................................................................... 24 GENETIC/MOLECULAR TEST CODING ........................................................................................................................... 25 HOSPITAL-ACQUIRED CONDITIONS (HAC) AND NEVER EVENTS POLICY REMINDER AND UPDATE ............................ 25 INDEPENDENT CLINICAL LABORATORY .......................................................................................................................... 26 INPATIENT SERVICES ..................................................................................................................................................... 26 INTERIM BILLING ............................................................................................................................................................ 26 INTRAOPERATIVE MONITORING ..................................................................................................................................... 27 INTRAVENOUS ANALGESIA ............................................................................................................................................. 27 INVOICES ........................................................................................................................................................................ 27 ITINERANT SURGEON ..................................................................................................................................................... 27 LATE CHARGES .............................................................................................................................................................. 28 LEAVE OF ABSENCE/BED HOLD .................................................................................................................................... 28 LOCUM TENENS ............................................................................................................................................................. 28 MATERNITY CLAIMS ....................................................................................................................................................... 28 MEDICAL RECORDS ....................................................................................................................................................... 28 MEDICAL/SURGICAL SUPPLIES ...................................................................................................................................... 28 MODERATE SEDATION ................................................................................................................................................... 28 NERVE BLOCKS ............................................................................................................................................................. 28 OBSTETRICAL ANESTHESIA ........................................................................................................................................... 28 OBSTETRICAL/MATERNITY SERVICE GUIDELINES ........................................................................................................ 28 INSTITUTIONAL ............................................................................................................................................................... 31 OUTPATIENT AND EMERGENCY ROOM SERVICES ........................................................................................................ 32 OUTPATIENT SURGICAL ENCOUNTERS- MULTIPLE PROCEDURES (ALSO REFERENCE MULTIPLE
SURGEONS/MULTIPLE SURGICAL SESSIONS)............................................................................................................... 33 OXIMETRY ...................................................................................................................................................................... 34 PATHOLOGY ................................................................................................................................................................... 34 PHARMACY ..................................................................................................................................................................... 34 PHYSICAL REHABILITATION (ACUTE INPATIENT PROGRAMS) ....................................................................................... 34 PROLONGED PHYSICIAN SERVICE ................................................................................................................................. 35 PROFESSIONAL SURGERY GUIDELINES ........................................................................................................................ 35 PRORATION .................................................................................................................................................................... 37 RADIOLOGY .................................................................................................................................................................... 37 RADIOPHARMACEUTICAL ............................................................................................................................................... 38 RAPID FLU TEST ............................................................................................................................................................ 38 REDUCED SERVICES ...................................................................................................................................................... 38
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RESIDENT/STUDENTS .................................................................................................................................................... 38 ROBOTIC ASSISTANCE ................................................................................................................................................... 38 RURAL HEALTH CLINICS ................................................................................................................................................ 38 SEPSIS (BILLING GUIDELINES) ...................................................................................................................................... 39 SITE OF SERVICE FOR PROFESSIONAL REIMBURSEMENT ............................................................................................ 39 SLEEP LAB ..................................................................................................................................................................... 39 SPEECH THERAPY ......................................................................................................................................................... 40 STANDBY ........................................................................................................................................................................ 40 STAT OR AFTER-HOURS LABORATORY CHARGES ........................................................................................................ 40 THERAPY ........................................................................................................................................................................ 40 TRANSPLANT SERVICES ................................................................................................................................................ 41 UNLISTED PROCEDURE OR SERVICE ............................................................................................................................ 42
SECTION 3: HOME MEDICAL EQUIPMENT, HOME INFUSION, HOME HEALTH, AND HOSPICE .... 44
AMBULATORY INFUSION CENTER (AIC) ........................................................................................................................ 44 APNEA MONITOR ........................................................................................................................................................... 44 CPAP ............................................................................................................................................................................ 44 DATE SPAN .................................................................................................................................................................... 44 DRUGS DISPENSED OR ADMINISTERED ........................................................................................................................ 44 EQUIPMENT RENTAL POLICY ......................................................................................................................................... 44 HOME HEALTH CARE ..................................................................................................................................................... 45 HOME INFUSION BILLING GUIDELINES ........................................................................................................................... 45 HOME MEDICAL EQUIPMENT RENTAL ........................................................................................................................... 48 HOSPICE (INPATIENT/OUTPATIENT) .............................................................................................................................. 48
Billing Guidelines (when BCBS is primary .................................................................................................................. 48 HOSPITAL HME BILLING ................................................................................................................................................ 49 HOSPITAL - BILLING FOR HME EQUIPMENT AND SUPPLIES ......................................................................................... 50 INSULIN PUMP AND SUPPLIES ....................................................................................................................................... 50 LIFT CHAIRS (RECLINER WITH ELEVATING SEAT) .......................................................................................................... 50 LOAN EQUIPMENT .......................................................................................................................................................... 50 LYMPHEDEMA SLEEVE/GLOVE ...................................................................................................................................... 50 MEDICARE-RELATED ISSUES ......................................................................................................................................... 50 OXYGEN ......................................................................................................................................................................... 51 PLACE OF SERVICE FOR HOME VERSUS STORE ........................................................................................................... 51 PRICING METHODOLOGY ............................................................................................................................................... 52 PURCHASE OF HOME MEDICAL EQUIPMENT ................................................................................................................. 52 RENT TO PURCHASE (HME EQUIPMENT - RR OR NU MODIFIER - REQUIRED) ........................................................... 53 RENTAL PRORATION ...................................................................................................................................................... 54 REPAIR OF EQUIPMENT ................................................................................................................................................. 54 ROLLER AID ................................................................................................................................................................... 54 TRANSCUTANEOUS AND/OR NEUROMUSCULAR ELECTRICAL NERVE STIMULATOR (TENS) UNIT .............................. 54 VENTILATORS ................................................................................................................................................................. 55 WOUND CARE - PUMP AND SUPPLIES ........................................................................................................................... 55
SECTION 4: MENTAL HEALTH ................................................................................................................. 55
ALCOHOL AND DRUG ASSESSMENTS ............................................................................................................................ 55 APPLIED BEHAVIORAL THERAPY ................................................................................................................................... 55 COMMUNITY TREATMENT AIDE ...................................................................................................................................... 56 CUSTODY EVALUATIONS ................................................................................................................................................ 56 ELECTROCONVULSIVE THERAPY (ECT)- 90870 .......................................................................................................... 56
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HOSPITAL PSYCHOTHERAPY SESSIONS ........................................................................................................................ 56 INITIAL ASSESSMENT (PSYCHIATRIC DIAGNOSTIC INTERVIEW) .................................................................................... 56 INTENSIVE OUTPATIENT/DAY TREATMENT/PARTIAL CARE ........................................................................................... 56 MODIFIER-22 ................................................................................................................................................................. 57 PSYCHIATRIC ................................................................................................................................................................. 57 PSYCHOLOGICAL TESTING (96130-96139) .................................................................................................................. 59
SECTION 5: DRUG REIMBURSEMENT POLICY ............................................................................................. 61
DESCRIPTION: ................................................................................................................................................................ 61 DEFINITIONS: ................................................................................................................................................................. 62
J Code Drugs .......................................................................................................................................................... 62 INJECTABLE DRUG ......................................................................................................................................................... 62 ADMINISTRATION ............................................................................................................................................................ 62 RECONSIDERATION OF UNLISTED CODE ALLOWANCES ............................................................................................... 63 INJECTION PLACE OF SERVICE RESTRICTIONS ............................................................................................................. 63
SECTION 6: INPATIENT INCLUSIVE BILLING POLICY .......................................................................... 63
OVERVIEW ...................................................................................................................................................................... 63 DESCRIPTION ................................................................................................................................................................. 64 REIMBURSEMENT INFORMATION.................................................................................................................................... 64 REFERENCE ................................................................................................................................................................... 71
SECTION 7: HOW TO CONTACT US ........................................................................................................ 71
Send an Inquiry ....................................................................................................................................................... 71
Preface Many “Blue” terms are used throughout this manual to describe the different BCBSNE
programs and products designed to meet the needs of both our contracting providers and our
members.
Each program/product is unique in its focus and because it carries the term “Blue,” you can be
assured that it is supported by our mission to deliver the health and wellness solutions people
value most.
Please note that your subcontractors are subject to the terms of your contract with us, and you
are responsible for ensuring their compliance with it, as well as this manual and all applicable
federal and state statutes, laws and regulations.
When there is a discrepancy between the terminology in this manual and the provider contract,
the specific contract language will prevail.
The information in this manual is subject to change. Deletions and additions are published
periodically. Some will have an effective date. Those with no effective date are effective as of
the date the manual is published. We encourage you to utilize the most current version of the
manual by visiting NebraskaBlue.com/Providers by clicking “Providers” then “Policies and
Procedures.”
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Revisions are often published in our Provider UPDATE newsletter and in direct mailings to your
office.
View newsletters by going to NebraskaBlue.com/Providers and click on “Alerts and Updates.”
To receive an e-mail each time we post a new issue of the Provider UPDATE newsletter on the
website, fill out the information in Contract Update Signup. In addition, we encourage you to
view our comprehensive online provider library of past issues.
The information in this manual should not be considered all-inclusive. It contains general
information that applies to many - but not all – employer group health plans. Employers can
and do request variations of endorsements.
Health care providers should take advantage of our online provider portal through NaviNet to
verify member eligibility and benefits, verify claim status or access a remittance advice. Go to
NebraskaBlue.com/Providers and click on NaviNet go directly to the NaviNet sign in page to
register or log-in. This information is available for you free of charge by BCBSNE and should
be your primary source of verification.
Call our toll-free voice response system at 800-635-0579 to get answers to claim or benefit
questions that may not be available on NaviNet.
About Blue Cross and Blue Shield of Nebraska Who we are
Blue Cross and Blue Shield of Nebraska (BCBSNE) is a member of the national Blue Cross
and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
BCBSNE is an independent mutual health insurance company licensed by the State of
Nebraska.
BCBSNE has done business in Nebraska for nearly 80 years. We work with network health
care professionals statewide to provide the best health care possible to our customers.
Financial stability Although the Blue Cross and Blue Shield Association does not act as a guarantor of each
Plan’s financial obligations, all Plans are subject to uniform financial standards established by
the Association. These standards are intended to foster a system in which each Plan maintains
adequate resources to meet its obligations to its customers. We have an A- financial rating with
A.M. Best, which reflects a stable outlook.
BCBSNE monitors financial and operational performance through strict customer service and
claims processing standards, performance guarantees and other methods of measurement.
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Our Board of Directors Business leaders, consumers and health care professionals across the state comprise our
board of directors. The Board sets standards for operations and financial performance. Such
standards include the amount of operating reserves we maintain. Reserves are funds that are
set aside over and above dollars needed to pay claims and run the business.
The board also establishes and monitors all policies governing the conduct of our employees, officers and directors. These policies ensure the corporation operates ethically and within the laws and regulations prescribed for us.
Our mission, vision and values BCBSNE’s mission is to deliver the health and wellness solutions people value most. Our vision is a health care world without confusion that adds more good years to peoples’ lives.
Our values include:
• Innovate to differentiate.
• Invite change to create opportunity.
• Enable customer passion.
• Openly embrace our communities.
• Be open, honest, and respectful to inspire trust.
• Collaborate to create excellence.
Advertising Policy With prior approval from BCBSNE, as a contracting health care provider, you are permitted to
mention your Blue Cross and Blue Shield of Nebraska (BCBSNE) network affiliation(s) in any
electronic or print advertising or promotional materials, such as telephone directories, websites
and brochures.
You are NOT permitted to use the Blue Cross and Blue Shield symbols at any time.
You are required to submit your camera-ready copy for review and approval to:
Blue Cross and Blue Shield of Nebraska
Marketing Department
P.O. Box 3248
Omaha, NE 68180-0001
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Section 1: Federal Employee Health Benefits
Program®
Overview For specific FEP options and more information see the General Policies and
Procedures Manual.
The Federal Employee Program® and Medicare A provision of the Omnibus Budget Reconciliations Act (OBRA) of 1993 applies the Medicare
participation and physician payment rules and requirements to all retired individuals covered
under the BCBS Federal Employee Program (FEP). These payment rules include CMS-
approved demonstration projects.
OBRA affects FEP reimbursement when the patient:
• is 65 years of age or older;
• does not have Medicare Part A, Part B, or both;
• is an annuitant of the FEP as a former spouse OR as a family member of an
annuitant of former spouse; and
• is not employed in a position that offers FEP coverage
Inpatient Reimbursement
OBRA bases inpatient care reimbursement on an amount that is equivalent to Medicare’s
payment amount unless the charge is less than the Medicare equivalent amount. FEP
members are NOT responsible for any charges greater than the Medicare equivalent amount.
The law prohibits a hospital from collecting more than the Medicare equivalent amount. FEP
members who have Standard Option coverage are responsible for deductibles, coinsurance,
and/or co-payments.
Physician Reimbursement
OBRA bases physician services reimbursement on the lesser of the Medicare approved
amount or the actual charge. Member liability is dependent on the physician’s participating
status with Medicare and/or the physician’s contracting status.
If the physician participates with Medicare or accepts Medicare assignment and is in the
NEtwork BLUE network, the FEP member is responsible for:
• Standard Option - deductibles, coinsurance, and copayments
• Basic Option - copayments and coinsurance
If the physician participates with Medicare or accepts Medicare assignment and is NOT in the
NEtwork BLUE network, the FEP member is responsible for:
• Standard Option - deductibles, coinsurance, copayments, and any balance up to
115% of the Medicare approved amount
• Basic Option - all charges
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If the physician does not participate with Medicare and is in the NEtwork BLUE network, the
FEP member is responsible for:
• Standard Option - deductibles, coinsurance, copayments, and any balance up to
115% of the Medicare approved amount
• Basic Option – copayments, coinsurance and any balance up to 115% of the
Medicare approved amount
If the physician does not participate with Medicare and is NOT in the NEtwork BLUE network,
the FEP member is responsible for:
• Standard Option - deductibles, coinsurance, copayments, and any balance up to
115% of the Medicare approved amount
• Basic Option - all charges
Waiver Copy Required for Denial Review If an FEP member files an appeal on a claim denied as not medically necessary and the
member has signed a waiver, the Office of Personnel Management (OPM) requires the
provider to send us a copy of the waiver for final review. If the provider cannot find the signed
waiver, the member must be held harmless. OPM will not allow the submission of medical
record documentation.
For requirements of an Advanced Beneficiary Notice (ABN) or waiver see “Hold Harmless and
Balance Billing” in Provider Responsibilities.
For billing and claim guidelines and other information for FEP members, please see the
appropriate section throughout this document.
Section 2: Provider Reimbursement and Billing
Guidelines
A9279 Effective July 1, 2022, BCBSNE will no longer cover A9279. This code is for the use of
equipment and is calculated into the reimbursement allowance. Billing this code separately is
considered unbundling and will be denied as inclusive.
Advanced Practice Provider Physician Assistants (PA), Advanced Practice Registered Nurses (APRN) and Certified Nurse
Midwives CNMW) need to be credentialed with Blue Cross and Blue Shield of Nebraska.
Services by a PA, APRN and CNMW must be billed under the Advanced Practice provider’s
name and rendering NPI.
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Modifier -AS
Physician Assistants, Advanced Practice Registered Nurses and Certified Nurse Midwives are
to use the “AS” modifier when billing for assistant surgery. Physicians should continue to use
the “80” modifier. Claims will be returned if the appropriate modifier is not used.
Blue Cross and Blue Shield of Nebraska (BCBSNE) applies a 15% differential to the applicable
Physician fee schedule for covered services performed or provided by Physician Assistants
(PAs), Nurse Practitioners (NPs), Advanced Practice Registered nurses (APRNs), and Certified
Nurse Midwives (CNMWs). All advanced practice providers are expected to bill under their own
NPI for services rendered; and NOT under the physician’s NPI.
The 15% differential does not apply to the following codes which will be reimbursed at the
applicable physician fee schedule amount:
• Radiology
• Pathology and Lab
• Rx
• All HCPCS Level II Codes
Ambulance Services BCBSNE Ambulance policy sources CMS for Ambulance billing guidelines including but not
limited to; content denials, origin destination modifiers, and frequency edits.
Ambulance (Hospital-Based)
Submit hospital-based helicopter, fixed wing and ground ambulance charges separately on a
UB04 claim form with the appropriate Level II HCPCS Codes. Hospital-based providers shall
bill BCBSNE directly for these services, regardless of patient destination. Air ambulance
providers must file claims to the Blue Plan in whose service area the point of pick-up occurred
based on ZIP code.
Claims will be rejected if:
• There is no point-of-pickup zip code listed
• The point-of-pickup zip code is not in the BCBSNE service area
• Multiple zip codes are listed
• The zip code submitted does not comply with the required format
Note: This change does not apply to hospital-based air ambulance services billed on a UB-04
under a hospital’s tax ID number and NPI.
Ambulance Mileage
Ambulance transport is only covered to the nearest appropriate facility. Report non-covered
miles with appropriate code in the units’ field.
An example of non-covered miles would be when the patient requests to be transported
beyond the nearest appropriate facility. For hospital to-hospital transfers, please indicate why
the transfer was necessary (“transportation for specialized care,” for example). Claims that do
not contain this information will be returned. For non-emergent transports, please include
information why ambulance transport was necessary.
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Non-hospital-based A hospital may not bill charges from an ambulance provider for a patient
brought to their facility. Ambulance providers shall bill BCBSNE directly for these services on
the CMS 1500 claim form.
Ambulatory Surgery Center (ASC) There are two acceptable claim formats to submit Ambulatory Surgery Facility Charges (ASC):
the paper CMS 1500 claim form or the 837P electronic claim transaction.
The facility fee (technical component) charge needs to be billed using CMS 1500 form. The
facility charge for each coded procedure is all-inclusive of the facility cost for the procedure.
For exceptions, please refer to your specific contract.
SG Modifier must be appended to all lines on the claim.
The agreed upon payment amount as specified in the Provider Agreement for any Covered
Service will be reduced by the Covered Person’s liability of any co-payment, deductible, or
coinsurance amount(s).
Single Procedures:
When one operative/diagnostic procedure is performed in an encounter, the billing for the
Facility Fee (Technical Component) shall be billed with the appropriate CPT code of the
procedure performed.
Multiple Procedures:
In addition to billing the appropriate CPT codes for the procedures performed, BCBSNE will
provide benefits, following CMS’s policy of procedures that can be performed in an ASC.
Inquiries for any other codes should be directed to the Provider Executive assigned to your
area.
The primary procedure (procedure with the highest RBRVS value) will be priced at 100% of the
ASC fee schedule amount. Additional covered surgical procedures will be reduced by 50% of
the ASC fee schedule amount.
Debridement:
Debridement after endoscopic sinus surgery or other sinus surgery may be addressed by
several codes. BCBS Nebraska will be monitoring routine and complex sinus debridement for
the required documentation with use of forceps or scalpel when performing complex
debridement.
Appropriate documentation will be required for payment of complex nasal/sinus endoscopic
debridement.
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Post Procedure Overnight Observation:
For those facilities licensed by the State of Nebraska to provide continuous 24-hour per day
nursing services for the post procedure treatment and follow up observation of a surgical
patient, and so approved by BCBSNE to perform those services, additional reimbursement
outside of the surgical procedure reimbursement will be provided as specified in the Provider
Agreement.
Cataract Surgery and Lens Insertion Effective March 1, 2021
Only the facility can bill for procedure codes related to the removal of the cataract and the
insertion of a standard intraocular lens (IOL).
Standard IOL reimbursement is included in the surgery rate, additional reimbursement is not
allowed. Premium IOLs (V codes) will no longer be covered.
If a Premium IOL needs to be billed in order to receive a denial, use appropriate IOL CPT code,
this will trigger a content denial.
Note: Surgeons cannot bill for intra-ocular lens implants.
Fluoroscopic Guidance of Needle
Procedures done in an ASC will be reimbursed only the technical component for these
procedures. (A separate professional component for each of these procedures may also be
payable and should be submitted by the physician on a separate CMS 1500).
Tissue Expanders
When implantable tissue expanders are inserted in an ASC, the procedure should be billed
using the appropriate code. The implantable tissue expander itself should be billed with the
correct code and the invoice should be sent with the claim. Purchase orders are not
acceptable as an invoice.
Anesthesia Guidelines Benefits for anesthesia services provided in the operating suite include:
• Pre-anesthesia visits, services in the preoperative area and post-anesthesia visits
• All preoperative visits, postoperative visits and/or monitoring (including consultations).
• Constant physical attendance while surgery is being performed and monitoring the
patient’s vital signs throughout surgery
• Administration of fluids or blood incident to the anesthesia or surgery, the administration
of drugs which change the state of sensation or consciousness or in a very few cases,
withholding such drugs deliberately where it is in the best interest of the patient
• Following the patient through recovery from the effects of drugs; (those administered
before, during and immediately after the surgery)
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Anesthesia Time
Anesthesia time begins with the initial administration of anesthetic agents by the
anesthesiologist and ends when the patient is released to the recovery area.
The total anesthesia allowed amount is an accumulation of base units plus time units. Base
units will be internally assigned by BCBSNE using the American Society of Anesthesiologists
(ASA) Relative Value Guide based on the ASA anesthesia procedure code submitted. Every 15
minutes is considered onetime unit. LIST ONLY TOTAL NUMBER OF MINUTES IN THE
UNITS FIELD. DO NOT LIST CALCULATED TIME UNITS NOR START/STOP TIMES ON
THE CLAIM.
The base units + time units are calculated by BCBSNE’s claims processing system. Reporting
time units in the unit’s field can result in an underpayment.
Exceptions: OB anesthesia codes which are priced at a flat fee and should be reported as one
unit. Any non-ASA procedures should also be reported with one unit.
Anesthesia Modifiers
An anesthesia modifier is not required. Please reference physical status modifiers.
There are other modifiers that are also valid, however modifier 30 is not valid. The modifiers do
not affect payment.
CRNAs who are employees of a hospital – See “Participation Requirements” in the General
Policies and Procedures Manual. Services provided by a CRNA must adhere to the following
billing guidelines:
• Anesthesia claims must be billed with minutes, not units
• Never put the surgeon’s NPI number on the claim
• Do not write start and stop times on the claim
Paper Claims Guidelines
• Box 24J must include the CRNA’s individual NPI
• Box 31 must include Prof Serv CRNA with the CRNA’s first and last names underneath
Prof Services CRNA. No punctuation.
Electronic Claim Guidelines
• The 2310B Loop (Rendering) should include the CRNA’s name and individual NPI.
• The 2010AA Loop (Billing) should include the billing entity’s name and organizational
NPI.
Anesthesia Risk and Qualifying Circumstances
Services involving administration of anesthesia must be reported using the correct CPT
anesthesia code plus modifier codes, if applicable. There will be no additional reimbursement
for modifiers.
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Qualifying circumstance codes are used to report difficult circumstances. These codes are
considered content of service, and there is no additional reimbursement for these codes.
Anesthesia Billing Situations, Specific Anesthesia for Multiple Procedures
If anesthesia has been given for a procedure and a secondary procedure is also done, the
primary procedure will be reimbursed the normal base plus time units, the secondary
procedure will be reimbursed base units only.
Anesthesia Standby
Non-active participation by an anesthesiologist who is physically present during a surgical
procedure is not a covered service. Charges for anesthesia standby will be denied as not
covered, subscriber liability.
Anesthesia Supervision
BCBSNE reimburses the physician for medical direction of a CRNA. BCBSNE will not accept
“split” claims for medical direction services. Submission of claims by the physician and the
CRNA for medically directed anesthesia services will result in the CRNA claim being denied as
content of service. Reimbursement for anesthesia services when medically directed by a
physician are reimbursed if the following criteria are met:
• Not more than four anesthesia procedures are being performed concurrently.
• The physician is physically present in the immediate area of the operating suite(s).
• Medical direction is a Covered Service only if:
o the physician performs a pre-anesthetic examination and evaluation;
o the physician prescribes the anesthesia plan;
o the physician personally participates in the most demanding procedures of the
anesthesia plan, including, if applicable, induction and emergence, block
placement if regional anesthesia and/or start of intravenous sedation if MAC
anesthesia;
o the physician ensures that a qualified anesthetist performs any procedures in
the anesthesia plan that he or she does not perform;
o the physician monitors the course of anesthesia administration at frequent
intervals;
o the physician remains physically present and available for immediate diagnosis
and treatment of emergencies; and
o the physician provides indicated post-anesthesia care.
o the physician does not perform any other services that require leaving the
immediate area of the operating suite, devote extensive time to an emergency
case, or is otherwise not available to respond to the needs of surgical patients
during the same period. A physician directing the administration of not more
than four anesthesia procedures may provide the following without affecting
eligibility of his/her medical direction services:
• Address an emergency of short duration in the immediate area;
• Administer an epidural or caudal anesthetic to ease labor pain;
• Provide periodic, rather than continuous, monitoring of an obstetrical patient;
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• Receive patients entering the operating suite for the next surgery;
• Check or discharge patients in the recovery room;
• Handle scheduling matters.
The medically directing physician is personally responsible for determining the diminishment of
his or her directing capability while involved in the performance of a procedure and to provide
service consistent with these policies.
Conscious Sedation
If an anesthesiologist is doing the conscious sedation and is documenting the monitoring of all
the vitals as expected for someone under anesthesia, the anesthesiologist may bill for the
service using the anesthesia codes. Documentation is expected to be in place for this service
to qualify as anesthesia.
Oral Surgeons or Dentists should bill conscious sedation with the appropriate CDT codes:
Epidural Anesthesia
Use appropriate CPT code range for epidural anesthesia.
Intravenous Analgesia
Intravenous Analgesia is defined as the administration of analgesic, narcotic, neuroleptic, hypnotic or amnesic agents for rendering a patient insensible to pain during surgical, obstetrical and certain other medically necessary procedures.
Benefits for the administration of intravenous analgesia is content to the administration of
anesthesia. Local Infiltration, Digital Block Anesthesia, Regional Block Anesthesia (Spinal,
Saddle, Caudal Blocks) by the Surgeon or Assistant Surgeon When administered by the
surgeon or assistant surgeon, charges for these procedures are considered to content of
service.
Local Infiltration, Digital Block Anesthesia, Regional Block Anesthesia (Spinal, Saddle,
Caudal Blocks)
When administered by the surgeon or assistant surgeon, charges for these procedures are
considered to content of service.
If the nerve block is the mode by which anesthesia and pain control are administered, it is
considered part of the anesthesia and the anesthesia code should be billed.
Note: Time units do not apply certain codes. The allowance is a flat fee. Please follow
appropriate billing guidelines.
We only accept one claim from one provider per labor and delivery encounter. Do not split
charges or codes to report the services of more than one professional involved in the care.
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Services Not Related to Anesthetic Administration
When the anesthesiologist/anesthetist performs a service not related to anesthetic
administration, the services must be billed under the appropriate CPT code which describes
the service.
Bilateral Procedures Effective for dates of service 6/1/2020 and after, providers will need to bill bilaterally on 1 line,
instead of the 2 lines as they have been familiar with for BCBSNE processing.
• Bilateral surgery code billed on 1 line with modifier 50 with 1 unit
o DO NOT bill bilateral surgery code on 2 lines (one with a modifier 50 and one
without)
• Radiology services that can be performed bilaterally should be billed using modifier 50 with
one unit and on one line item – modifiers LT and RT should not be used
Prior to 6.1.2020
• Bill bilateral procedures on two lines with modifier-50 on the second line.
• Claims processed in Corelink will price the 1st line at 100% and the 2nd line at 50%; total
allowance 150%
• Claims processed in HealthRules while we are still requiring two-line submission on a
bilateral surgery will process as follows:
Line with modifier -50 will be priced at 150%
Line with no modifier will be priced at $0
Total allowance 150%
For FEP CareFirst claims prior to implementation:
• Bill bilateral procedures on two lines with modifier-50 on the second line.
• Claims processed in Corelink will price the 1st line at 100% and the 2nd line at 50%; total
allowance 150%
• If the 150% profile is greater than billed charge, the excess will be reflected in the
amount on line 2
Birthing Centers Birthing Centers are to bill on the CMS 1500 using the facility NPI in Box 24J and birthing
center name in Box 31. Procedure codes must have the SB modifier. Contracted birthing
center facility charges are separately payable in addition to the professional provider’s charge.
Blue Card and Medicare The following are guidelines for the processing of traditional Medicare-related claims:
When Medicare is primary payor, submit claims to your local Medicare intermediary.
All Blue claims are set up to automatically cross-over to the member’s Blue Plan
after being adjudicated by the Medicare intermediary.
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Include the prefix as part of the member identification number. The member’s ID will include the
prefix in the first three positions. The prefix is critical for confirming membership and coverage,
and key to facilitating prompt payments.
When you receive the remittance advice from the Medicare intermediary, look to see if
the claim has been automatically forwarded (crossed over) to the Blue Plan:
• If the remittance advice indicates that the claim was crossed over, Medicare has
forwarded the claim on your behalf to the appropriate Blue Plan and the claim is in
process. DO NOT file the claim to BCBSNE.
• If the remittance advice indicates that the claim was not crossed over, submit the
claim to BCBSNE with the Medicare remittance advice.
• In some cases, the member identification card may contain a COBA ID number. If
so, be sure to include that number on your claim.
• Verify claim status by submitting a Claim Status Inquiry on NaviNet, or by calling
GABBI (800-635-0579).
Expect to receive payment:
Claims submitted to the Medicare intermediary will be crossed over to the Blue Plan only after
they have been processed. This process may take up to 14 business days. This means that the
Medicare intermediary will be releasing the claim to the Blue Plan for processing about the
same time you receive the Medicare remittance advice. As a result, it may take an additional
14-30 business days for you to receive payment from the Blue Plan.
What to do in the meantime:
If you submitted the claim to the Medicare intermediary/carrier and haven’t received a response
to your initial claim submission, don’t automatically submit another claim. Rather, you should:
• Review the automated resubmission cycle on your claim system.
• Wait 30 days.
• Check claims status before resubmitting.
Sending another claim, or having your billing agency resubmit claims automatically, slows
down the claim payment process and creates confusion for the member.
Blood sugar monitoring billing guidelines When billing the hemoglobin A1C lab test CPT codes, providers must also bill the associated
CPT Category II codes which represent results of the test in the form of a range of values. We
will not reimburse provider offices for lab services without submission of the appropriate CPT II
code. Please refer to the American Medical Association for correct billing and coding
guidelines.
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Breastfeeding Support Supplies and Lactation Counseling
Breast Pump Billing Guidelines
Breast pump and supplies benefits must be submitted with the mother as the patient. BCBSNE does not provide breast pump benefits to the baby. The HCPCS code for the breast pump must be appended with modifier RR or NU to indicate rental versus purchase. Benefits will be provided for one pump per pregnancy, at no cost to the member. This includes pump and supplies included in a starter kit. Replacements and additional supplies are not covered. Because federal law mandates 100% coverage for breast pumps, BCBSNE does not allow providers to balance bill members for any of the breast pump models. Providers are not allowed to have members sign waivers accepting additional liability and BCBSNE will not accept any such waiver.
FEP members must obtain breastfeeding pump kits by visiting www.fepblue.org/maternity or by calling 800-411-2583.
Breastfeeding Support and Counseling Billing Guidelines
Lactation services, including breast pumps and supplies, provided to a covered member during an inpatient hospitalization are considered inclusive in the reimbursement made to the hospital and cannot be billed separately.
Cancelled Procedure When a patient is admitted as an inpatient for surgery or some other specific treatment, and the
procedure needs to be cancelled due to medical circumstances with the patient, and the patient
is discharged, BCBSNE will pay the case at the contracted rate for the DRG category of that
stay.
Case Management/Care Plan Oversight Services Case Management codes 99366-99368 and Care Plan Oversight Services codes 99374-99380
are not separately reimbursed. They are considered content of service and no additional
reimbursement is allowed regardless of whether they are submitted with another E and M
service. The denial is provider liability.
Casts and Strapping Initial Cast Application during fracture care including closed, percutaneous, open, or
dislocations includes the application and removal of the cast or traction device. Casting or
traction is an integral part of fracture care and should not be reported separately.
Casting, splinting, and strapping should only be reported when a fracture, dislocation, injury, or
strapping is the method of treatment as an initial service without definitive procedure or
treatment.
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Casting and Strapping Supplies
Following CMS, casting and strapping supply codes should be reported using the appropriate
Q codes when billing for cast application. Supplies are reimbursed for casting and repairs only.
Catheterization Simple catheterization is considered part of the “global charge” to an emergency room, office
visit or inpatient room charge. No additional reimbursement is allowed.
Cerumen (Ear Wax) Removal When billing an earwax removal in addition to an E & M service, the ear wax removal will be
denied as content to the E & M Code. Ear Wax cleaning is reimbursable in the absence of an
E & M service with appropriate coding. If both ears are cleaned, bill as a bilateral service on
one line with modifier 50.
Chemotherapy Chemotherapy Drugs
The chemotherapy drug used must be indicated by the specific HCPCS code. If there is not a
specific HCPCS code for the chemotherapy drug, use an unlisted J code and include a valid
National Drug Code (NDC) number.
Chemotherapy Administration Procedure Codes 96400-96549
Chemotherapy administration procedure codes will be considered for payment when the
service was performed by a physician. If the service was performed by a nurse, the service is
considered global and will be denied.
Monitoring services by the physician are not covered.
When chemotherapy administration is performed in a place of service other than the office, the
claim will pend for review for content of service determination. If the service is performed by a
nurse in a setting other than the office, the service is considered global and will be denied.
When a heparin flush and chemotherapy are administered on the same day, the heparin flush
will be considered content of service and no additional reimbursement will be allowed.
Separate reimbursement is not provided for supplies used in the office setting for
chemotherapy services. Supplies necessary for the delivery of chemotherapy are already
considered within the reimbursement level for the services performed.
Co-Surgery - see “Surgery Guidelines”
Consultation Codes BCBSNE will not accept CPT codes for consultation (99214-99245 or 99251-99255). These
consultation codes will be noncovered as provider liable services regardless of the place of
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21
service. The denial reason will instruct the provider to resubmit with the most appropriate
Evaluation and Management (E & M) code.
Services in the Office or as an Outpatient
These services should be submitted using the new or established patient office or other
outpatient visit codes. New and established patient visit criteria remain according to the CPT
definition.
Services in the Emergency Room
When a service takes place in the emergency room, the service may be submitted with either
an appropriate E&M ER visit or as an outpatient visit E&M using the appropriate place of
service (POS)code. Documentations must support the CPT code definition.
Services during Observation
Only the admitting physician can use the initial observation care codes. Other physicians
performing a service should use the new or established patient office or other outpatient visit
codes.
Inpatient Stay
The first time a physician sees a patient in consultation, an initial hospital care code (99221-
99223) may be billed regardless of when the visit occurs during the inpatient stay. There may
be multiple initial hospital care codes on the admit date or other dates, depending on the
physician(s) who assesses the patient in consult. However, there should never be more than
one initial hospital care code per physician. Bill subsequent visits to the patient using
subsequent care hospital visit codes (99231-99233).
When a second physician sees a patient as an initial consult and all other required components are performed and documented, an initial hospital care code may be used (99221-99223).
If the criteria for an initial hospital care code is not met and the documentation and criteria support a subsequent hospital care code (99231-99233), those codes should be used even if an initial care code has not been submitted by that physician. Rarely would code 99499 (unlisted E and M service) be used if documentation does not meet criteria for subsequent care. Documentation must establish that a medically necessary service was rendered and where the service took place.
Services in a Nursing Facility
The first time a physician sees a nursing facility patient in consult, an initial nursing facility care
code should be billed if he or she is the admitting physician, regardless of when the visit occurs
during the nursing facility stay. Other providers seeing the patient should be subsequent care
E&M codes.
The admitting physician may append modifier Al to the initial nursing facility care code to
identify the admitting physician of record. There should only be one initial nursing facility care
code with modifier Al. Any additional initial care codes with this modifier will be non-covered as
a duplicate service.
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When a second physician sees a patient as an initial visit and all the required components are
performed and documented, a subsequent nursing facility care code should be used.
subsequent nursing facility care code, those codes should be used even if an initial code has
not been submitted by that physician. Only rarely would code an unlisted E and M service be
used.
Contrast Media Low and High Osmolar Contrast Agents
Low and high osmolar agents are used with the appropriate range of CPT codes.
Low osmolar agents (i.e. Isovue) are used primarily in patients with sensitivities to the high
osmolar agents or patients whose medical condition (i.e. cardiac disease, asthma) warrants
the use of the low osmolar agent. BCBSNE currently recognizes and allows benefits for the
low osmolar agents. If you are working with the low osmolar agents, you should check the
HCPCS manual.
Codes for “radiopharmaceutical” agents should not be used to bill for the low or high osmolar
(i.e. Hypaque) “contrast” agent. These are two separate and distinct types of agents and the
appropriate codes should be used for the type of agent used.
High osmolar agents are already calculated into the RVU and reimbursement rate for each
code. The cost of these agents is “content” to the procedure. Therefore, charges for high
osmolar agents should not be billed.
Radiopharmaceutical Agents
Radiopharmaceutical Agents should be billed with the appropriate range of CPT codes. When
billing for a radiopharmaceutical, you must be as specific as possible with your coding or the
claim will be returned.
Include the name of the radiopharmaceutical used and bill under the appropriate code in the
HCPCS manual.
Do not use an unlisted code as they do not identify the specific agent used. Since HCPCS now
carries a large volume of codes that identify these specific agents, the specific code (if
available) must be used rather than the unlisted code.
Some agents have medical policies tied to them and others may be affected by a policy in the
future.
The introduction of a needle or intracatheter, vein used as the delivery mode for the
radiopharmaceutical contrast agent is incidental and will be denied as such. Because this is a
necessary part of delivering the radiopharmaceutical agent, it is already considered and is
included in the calculation of the allowance for the code.
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Note: When claims are returned requesting more information, do not just attach the pharmacy
slip for the agent or just give the radiopharmaceutical name. This does not complete the coding
process because you still have not assigned the specific code for that agent. This is considered
improper coding. When there is a specific code for the agent that is the code that should be
used.
Another resource would be to contact your dispensing department for information on the agent.
They should be able to provide you with both the trade name and the radiopharmaceutical
agent’s name. Using that, you could then find the HCPCS code.
Critical Care Codes Critical care services should be reported following AMA CPT Coding Guidelines. Add on code
99292 must be performed by the same physician that is reporting 99291. Critical care codes
apply only to professional services and are not applicable to facility services provided in the
emergency department. Critical care codes will not be reimbursed when submitted on a UB04
claim.
Developmental Testing Developmental testing is normally considered part of a preventative medicine visit. If CPT
codes for developmental screening/testing are billed with a routine diagnosis, along with a
preventative medicine visit, the developmental testing will be denied as content to the
exam.
Diabetes Education Providers that can provide these services are:
• Certified Diabetes Educators (CDEs) working independently, in a medical office setting
or in a facility whose program is not recognized by the American Diabetes Association
(ADA)
• Individuals working in a facility whose program is recognized by the ADA
Note: Diabetes education must be ordered by a physician and must be medically necessary.
For information on how to join the BCBSNE network – please see the information on our
website Credentialing Information for Providers | BCBSNE (nebraskablue.com)
Dialysis Bill dialysis services on a UB04 claim form. All dialysis claims, and services must be
submitted once a month, to include services rendered during that month. Bill one date of
service and 1 unit per line.
The rates specified in the provider contract for the covered services listed is an all-inclusive per
treatment rate including drugs, immunization and any other service. Any drugs, immunization
or other services will not be separately reimbursable. If more than one code is billed on any
given day the higher dollar allowance will be paid.
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Use valid and acceptable Revenue Codes to assess the charge for Dialysis Services.
Hemodialysis
For Hemodialysis services, providers may bill up to three times per week. If it is necessary to
dialyze the patient more than three times per week, then appropriate documentation of the
medical rationale in the medical record must be submitted with the claim and the claim will be
reviewed for medical necessity. BCBSNE, or the applicable Blues Plan, will determine whether
services are Medically Necessary. Services will not automatically be considered Medically
Necessary because they have been ordered or provided by a Provider. If medical rationale is
not provided, the claim will be denied.
Peritoneal Dialysis
Continuous Ambulatory Peritoneal Dialysis (CAPD): Variation of peritoneal dialysis where
peritoneal membrane is used as a filter. CAPD is generally done several times a day, requiring
a bag of solution attached to the peritoneal catheter. The solution is left in the peritoneal cavity
to exchange toxins, then drained. This occurs 3-4 times during the day and takes 30-40
minutes for each exchange.
Continuous Cycler-assisted Peritoneal Dialysis (CCPD): Peritoneal dialysis which requires
a machine called a cycler to fill and drain the abdomen 3-4 times usually during sleep. For
Peritoneal Dialysis services (both CAPD and CCPD), providers may bill appropriate CPT Code
according to the provider contract.
Discontinued Services Professional
Discontinued services should be appended with appropriate modifier and are reimbursed at
50% of the professional fee schedule.
Institutional
When a surgical case is discontinued in an ASC/outpatient hospital setting, the proper
modifiers must be used. Discontinued procedures are priced at 50% of BCBSNE’s allowed
amount.
Emergency Room Services See “Outpatient and Emergency Room Services.”
Evening, Weekend or Holiday Office Hours BCBSNE does not reimburse at a higher rate for non-typical office hours.
Fracture Care See “Casts and Strapping.”
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Genetic/Molecular Test Coding Effective August 1, 2021
BCBS Nebraska will expand the requirements for billing of genetic and molecular testing. In
accordance with the Reimbursement Policy for Genetic/Molecular Test Coding, all providers
billing for genetic and molecular testing services will be required to adhere to the coding
recommendation in the Concert Genetics portal.
The portal can be accessed here: join.concertgenetics.com/BCBSNE
The quality and billing integrity requirements in the reimbursement policy will be facilitated by
Concert Genetics--our partner and a software and managed services company that promotes
health by providing the digital infrastructure for reliable and efficient management of genetic
testing and precision medicine.
We are asking you, our laboratory partner, to do the following:
• Register with Concert Genetics • Self-report on quality metrics in a common framework supplied by Concert • Verify accuracy of test catalog and view coding recommendations and fee schedule • Utilize Concert’s recommended codes when billing for genetic and molecular tests
Hospital-Acquired Conditions (HAC) and Never Events Policy Reminder
and Update
1. Never Events are defined as adverse events or errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients.
• Performance of wrong procedure (operation) on correct patient • Performance of procedure (operation) on patient not scheduled for surgery • Performance of correct procedure (operation) on wrong side of body parts • Leaving sponge, gauze or surgical instrument in body after surgery
2. The terms “HAC” and “Never Events” are not used interchangeably.
• HAC is defined by CMS https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/icd10_hacs.html
3. POA stands for present on admission.
4. Acute care inpatient facilities include all acute general hospitals, children’s hospitals,
critical access hospitals, long-term acute care hospitals and acute rehabs.
5. Skilled Nursing Facilitates (SNF) and Veteran’s Administration Medical Centers (VAMC) are exempt from this policy.
6. All participating acute care facilities are not permitted to receive or retain reimbursement
for inpatient services related to Never Events.
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7. All participating acute care facilities are required to hold members harmless for any inpatient services related to Never Events.
8. BCBSNE follow Medicare’s definition of Never Events/POA/HAC: CMS.gov
9. Post-payment audits are generally conducted as a desk review at BCBSNE of selected
medical records. Please refer to Section 14 Provider Audit and Special Investigations Unit (SIU) in the General Policy and Procedure Manual.
Independent Clinical Laboratory See “Ancillary Billing Guidelines.”
Inpatient Services Services Provided by another Facility
Charges for non-professional services provided by any provider in conjunction with an acute
care stay should be included on an inpatient claim. These charges are considered content of
that inpatient stay and are included in the reimbursement amount for that stay.
Services provided during a stay at a freestanding skilled nursing facility may be billed on an
outpatient claim if the skilled nursing facility does not normally provide such services and the
facility is allowed contractually to bill for such services.
A patient cannot be considered an inpatient at one facility and an outpatient at another facility
during the same period.
Professional Services
The professional component must be billed separately on a CMS 1500 claim form under the
name and NPI number of the rendering provider.
Interim Billing Submit interim bills with the appropriate third digit in the Bill Type (xx2-xx4) as stated in the
UB04 Manual in FL 4. Enter a Patient Status Code of 30 in FL 22. Submit billings in
chronological order.
Submit all interim billings to BCBSNE even if the charges are paid in full by another payer. The
claims are posted to the patient’s claim history and may be used to credit out-of-pocket
expenses such as deductible and coinsurance.
When an interim claim is prepared, be sure to coordinate the “Bill Type” and the “Discharge
Status” for the first, continuing and final claims. Interim inpatient claims (bill types xx2 and xx3)
should not be for time periods less than 30 days and should contain patient status code 30.
Billing periods should not over-lap.
Inpatient
Where an appropriate interim inpatient bill is submitted, and when a specific
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Inlier/Outlier Contracted Rate has been established for the DRG category for that claim, the
first interim claim will be paid based on the contracted rate calculation. Subsequent interim
claim(s) reimbursement will be made via the combined calculation of the payment amount(s)
made on the previous claims(s) plus any additional amounts due for the current claim based on
the resultant DRG category of the billing combination process. The final payment (or refund) on
the claim will be based on the regrouping of all previous interim claim data and all previous
payments made subject to the reimbursement amount for the final DRG category.
Outpatient
Interim billings may be submitted for outpatient services that are expected to occur over a
period (i.e., physical therapy, cardiac rehabilitation, etc.). Appropriate use of the third digit of
the bill type code is essential to proper claim payment.
Intraoperative Monitoring Report 95940-95941 when continuous attendance is required. The time documented on the
claim only includes actual time spent monitoring and excludes time to set up, record and
interpret base studies and to remove electrodes at the end of the procedure. When the service
is performed by the surgeon or anesthesiologist the professional services are included in the
surgeon’s or anesthesiologist’s primary service code(s) for the procedure and are not reported
separately. Do not report these codes for automated monitoring devices that do not require
continuous attendance by a professional qualified to interpret the testing and monitoring.
Please see the CPT professional edition manual for further coding explanation. It is also
beneficial to review the medical policy (MedPolicy Blue) and use appropriate POS as well as
correct modifiers.
Intravenous Analgesia See “Anesthesia Guidelines.”
Invoices When billing a charge that requires an invoice, make sure the invoice meets the following
criteria. Failure to follow these instructions may result in the claim being returned or denied.
• Invoices that do not coincide with the date of service (within reason) • Invoices that are not clearly marked as to what charge it coincides with on the claim • Invoices that are not legible • Provider to Member invoices are not acceptable • Packing slips, catalog pages or order forms are not acceptable • Charges for shipping, handling, or tax will not be reimbursed • If a claim has multiple lines requiring an invoice, indicate the page and line number for each charge on the invoice
• Information on the invoice should not be removed, blacked out or omitted
Itinerant Surgeon See “Surgery Guidelines, Proration.”
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Late Charges See “Replacement Claims.”
Leave of Absence/Bed Hold When a Leave of Absence Day (or days) is incurred:
• Record the applicable number of leave days in Form Locator 8 (non-covered days)
using Revenue Code 018X
• Record the number of covered (billable) days in Form Locator 7
• The total of the days in Form Locators 7 and 8 must equal the span of days in Form
Locator 6
• A charge for the leave day(s) is not reimbursable
Leave days (member not in facility) are not reimbursable.
Locum Tenens See the “Provider Responsibility” section of the General Policies and Procedures Manual.
Maternity Claims See “Obstetrical Services Guidelines.”
Medical Records See the Medical Record Standards.
Medical/Surgical Supplies When provided in physician’s office are considered content of service and not separately
reimbursed.
Moderate Sedation Please see “Conscious Sedation” under the “Anesthesia billing Situations, Specific” section.
Nerve Blocks See “Anesthesia Guidelines.”
Obstetrical Anesthesia See “Anesthesia Guidelines.”
Obstetrical/Maternity Service Guidelines Professional
“Obstetrical Guidelines” include:
• Definitions
• Diagnosis Codes
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• Obstetrical Complications:
- External Cephalic Version
- In Hospital Treatment of Complications
- Multiple Deliveries
- Procedure Codes Global vs. Non-Global Services
- Partial OB Care
- Total OB Care
Global vs. Non-Global Service:
Global maternity services include antepartum care, delivery, and postpartum care. The total
global service is submitted after delivery with the delivery date as the date of service.
Non-global maternity services are payable as separate services outside of the total global
service.
Initial OB Visit
Consistent with American Congress of Obstetricians and Gynecologists (ACOG)
recommendations, BCBSNE considers the “Initial OB visit” the visit when the OB
(prenatal/antepartum) record is begun and therefore part of “Global OB care”.
Obstetrical Complications
For complex obstetrical patients with frequent antepartum visits or a complicated delivery, bill
the appropriate procedure code with a modifier-22 and include medical rationale (example:
repair to a third- or fourth-degree perineal tear that occurs during delivery). Your claim will be
reviewed to determine if extra reimbursement is warranted.
Services such as hemorrhage, hypertension, pre-eclampsia, infections, diabetes, etc., are not
considered part of the global maternity services. Those services must be billed using the
appropriate E and M code(s) and not the antepartum visit code.
Standby Services (CPT 99360)
Standby services during a C-section are not payable unless the standby physician performs
some service/procedure during the delivery.
Bill the specific services/procedures performed rather than using the standby code. Standby
services (CPT 99360) are a contract exclusion for BCBSNE and will be denied as member
liability. If services are being rendered in a facility which requires “stand by” (for example “at
time of delivery”), the member should be advised by the facility and/or the physician that this
charge will be their liability.
Newborn Delivery and Initial Stabilization (CPT 99464)
Attendance at delivery and initial stabilization of newborn (CPT 99464) should not be billed to
BCBSNE unless medically necessary. If documentation substantiates the medical necessity for
99464, the charges will be payable. If the claim is denied as not medically necessary, the claim
will be provider liability.
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NICU Level of Care
See General Policies and Procedures Manual.
External Cephalic Version
The reimbursement for total obstetric care does not include medically necessary external
cephalic versions when performed after the 34th week of pregnancy. Reimbursement is limited
to no more than two external cephalic version procedures during any one pregnancy.
In-Hospital Treatment of Complications
When hospitalization is required for severe complications during either the antepartum or
postpartum period, in-hospital medical care fees may be made for the management of the
condition. Payment will be subject to medical necessity review of medical records which
support the additional care and direct attendance.
Multiple Deliveries
Delivery method Twin A Twin B
Both twins
delivered
vaginally
Bill 59400 or
59610
Bill 59409 or 59612
modifier-59
Both twins
delivered by
caesarian
Bill 59510 or
59618
Bill 59514 or 59620
modifier -59
Provide operative report and/or
documentation for special consideration
and additional reimbursement
One delivered
vaginally & one
by caesarian
59400 59514 modifier -59
Partial OB Care
In those instances when it is inappropriate to bill global OB care (i.e., transfer of care, coverage
termination mid-term of the pregnancy, spontaneous abortion situations), the antepartum care
should be billed at the time of service and within the timely filing period using the applicable
CPT code as follows:
Visits Description
1-3 Bill the appropriate E and M code for each visit separately
4-6 Bill 59425 on one line
7 or more Bill 59426 on one line
When billing 59425 or 59426, list the date the patient was seen for antepartum care. Example:
If the antepartum visit was on May 15, you would put May 15 in both the FROM and TO
DATES in Box 24A of the CMS (CMS 1500 claim form).
Box 24 G should always have a unit value of “1.” Include the date of delivery, if known, in the
comments section of the claim.
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Transfer Reason How to Bill
Patient is transferred permanently from one practitioner to another (different TINs)
The initial physician should bill for the prenatal care provided prior to the delivery using the Partial OB billing guidelines.
The claim must clearly indicate a transfer of the patient to another physician. On a paper claim, note the transfer below the last item charge. For electronic filers, note the transfer in the available narrative field. Please indicate the name of the physician who will be assuming care for the patient.
Patient’s transfer of care is between practitioners under the same tax ID number
Regardless of location or specialty - we will accept only one claim for the total OB care. It is not permitted for an OB provider to bill total OB care when a provider under another tax ID provides partial OB services to the patient. If a physician under a different tax ID than the primary OB renders services (ex. delivery only) that provider must bill separately his or her services according to partial OB billing guidelines.
OB provider changes
tax ID’s
A practitioner changes TIN (e.g. transfers to another clinic) and continues to see a patient who was seen under the previous tax ID, transfer of care guidelines applies.
Member changes
insurance carriers
during
the pregnancy
Depending on services rendered, the provider may bill partial OB care or global.
Postoperative Pain Control
Continuous infusion of anesthetic agents to operative wound sites using an elastomeric pump
is scientifically validated as a technique for postoperative pain control for surgeries typically
requiring oral or parenteral narcotics for pain relief.
Trade names of elastomeric pump and associate catheters that have received approval for
marketing from the U.S. Food and Drug Administration (FDA), include, but are not limited to,
Infusor SystemTM, On-Q® Post Op Pain Relief System, On-Q SoakerTM catheter delivery
system, and the Pain BusterTM Pain Management System.
While the charge for the elastomeric pump may be covered, the insertion will be denied as
global to the surgery.
Institutional “Obstetrical Guidelines” include:
• Mothers and Newborns
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• Obstetrical Complications
Mothers and Newborns
Submit separate claims for a mother and her newborn.
Obstetrical Complications
Standby services during a C-section are not payable unless the standby physician performs
some service/procedure during the delivery. The specific services/procedures performed
should be billed rather than using the standby code of 99360.
Outpatient and Emergency Room Services Outpatient Charges Related to an Inpatient Admission
Emergency room visit leading to an inpatient admission
If the patient is seen in the emergency room with in twenty-four hours of an inpatient admission
for the same diagnosis, the charges for the emergency room should be included on the
inpatient claim.
Include outpatient charges on the UB04 as part of the inpatient billing.
Multiple visits – same day
If a patient visits the emergency room more than once on the same day, the visits can be rolled
into one if the reason for the visit was the same diagnosis.
If each visit was caused by a different diagnosis, bill the charges separately.
Non-emergent and scheduled admissions
Include any outpatient services related to the same condition and reason for the admission that
were provided within 24 hours prior to the inpatient admission as part of the inpatient billing.
A4649 billed on an outpatient facility claim will be denied as inclusive.
Note: Critical Access Hospitals may bill the ER charges separate from the Inpatient claim.
Observation
Observation services refers to the period of treatment:
• when the physician is evaluating the patient’s medical condition to determine whether
the patient can be released from the outpatient department or admitted to the facility as
an inpatient or transferred to another facility OR
• following an outpatient procedure when the physician is evaluating the patient’s medical
condition to determine whether the patient can be released from the outpatient
department.
A physician must justify and provide the order on the patient. Medical record documentation
must prove that the patient was admitted to observation.
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BCBSNE follows the Medicare definition, which requires the use of a bed and nursing services.
Observation is NOT:
• A substitute for an inpatient admission
• For continuous monitoring
• For medically stable patients who need diagnostic testing or outpatient procedures
• For patients who routinely need therapeutic procedures provided in an outpatient setting
• For patients waiting for nursing home placement
• To be used as a convenience to the patient, his or her family, the hospital or the
attending physician
• For routine prep or recovery prior to or following diagnostic or surgical services
Also note the following:
• Revenue code 761 is for a treatment room and should not be used in place of an
observation room.
Observation services will be paid as an outpatient service type under the outpatient provider
contract provisions.
Observation should be billed all on one line (even when it is spread across two dates). Ex:
Patient is under 24 hr. observation. They come in at p.m. on the June 1st and are released at
p.m. on June 2nd. This should be billed on one line not on two separate lines.
NOTE: Revenue Code 769 is not valid for reporting observation services and will be returned
for proper coding
Inpatient Following Observation
• Bill observation services that convert to an inpatient admission on the same UB-04 form as the inpatient admission.
• Enter the outpatient observation admission date in Form Locator 6 as the beginning (from) date of the UB-04 form.
• Enter the date on which the patient was admitted for inpatient services in Field Locator 12
• Enter the time at which the patient was admitted for inpatient services in Field Locator 13; hours are entered in two-digit military time (e.g., use 14 for 2:00 p.m.)
Outpatient Surgical Encounters- Multiple Procedures (also reference
Multiple Surgeons/Multiple Surgical Sessions)
When one or more separately codable surgical procedures are performed in one outpatient
surgical encounter please be advised:
• All applicable surgical CPT procedure codes should be shown on the claim
(unless coding rules indicate one or more of the procedures are content of a code that
better describes that procedure)
• When a surgical procedure is performed bilaterally, the CPT surgical procedure code
should be shown once on the claim with the appropriate modifier
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Oximetry Regardless of what other charges are billed, pulse oximetry (94760-94761) will be denied as
content of service.
Pathology The usual fee for pathology is generally considered to include the costs of equipment and
supplies used in performing a test or examination as well as the performance of the test and
the professional evaluation and report.
For hospital-based physicians, the usual professional fee is expected to represent just the
charge for examination and opinion of laboratory specimens (collected at the expense of a
facility or institution) that require a pathologist for interpretation. Payment for these professional
interpretations is generally considered to be available only for anatomical tests.
When all-inclusive codes exist for multiple component tests, the all-inclusive code must be
used.
Modifier 91 should be used when billing a pathology code more than one time by the same
physician on the same date of service.
The collection and or handling fee of a specimen is considered content of service to the
laboratory/surgical procedure and/or the level of service being performed, regardless of
whether the physician bills for the laboratory tests or if the specimen is sent to an outside
laboratory.
Specimen collection and handling codes deny as content to service, regardless if billed alone
or with other charges, and include 36591, 36592 and 99000-99002.
Venipuncture CPT 36415 may be separately billed and reimbursed related to outpatient
services only. If performed as part of inpatient services, the fee is considered inclusive to the
lab testing.
If the revenue code is not 0311 or 0923 and the HCPC is equal to codes P3000, P3001,
Q0091, 88141, 88142, 88150, 88152, 88155, 88164 or 88166, then it will be rejected.
Pharmacy See “Ancillary Billing Guidelines.”
Physical Rehabilitation (Acute Inpatient Programs) For information on benefit provisions - see Physical Rehabilitation in the “Member Benefits”
section of the General Policies and Procedures Manual.
Physical Rehabilitation Outpatient: Billing for timed units
When billing for outpatient rehab services and units described as “each 15-minute,” please
adhere to the following guidelines when determining the total number of units to bill:
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• When only one service is provided in a day, providers should not bill for services
performed for less than 8 minutes.
• For any single-timed CPT code in the same day measured in 15-minute units, bill a
single 15-minute unit for treatment greater than or equal to 8 minutes through and
including 22 minutes.
If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes,
through and including 37 minutes, then 2 units should be billed.
Use appropriate time intervals for units.
When more than one service, represented by 15-minute-timed codes, is performed in a single day, the total number of minutes of service determines the number of timed units to bill.
Physical Therapy See “Therapy.”
Prolonged Physician Service Prolonged Physician Service without face-to-face patient contact are considered “content of
service” and therefore, not separately reimbursable.
Professional Surgery Guidelines Assistant Surgery
CPT codes with an indicator of 2 allow an assistant. CPT codes with indicators 0, 1, and 9 in
the assistant surgery column do not allow payment for assistant surgeon. If the CMS indicator
is 0 and the service is denied, you may submit an appeal along with the appropriate medical
record documentation and the claim will be reviewed. Please refer to CMS Physician Fee
Schedule for assistant surgeon indicators.
Assistant Surgeon Modifiers
BCBSNE follows CMS guidelines on the use of assistant surgeon modifiers.
Assistant-Multiple Assistants During Surgery
The use of more than one assistant surgeon is subject to individual consideration and covered
only upon substantiation of medical necessity. Participating physicians agree to accept our
medical director’s decision in such cases.
Bilateral Surgeries
Modifier -50
Bilateral surgeries should be reported on one line with Modifier 50 on one line, with one unit.
Co-Surgery
Modifier-62
Under certain circumstances, the skills of two surgeons (with different skills) may be required in
the management of a specific surgical procedure:
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• The procedure when performed by co-surgeons requires that Modifier 62 be appended
o on both claims. A surgeon cannot be a co-surgeon and an assistant surgeon
during the
o same operative session, they can only bill for co-surgery or assistant surgery.
• Both surgeons will be reimbursed 62.5% of the allowable amount.
• Skills (specialty/taxonomy) of different surgeons are required for reimbursement of co-
surgery.
Global Surgery
BCBSNE follows global surgery as defined by CMS. The global surgery period can be found on
the CMS Physician Fee Schedule.
Major Surgical Procedures
Major surgical procedures have a ninety 90-day global period.
Minor Surgical Procedures
Minor surgical procedures have a 0–10-day global period.
Multiple Surgeries – Not ASC
When a surgeon performs multiple surgical procedures on a patient during one surgery,
BCBSNE reimburses the physician for the procedures based on Relative Value Unit (RVU).
We reimburse providers:
• 100 percent of the allowable amount for the procedure with the highest RVU
• 50 percent of the allowable amount for the procedure with the next highest RVU
• 25 percent of the allowable amounts for the third, fourth and fifth procedures in
descending order of RVU.
All additional procedures will be denied as content to the other procedures.
Post-Operative Care Only
If a provider other than the surgeon manages post-operative care only, their claim must be
billed with the surgical procedure code, the -55 modifier, and the date of surgery as the date of
service. For postoperative care only to be payable, the surgeon would need to bill their claim
with modifier -54.
Reimbursement for the post-operative care only (-54 modifier) will be at the lesser of the
charge or 10% of the contracted rate of the surgical procedure.
Surgical Care Only
Use the Surgical CPT code with -54 modifier to report surgical care only. We reimburse the
lesser of the charge or 90% of the contracted rate to the surgeon for surgical care only. Date
of service is the date of surgery.
Surgical Standby/Physician Attendance
Attendance/standby services are not covered. If a physician performs a service, the specific
CPT code that describes the service should be billed.
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Surgical Team
Modifier-66 A highly complex procedure requiring the concomitant services of several
physicians, often of different specialties, plus other highly skilled, specially trained personnel
and various types of complex equipment (e.g. patient requiring surgical correction of an ankle
fracture by an orthopedic surgeon, treatment of a head injury by a neurosurgeon and complex
laceration repair by a plastic surgeon all operating in the same surgical suite) is described with
modifier -66:
• Each physician’s claim should be submitted with modifier-66 indicating team surgery.
• Because each surgeon is operating independently, benefits would be determined as if
they were separate operative sessions.
Proration See “Surgery Guidelines, Proration.”
Radiology The usual fee for therapeutic radiology does not include:
• Consultations regarding need for radiotherapy
• Treatment planning
• Concomitant surgical, diagnostic radiology or laboratory services
Overreads/Second Interpretations
If more than one of the same X-ray is taken of a location (e.g., because patient moved or film
not clear) only one X-ray is considered payable, and the others would be considered content of
that service. If more than one physician interprets an X-ray, only one will be paid. BCBSNE
does not pay for “overreads.”
Professional/Technical Components
Professional and technical components together represent a global charge and should not be submitted with either 26 or TC modifiers. Modifier 26 identifies the professional component of a two-component service. Modifier TC identifies the technical component of a two-component service.
When both professional (modifier-26) and technical (modifier-TC) components are included in
the charge, representing a global service, the usual fee is considered to include the cost of
materials and technical operation costs as well as the professional fee for the administration of
diagnostic ultrasound/imaging and other high energy modalities.
Date of service for the professional component should be submitted with the same date of service as the technical component even if the professional service is performed on a different date. Both professional and technical components should be billed with the date of service that services were rendered.
Please refer to the Medicare Physician Fee Schedule (PPRVU) for services valid with modifier 26 and modifier TC. Radiology services with a PCTC indicator of 1 represent services that can have both professional and technical components.
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Repeated Radiology Procedures on Same Day
If more than one of the same X-ray is taken of a location (e.g., because patient moved or film
not clear) only one X-ray is considered payable, and the others would be considered content of
that service. Charges should be billed out as separate lines when the same radiology
procedure is repeated by the same or different doctor on the same day. Modifiers should be
used to indicate a repeat radiology service was performed.
Documentation may be requested by BCBSNE from the provider that supports the use of this
modifier. Please review the modifier definition according to CPT coding guidelines to assure it
is being applied correctly.
Bilateral Radiology Service
Payment for bilateral radiology service is based off CMS bilateral indicators found on the
Medicare Physician Fee Schedule (PPRVU). Radiology services reported as bilateral should
be submitted with 50 modifier and 1 unit on 1 line or RT and LT modifiers with 2 units. Payment
is based on each side.
Radiopharmaceutical See “Contrast Media.”
Rapid Flu Test Infectious agent antigen detection by immunoassay with direct optical observations; influenza is
covered. For Influenza A and B, (two tests) correct code with 2 units.
Reduced Services Use modifier -52 on a procedure code to reduce the allowance by 20%.
Resident/Students Patient services provided by a resident as part of their education and training are not billable by
the resident.
The teaching physician may bill for the applicable E/M visit under the teaching physician’s name and NPI number, using modifier GC (service furnished in part by a resident under the direction of the teaching physician) with the applicable CPT code to bill the service.
Robotic Assistance BCBSNE does not allow additional reimbursement for the use of any robotic surgical
assistance.
Rural Health Clinics This is a Medicare (CMS) designation. When BCBSNE is the primary payor, rural health clinics
(RHC) and Federally Qualified Health Centers (FQHC) must always file claims on a CMS 1500
claim form under the provider of service name, credentials and individual NPI with Place of
Service 72 using standard BCBS billing guidelines. BCBSNE does not follow CMS’s incident-
to-rules.
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When BCBSNE is the supplemental or secondary payor to CMS, you must include the
attending provider’s name and NPI and the CPT and/or HCPCS codes identifying the services
provided on the UB04. The claims should automatically cross over to BCBSNE from Medicare
and the RHC or FQHC will be paid directly if the appropriate information is on the claim. RHCs
and FQHCs should never submit Medicare supplemental/secondary claims on a CMS 1500.
If you have not received payment after 30 days of the CMS paid date on your remit, you should
check the claim status. If the claim has not crossed over from Medicare, you will need to submit
a UB-04 claim with the EOMB for processing.
Sepsis (Billing Guidelines) Effective September 1, 2021
Based on recommendation from JAMA, The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), sepsis should be defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. Patients are likely to have a prolonged hospital or ICU stay. As such, admissions with a diagnosis of sepsis but a stay of less than three (3) consecutive days will be denied for improper diagnosis. It is likely these cases are instead a rule out sepsis and more likely dehydration, urinary tract infection or other diagnosis that should be more accurately submitted. We will accept a sepsis diagnosis with an appropriate discharge status code for patients who expire or are transferred to other facilities or hospice with a diagnosis of sepsis resulting in a stay of less than three days.
Site of Service for Professional Reimbursement BCBSNE has implemented professional reimbursement based on site of service. BCBSNE will
determine the rate to pay (facility or non-facility rate) for covered services provided by a
participating professional based on the place of service (POS) code. This code is used to
identify the setting in which the patient received the face-to-face encounter with the physician,
non-physician practitioner (NPP) or another supplier.
Professional claims will be reimbursed according to facility allowances when they are submitted
with POS codes 19, 21, 22, 23, 24, 31, 51, 53 or 61. All other covered professional services will
continue to be reimbursed according to non-facility allowances.
Not all procedure codes will have a facility allowance. In some instances, BCBSNE may
choose not to use a facility allowance that the Centers for Medicare and Medicaid Services
(CMS) identifies for a procedure code. The non-facility and facility allowances that will be
applicable to BCBSNE professional claims will be identified in BCBSNE’s fee schedules.
Sleep Lab Independent Sleep Lab
CPT codes 95805, 95807, 95811 should be billed on the professional claim form with a place
of service 11 for clinic. Do not bill sleep lab claims with POS 81 Independent Lab. For technical
component billing, codes should be billed on the professional claim form with modifier TC and
under the lab’s name and NPI number. Professional component charges should be billed with
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modifier 26 under the physician’s name and NPI number. If a physician owns the clinic and
wishes to bill global, the appropriate CPT code should be billed without a modifier under the
physician’s name and NPI number.
Hospital-Based Sleep Lab
Sleep lab charges are billed under the hospital’s acute care NPI number, bill type 141, revenue
code 920, and the appropriate CPT code.
Speech Therapy See “Therapy.”
Standby See “Physician Attendance.”
Stat or After-Hours Laboratory Charges These are charges submitted to perform laboratory procedures immediately or outside
scheduled laboratory hours.
Benefits in addition to those allowed for laboratory procedures are not covered when such are
ordered to be performed “stat” or outside of the scheduled laboratory hours.
Stat 1 Testing / Rapid Service Time Stat 1 testing/rapid service time charges are not covered. If rapid service time is submitted, the
charge will be denied as “content of service.”
Therapy For information on therapy benefits (Occupational, Physical and Speech) see “Therapy” in the
Member Benefits section of the General Policies and Procedures Manual.
Inpatient Claims BCBSNE does not have any contract limitations for inpatient physical therapy.
Therapy modalities do not have to be billed out separately with a HCPCS code. Bill all charges
for therapy provided during the hospital stay with one charge applicable to the appropriately
assigned Revenue Code(s).
BCBSNE reimburses contracted therapists for all medically necessary covered physical
therapy, occupational therapy and speech therapy services when provided in a non-facility
setting according to the member’s contract/benefit plan.
• BCBSNE covers short-term rehabilitation services to meet the functional needs of
patients suffering from physical impairment due to disease, trauma, or prior therapeutic
intervention
• BCBSNE only covers physical therapy and occupational therapy for one-on-one
services
• BCBSNE does not provide coverage for group therapy sessions
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General Benefit Information Services and subsequent payment are based on the member’s
benefit plan and provider Agreement.
• A therapist/clinician must not merely supervise but must apply the skills of a therapist by
actively participating in the treatment of the patient during each Progress Report Period
• In addition, a therapist’s skills may be documented, for example, by the clinician’s
descriptions of their skilled treatment, the changes made to the treatment due to a
clinician’s assessment of the patient’s needs on a treatment day or changes due to
progress the clinician judged sufficient to modify the treatment toward the next more
complex or difficult task. Beneficiary’s diagnosis is not the sole factor in determining
coverage, the key is that the skills of the therapist were needed to treat the illness or
injury
• Amount, frequency, and duration must be reasonable under accepted standards of
practice
• Duration is identified as time in and time out or total time for each therapy
• A patient may have up to 4 units of physical therapy, 4 units of occupational therapy and
4 units of speech therapy daily
o Beginning June 1st, 2020 this should be submitted on the claims as 1 unit per
line by therapy type
Consistent with CMS:
• Unattended electrical stimulation will not be considered for reimbursement; the
appropriate codes should be used for wound healing of stage III and IV
• Electrical stimulation when using G0281 and G0282 for wound treatment and G0283 for
electrical stimulation is covered (All are subject to the modality limit)
• All other electrical stimulation for all other conditions is considered inclusive
Hot or cold packs: This service does not require the provider to have one-to-one patient
contact. The application of this modality is an integral part of a service or visit by CMS.
Therefore, the service for the application of hot or cold packs is a status B (bundled) code on
the Medicare Fee Schedule Data Base (MFSDB). Separate payment is not allowed for this
service.
BCBSNE does not reimburse:
• Dry hydrotherapy
• More than four modalities or units per therapist on a single date of service
• More than three modalities in addition to a PT or OT re-evaluation service
• Application of hot or cold packs
• Iontophoresis
• Whirlpool
Transplant Services Coverage for donor services will vary depending on the member’s contract. Under some
contracts services are only covered if the recipient is covered under a BCBSNE policy. For
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members covered under this type of policy, BCBSNE does not cover organ donation if the
recipient is not covered under a BCBSNE policy.
Under other BCBSNE member contracts, if the donor and the recipient are both covered under
the same policy then all services will be processed under the recipient.
Member eligibility and benefits should be verified.
Bone Marrow / Stem Cell Transplants:
All donor related services for allogenic bone marrow / stem cell transplants must be billed with
revenue code 819.
All donor related services for autologous bone marrow /stem cell transplants can be billed
either with revenue code 819 or under the appropriate revenue code based on the services
performed (i.e. 300 for lab, 320 for X-ray, etc.).
Cadaver Donor:
Donor services must be billed under revenue code 812 for all cadaver donor transplants.
Donor Maximums: Please check with Provider Service since coverage and restrictions can
vary.
Living Donor: Donor services must be billed under revenue code 811 for all living donor
transplants.
Living donor services must be billed with a donor diagnosis and must include the donor name
and relationship to the transplant recipient in Field Locator (FL) 80 of the UB04 or in Box 19 of
the CMS 1500 claim form.
In addition, Box 6 of the CMS 1500 claim form must indicate “Other”. The name of the donor is
needed to avoid possible duplicate denials since there may be more than one potential donor.
These claims should be submitted as paper claims. When submitted electronically they will
deny as duplicate.
Nebraska Organ Retrieval Services (NORS):
NORS performs the service of removal of organs from patients that have expired to be used for
transplants. Reimbursement for these services should be provided to the hospital and should
not be submitted to either the patient’s family or to BCBSNE.
Search Activation
Coverage for search activation fees are dependent on the member’s contract with BCBSNE.
Unlisted Procedure or Service Unlisted procedure codes have been designated to report services or procedures that do not
have a specific CPT/HCPCS code to identify the service/item provided.
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When billing an unlisted code, the claim must include a description of the service or item. You
will also need to include appropriate medical records (such as the operative report) for
services; and documentation of the item provided (including the make, model and
manufacturer) along with an invoice for equipment, supplies, orthotics/prosthetics.
If you are billing an unlisted code for a drug/biologic, you must provide the full NDC number on
the claim. When filing electronically, the NDC number must be submitted in loop 2410 and in
the following format: xxxxx-xxxx-xx.
Additional information Reimbursement for unlisted drug codes is based on AWP (Average Wholesale Price) or the
amount shown on the manufacturers invoice for a drug. Purchase Orders are not acceptable as
a cost invoice. Charges for covered drugs which are unlisted are reimbursed at the lesser of
billed charge or invoice cost.
Since there is no code to bill a 3ml vial of saline you can bill the code for a 10ml vial with your
charge or bill the item unlisted with NDC number.
When billing a specific HCPCS code, units should be calculated using the nomenclature associated
with the HCPCS code. If there is no valid HCPCS code that corresponds to the drug, then a J3490
miscellaneous code (along with an NDC number) should be used and the units calculated using the
NDC unit of measure.
Example: Cinvanti NDC 47426-0201-01, 130mg. The below calculation should be used when determining the number of billable units.
• The amount of drug to be billed is 130mg
• NDC unit of measure is per milliliter (ML)
• According to the NDC description for 47426-0201-01, there are 130mg of Cinvanti in
18ml of solution (130mg/18ml)
• Take the amount to be billed (130mg) divided by the number of MG in the
description
(130mg) 130/130=1
• Multiple the result (1) by the number of ML in the NDC description (18ml) to obtain
the correct number of billable NDC units 1x18=18ml. This number (18) should be
used in the unit field of the claim form to obtain proper reimbursement.
It is improper to bill an unlisted code if there is a designated CPT/HCPCS code available for the
service provided.
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Section 3: Home Medical Equipment, Home
Infusion, Home Health, and Hospice
Ambulatory Infusion Center (AIC) For services provided to BCBSNE covered members, nursing charges for services provided in
an ambulatory infusion center should be billed on a UB 04 as if the services were provided in
the patient’s home.
If the member has coverage through another BCBS Plan that does not cover nursing in the
home but will cover services in an AIC, then charges may be billed on a CMS 1500 using CPT
code 99601 and 99602 with POS code 12.
Apnea Monitor Use A4556 for electrodes for Apnea monitor (per pair) if monitor has been purchased. Use
A4557 for lead wires for apnea monitor (per pair) if monitor has been purchased.
If monitor is rented, electrodes and lead wires are already included in the apnea monitor
allowable and will not be separately reimbursed.
CPAP 12V battery and battery charger for continuous positive airway pressure (CPAP) machine are
each billed under E1399. Submit the manufacturers invoice with the claim. Purchase Orders
would not be an acceptable substitute for an invoice.
Date Span For rental equipment, providers need to bill for 30 day increments even at the end of the year.
When a rental is not needed for a full month, the number of units should be adjusted to align
with the number of days (partial month) that the member rented the equipment.
Drugs Dispensed or Administered See “Drugs dispensed in office.”
Equipment Rental Policy BCBSNE member contracts provide benefits for purchase or rental of various HME, up to the maximum benefit amount (MBA). HME providers who rent equipment to our members should identify rental of the HME by using the “-RR” modifier on the claim. Our general guideline for rental of HME is that we provide benefits for rental, up to the allowable purchase price, if equipment is medically necessary. This includes, but is not limited to, oxygen therapy equipment, ventilation equipment, CPAP devices and apnea monitors. The rental allowance is generally based on 10% of the purchase price allowance. Once the allowable purchase price has been met, we consider the equipment to be purchased with
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ownership transferring to the member. New rentals starting after 1/1/2019 will see changes in applied benefits, denied claims will no longer be applied to the purchase price allowance. When a rental unit is not needed for a full month the unit will be paid based on the time frame the patient has the unit. Providers should not be billing a full month and should only bill based on the time the patient has the unit.
Home Health Care Home Health Services provided to BCBSNE covered members must be preauthorized. Check
the member’s contract for benefits as some contracts have per-day limits on the allowed
number of home health care hours.
Documentation must include the physician order, nursing notes, and care plans. BCBSNE will
return the claim requesting this information if it is not submitted with the claim.
Additional Billing Instructions
Each day’s visit must be on a separate line. If more than one visit is performed on the same
day, you should combine the hours from both visits and bill the authorized hours on the same
line.
EXCEPTION: If you elect to bill authorized and non-authorized hours, you must split the
authorized and non-authorized hours on different lines. For example, if four hours of care have
been authorized and six hours of care were provided, you must split the care for example:
Line 1 Rev 552 S9123 4 units mm/dd/yy
Line 2 Rev 552 S9123 2 units mm/dd/yy
• Do not mix and match S and G codes for the same discipline on the same day.
• The Attending (Ordering) Physician Form Locator must be completed with the UPIN
number of the physician. (The Nebraska license number will not meet the billing
requirement.)
• Supplies and drugs must be billed separately on a CMS 1500 under the HME/Infusion
provider name, TIN and NPI number.
• Travel time includes all time to and from patient’s home to your office or to another
patient’s home
Home Infusion Billing Guidelines BCBSNE is Primary: When providing any services related to Home Infusion (Enteral or IV therapy), the Home Infusion or HME provider must bill the appropriate S code (S9208-S9214). Since the S codes include supplies and equipment and are paid on a per diem basis, providers must not line itemize or bill separately for any supplies or equipment. Equipment that is part of the per diem reimbursement includes, but is not limited to pumps, poles, tubing and dressings for the IV site. Equipment that are reimbursed outside the S-code per diem rates are:
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• A4222 Infusion Supplies for External Drug Infusion Pump • A4432 Ostomy Pouch, Urinary • A4483 Moisture Exchanger, Disposable
Home Medical Equipment or Home Infusion providers can line itemize any drugs or enteral formula on the same claim as the S code services. Nursing visits must be billed by the home health agency on a UB-04. S9340, S9341, S9342, and S9343 are per diem codes for Enteral Therapy. If a Home Medical Equipment, Home Infusion or Pharmacy provider sends supplies or meds to a physician’s office that are dispensed to the member, they must have a financial arrangement with the physician’s office to obtain reimbursement from them. If Medicare is primary & BCBSNE is secondary (secondary plan or Medicare supplement) B codes are acceptable. A home medical equipment provider who dispenses wheelchairs, canes, walkers, oxygen, etc. must bill these items with the appropriate HCPC code and modifier (-NU or –RR). S Codes with Description
Code Description
S9340 Includes home therapy, enteral nutrition, administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment. Enteral Formula and nursing visits are coded separately.
S9341 Includes home therapy, enteral nutrition via gravity; administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment. Enteral Formula and nursing visits are coded separately
S9342 Includes home therapy, enteral nutrition via pump; administrative services, professional pharmacy services, care coordination and all necessary supplies and
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equipment. Enteral Formula and nursing visits are coded separately.
S9343 Includes home therapy, enteral nutrition via bolus; administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment. Enteral Formula and nursing visits are coded separately.
The S (per diem) codes are payable regardless of whether the enteral nutrition is payable or not. The appropriate S code is billed in addition to the Enteral Nutrition codes (B4102-B4162) as separate line items. If there is no appropriate code for a specific enteral formula, the product should be billed using the NDC number and an appropriate unlisted HCPCS code and number of cans (as units). Formulas with a specific HCPCS code should be billed using that code. Units should be calculated based on the description of the HCPCS code (e.g. 100 calories = 1 unit). All S code per diem charges must have the appropriate date span and units. Billing one date of care with multiple units will result in the claim being returned. Specialty tubing for enteral feeding is payable outside of the S (per diem) code and must be billed using B4083-B4086. Nasogastric tubing and extension tubing are part of the per diem. B4034, B4035, and B4036 are per diem supply codes for enteral feeding and are inclusive to S9340, S9341, S9342, and S9343.
Box 24G Must indicate a unit of one
Box 31 Must read “Infusion Therapy Specialists” – do not indicate an individual’s name or credentials
Box 33 Needs to read: Practice Name Practice Address Practice City, State and Zip
Box 24J Your NPI is required
The S and B codes are reported in Box 24D on a CMS 1500 claim form. No modifiers are required on the S and B codes. Note: If an HME, Home Infusion or Pharmacy provider sends supplies or medicine to a physician’s office that are dispensed to the member, they must have a financial arrangement with the physician’s office to obtain reimbursement.
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Home Medical Equipment Rental Below is a list of HCPCS codes require an RR (Rental) or NU (Purchase) modifier or they will be returned for proper coding.
A4000 – A8999 A9900 – A9999 E0100 – E9999 L0000 – L9900 Q0479
A9270 – A9300 B4000 – B9999 K0001 – K9999 Q0478 S1034 – S1037
If a patient is given medical equipment and supplies (listed below) to be used in their home, Place of Service 12 (home) should be used. Please note if billed with POS 11, the supply or equipment will deny as content. HME rental (RR) will require a beginning and ending date. Purchase items should be billed with the date dispensed, delivered or received by the member and not with a date span. Note: Prebilling for HME/DME rental is not permitted. Only purchased items may be billed at the time of delivery/pick- up. If multiple modifiers are used, the RR or NU modifier must be in the first position. If more than one item is dispensed, each item would need to be billed on a separate line.
Example: L3090 NU RT L3090 NU LT
NOTE: Ambulatory Surgery Centers (ASC’s) are required to always bill implant codes (ex. L8699) with a NU modifier.
Hospice (Inpatient/Outpatient) Hospice Services provided to BCBSNE covered members must be preauthorized.
Billing Guidelines (when BCBS is primary)
Inpatient Respite/Non-Respite Services
Bill Type 081X or 082X Revenue code 0655 or 0656 is an all-inclusive entry for ancillary, room and board charges for inpatient Respite care with the appropriate Q code. Charges for drugs, infusion supplies, or HME items should be included in the line items and should not be billed separately by an HME provider. Use Revenue code 0656 as an all-inclusive entry for ancillary, room and board charges for inpatient non-Respite care with the appropriate Q code - listed below.
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You may bill each day as a separate line item with a unit of one or bill one-line item of Revenue Code 655/656 with the total number of unit’s equivalent to the total number of covered days. Room and board should not be line itemized under revenue code 0115.
Home (Outpatient) Hospice Billing Guidelines
Bill Type: 081X or 082X Revenue Code 651 - to be used for hospice skilled nursing visits by an RN or LPN, home health aide services and hospice social worker services. Revenue Code 651 does not include drugs, infusion supplies, or any HME items. These items will continue to be billed by the HME company providing the service. Revenue code 651 must be billed with the appropriate Q code – in the chart below. For each day that a hospice nurse, an aide or a social worker saw the patient in an outpatient/home setting, the provider should bill the 651 Revenue Code (with the appropriate Q code). If more than one discipline has seen the patient that day, all charges must be lumped together under Revenue Code 651 and billed on a single line. Use discharge status code of 40 if patient expires at home. Use “3” in FL 19 for “elective” in Type of Admission/Visit.
Q Code Description
Q5001 Hospice care provided in patient’s home/residence
Q5002 Hospice care provided in assisted living facility
Q5003 Hospice care provided in nursing Long Term Care facility (LTC) or non-skilled nursing facility
Q5004 Hospice care provided in Skilled Nursing Facility (SNF)
Q5005 Hospice care provided in inpatient hospital
Q5006 Hospice care provided in inpatient hospice facility
Q5007 Hospice care provided in Long Term Care facility
Q5008 Hospice care provided in inpatient psychiatric facility
Q5009 Hospice care provided in place Not Otherwise Specified (NOS)
Hospital HME Billing When HME for patient home use is dispensed out of the hospital’s free-standing HME business, the HME should be billed on a CMS-1500 claim form under the HME provider’s name and NPI number. Supplies and drugs dispensed during an outpatient hospice visit must be billed separately on a CMS-1500 under the HME provider. When HME for patient home use is dispensed from the central supply or PT area of the hospital, the HME should be billed by the hospital on the UB 04 inpatient/outpatient claim form.
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Hospital - Billing for HME Equipment and Supplies Any HME equipment or supplies used by an inpatient or acute care facility must be billed to
BCBSNE by the facility. The HME provider cannot bill BCBSNE for these equipment and
supplies.
Insulin Pump and Supplies Insulin pumps and continuous glucose monitoring devices may or may not be covered items on
the drug card plan. If covered under the drug card plan supplies should be billed through the
pharmacy. If they are not covered under the drug card they should be billed on a CMS 1500
under the hospital’s HME provider’s NPI. If dispensed in a physician’s office, charges should
be billed under the rendering provider’s NPI. The claim is to be coded with Place of Service
12 (home) and the appropriate HME modifier (NU or RR). This includes Paradigm real-time
glucose sensors.
Lift Chairs (Recliner with elevating seat) The mechanism should be billed under E0627. Use E1399 for the chair portion (include make,
model and manufacturer information).
Lift Chairs are reviewed for medical necessity. Preauthorization is required.
BCBSNE will cover standard equipment. The charges for upgraded or luxury equipment are not
covered by BCBSNE. If a member wants a luxury lift chair, the member can be billed for the
difference in cost for the upgrade. To bill the member, prior to the equipment being
ordered, you must have the member sign a form that includes the following:
• The member is requesting the upgrade
• The member understands that these features are outside of what BCBSNE considers to
be standard and they are liable for the additional charges
• The amount of the member’s responsibility for the upgrade must be listed
Loan Equipment Bill loaned equipment with K0462, noting on the claim what equipment is being repaired or
temporarily replaced. The date range on the claim should only be for the days the loan
equipment was used.
Lymphedema Sleeve/Glove Bill under A6549 and include the manufacturers invoice with the claim. Purchase Orders would
not be an acceptable substitute for an invoice.
Medicare-Related Issues For information on Medicare –related issues regarding rental to purchase of equipment - see
“Medicare-Related Issues” in the Member Benefits section of the General Policies and
Procedures Manual.
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Medicare and Oxygen Concentrators
Medicare’s rental policy does not match BCBSNE’s rental policy. Medicare allows rental of the
concentrator for 36 months, but BCBSNE’s rental period is 10 months. Medicare requires the
Oxygen Concentrator to be a rental to pay for the supplies.
Once the purchase price is met (with BCBSNE), you can continue to bill Medicare for rental if it
is appropriate according to Medicare guidelines. The benefit as a secondary payer, however,
are limited to the purchase price.
Coinsurance liability once Purchase Price Met
When the customer has Medicare as primary and according to BCBSNE the purchase price of
an item has been met, the provider can bill the member for the coinsurance that is left over
from Medicare.
Oxygen Oxygen contents E0441-E0444
Normally BCBSNE does not pay for oxygen contents E0441-E0444 as they are inclusive of the
rental of the system. The only exception is if the patient is on a high liter flow. For the oxygen
contents to be covered the provider needs to submit documentation of the liter flow prescribed.
E0434 and E0439
Codes E0434 and E0439 would not have a price cap as they are rental only. The provider
would submit different/specific procedure codes if member is purchasing.
High liter flow billing
To bill a patient who is on a high liter flow use the correct HCPCS code for type of oxygen
(liquid or gas). Include the prescription from the physician for the high liter flow with the first
claim submitted.
Liquid Oxygen S8121
When billing liquid oxygen, code S8121, bill one unit for every one pound of liquid oxygen
provided. A manufacturers invoice must be included with your claim submission. Purchase
Orders would not be an acceptable substitute for an invoice.
Note: E1390 (Oxygen concentrator) is a capped rental item. Once we have paid the rental fee
for 10 months this item will be considered purchased and ownership will move to the patient.
Place of Service for Home versus Store Bill items purchased by the member and dispensed at your walk-in location with place of service 17 (Retail Clinic). Bill place of service 12 (Home) for items delivered or shipped to the patient’s home. When the equipment/supply is purchased in the retail store, the claim must be submitted to the Blue Plan in the state where the retail store is located. For items delivered/shipped to the
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patient’s home, the claim must be filed to the Blue plan located in the service area where the member resides.
Pricing Methodology Reimbursement rates for HME, supplies, procedures, orthotics/prosthetics and medications
identified by National Level II HCPCS codes shall be the lesser of the following rate setting
methodologies:
• Published Medicare payment rates for those HME, supplies and orthotics/prosthetics
that have a Medicare rate.
• When the item does not have a rate or is an unlisted code that is not for a
drug/biologic, it is priced using the manufacturer’s cost invoice. Payment will be
based on suggested retail price less a 15% discount or the provider’s acquisition cost
plus 35%, whichever is less. Purchase Orders would not be an acceptable substitute
for an invoice.
• A separately implemented fee schedule utilized for drugs and biologicals. Payment
for these items, including, but not limited to the “J” code series of the Level II HCPCS
codes is updated quarterly.
• Adjustments to these payment values will be made quarterly. Drugs and biologicals
that do not have a specific Level II HCPCS code and associated reimbursement
amount will be reimbursed at Average Wholesale Price (AWP) based on the NDC
number for the product. Claims submitted for drugs and biologicals that do not have
a specific Level II HCPCS code must include the specific drug name and associated
NDC number, dosage/units administered and the associated charge; or
• Using market analysis of charges submitted by providers for like procedures, a relative value scale that compares the complexity of services provided, or any other factor BCBSNE deems necessary, fee schedule allowances may be adjusted.
• BCBSNE allows 85% of the cost for Custom Orthotics manufactured by the Provider. If not custom made and a Manufacturer Invoice is supplied, the reimbursement is 135% of invoice cost or billed charge, whichever if the lesser of.
When CMS does not set a rate for a piece of equipment, BCBSNE will need the manufacturers
cost invoice to price the claim. Purchase Orders would not be an acceptable substitute for an
invoice. All claims are paid according to the member’s contract.
Provider may ask for a reconsideration of the reimbursement level of a submitted charge and
must supply all data necessary for BCBSNE to decide appropriate reimbursement. In all cases,
BCBSNE will make a final determination of reimbursement level based upon the criteria
detailed above. The covered person is not responsible for payment of disputed charges during
the reconsideration process. The provider may not bill the covered person for any payment
under dispute.
Purchase of Home Medical Equipment BCBSNE will preferentially purchase, not rent the HCPCS coded equipment items listed below
for its primary insured customers. This policy doesn’t apply to situations where BCBSNE is the
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secondary payer. Claims for preferentially purchased items must be submitted with the “NU”
modifier following the code. The date of sale must be listed as the date of service. When
submitting the claim, list the “from and through” date as the same date.
HCPCS Codes:
E0110 E0163 E0562 E0730 E2362
E0114 E0470 E0570 E0784 E2363
E0135 E0471 E0574 E0860 E2364
E0141 E0472 E0600 E2360 E2365
E0143 E0480 E0720 E2361 K0104
Reminder: In all cases, rental payment may apply to the purchase price of Home Medical
Equipment. Rent to purchase always applies unless the equipment cannot be purchased.
Rent to Purchase (HME Equipment - RR or NU Modifier - Required) BCBSNE member contracts provide benefits for purchase or rental of various HME, up to the
maximum benefit amount (MBA).
HME providers who rent equipment to our members should identify rental of the HME by using
the “RR” modifier on the claim. If a claim is billed with any of the following codes and no
modifier, the claim will be returned requesting the appropriate modifier.
A4000 – A8999 A9900 – A9999 E0100 – E9999 L0000 – L9900 Q0479
A9270 – A9300 B4000 – B9999 K0001 – K9999 Q0478 S1034 – S1037
Our general guideline for rental of HME is to provide benefits for rental, up to the allowable
purchase price, if equipment is medically necessary.
Our rental allowances are typically based on 10% of the purchase price allowance. Once the
allowable purchase price has been met, we consider this equipment to be purchased with
ownership transferring to the member.
When converting from a rental to a purchase do not subtract the rental charge from the
purchase price when billing for the purchase; BCBS will do this calculation.
Additional Guidelines:
If a member rented equipment for a period and several months later need the same equipment
again the number of months the item was previously rented do not count toward the 10-month
rental limit. There needs to be at least three months between rental periods for the earlier time
frame not to be counted toward the rental to purchase time cap.
Oxygen concentrators to convert from rent to purchase.
If a member opts for a piece of used HME instead of new, BCBSNE will pay the rental (if
covered) on the used HME but will not purchase the item.
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If multiple modifiers are used the -RR or -NU modifier must be in the first position. If more than
one item is dispensed each item would need to be billed on a separate line.
Example:
L3090 NU RT
L3090 NU LT
Rental Proration BCBSNE will prorate monthly rental charges (i.e. apply a daily rate) for Home Medical
Equipment when usage is terminated for any of the following reasons.
• Return of the equipment to the Provider
• End of need for the equipment
• Institutionalization of the Covered Person
• Death of the Covered Person
• Termination of Coverage
Repair of Equipment Reimbursement will only be made to an HME or medical supply company for Medically
Necessary repair, adjustments, and maintenance of purchased Home Medical Equipment.
Do not use modifier MS on any HCPCS code unless BCBSNE is secondary to Medicare.
While an original item is in the shop, a replacement item can be rented. - see “Loan
Equipment.”
Roller Aid Bill a roller aid with E0118. Please do not use E1399 or any other miscellaneous code. Roller
aids may be covered based on the member’s benefit plan.
Transcutaneous and/or Neuromuscular Electrical Nerve Stimulator
(TENS) Unit When renting a TENS unit, all supplies are considered as content to the reimbursement for the
TENS unit and cannot be billed out separately.
Only if a member has purchased a TENS unit, can supplies be billed out separately.
Unlisted Procedure or Service See “Unlisted Procedure or Service.”
Used HME items See “Rental to Purchase.”
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Ventilators Ventilators are reimbursed as rental only. If necessary, a backup ventilator may also be billed.
The backup ventilator should be billed on the same claim with HCPC code E1399 and modifier
RR. A note indicating the charge is for a backup ventilator should be included on the claim,
and the date spans should be the same for both the initial and back up ventilator.
Wound Care - Pump and Supplies A negative pressure wound therapy electrical pump is reimbursed as rental only. Wound care
equipment and services require prior authorization.
Section 4: Mental Health Categorization of Mental Health providers occurs based on their level of training/education.
BCBSNE recognizes three levels of Mental Health Providers, auxiliary, level II and level III. See
the chart below:
Provider Level Provider Type
Level I Psychiatrist
Licensed Clinical Psychologist
Advanced Practice Registered Nurse
Physician Assistant
Level II Special Licensed Psychologist
Licensed Mental Health Practitioner
Licensed Alcohol and Drug Counselor
Licensed Independent Mental Health Practitioner
Level III Auxiliary Providers
Provisionally Licensed Mental Health Practitioners
Provisionally Licensed Drug and Alcoholism Counselors
Certified Social Workers
Certified Masters Social Workers (without an LMHP license)
For more information about requirements for Auxiliary providers and credentialing
information, see the “Mental Health” section in the General Policies and Procedures
Manual.
Alcohol and Drug Assessments Bill the code that most accurately describes the assessment.
Applied Behavioral Therapy Bill with 90899 and indicate “Applied Behavioral Therapy” in the claim narrative field.
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Community Treatment Aide BCBSNE does not cover Community Treatment Aides. G0177 will deny as a non-covered
service.
Custody Evaluations Meeting with the child and doing a report to the court should be billed under 90899 with a
description of the service provided.
If individual, group or family therapy is done, those charges should be billed under the
appropriate CPT code with the patient’s diagnosis.
Just because a service is ordered by the court does not make it payable under the member’s
contract.
Electroconvulsive Therapy (ECT)- 90870 Reimbursement for this code includes the necessary monitoring. See “Drugs Dispensed in the
Office.”
Hospital Psychotherapy Sessions Behavioral health providers not on staff and not reimbursed by the facility can bill and receive
reimbursement for therapy sessions done while the member is in the hospital. The facility
cannot include psychiatric sessions rendered by an outside provider on its UB charges.
Initial Assessment (Psychiatric Diagnostic Interview) Only Level I and LMHP’s with advanced training in diagnostic evaluations should bill 90791. All
other providers should include an initial assessment as part of the first therapy session.
Intensive Outpatient/Day Treatment/Partial Care Intensive, medically necessary day/evening programming services such as treatment
programs, group and individual therapy and psychiatric, psychological, nursing and social work
assessments.
Provision of these services in an organized program, serves as an alternative to hospitalization
for those who need a structured, psychiatrically directed, multi-disciplinary treatment program.
These program services must be provided in a hospital or facility Licensed by the Department
of Health and Human Services Regulation and Licensure (or equivalent state agency) or
CARF.
*Note: All S code per diem charges must have the charges billed at the line level for each date
of service. Billing one date of care with multiple units, or a date span at the claim level, will
result in the claim being returned.
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Free-Standing Intensive Outpatient/Day Treatment/Partial Care
Programs For billing guidelines, please reference your contract.
Hospital-Based Intensive Outpatient/Partial Care/Day Treatment
Services
Billing for hospital-based services is done on a UB04.
All claims for Day Treatment, Partial Care and Outpatient Programs from a hospital-based
program must be billed according to the UB04 billing guidelines.
Special Note: Provider must be certified and a participating provider to be payable under
mental illness and drug abuse.
• One Revenue Code and one Unit may be billed for each day of program attendance.
• Services must be billed by line item and each line must have a date of service.
• Psychological Testing may be billed on a separate line item under Revenue Code 918.
• Do not submit psychological testing by a hospital employee on a CMS 1500 claim
form.
• Separate claims may not be submitted by or for program personnel.
If an employee is doing the psychiatric evaluation, it is included in the per diem.
IQ Testing See “Psychological Testing.”
Modifier-22 Modifier-22 indicates unusual procedural services. When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding Modifier-22 to the usual procedure code.
Claims submitted with Modifier-22 AND an explanation will be reviewed for special
consideration.
Modifiers and Modifier Usage See “Modifiers.”
Neurofeedback See Neurofeedback.
Psychiatric Psychiatric Diagnostic Interview (90791 [without medical evaluation] and 90792 [with
medical evaluation])
Only Level I and LMHP’s with advanced training in diagnostic evaluations should bill 90791. All
other providers should include an initial assessment as part of the first therapy session.
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Codes 90791 and 90792:
• are used for the diagnostic assessment(s) or reassessment(s)
• do not include psychotherapeutic services
• Psychotherapy services including for crisis may not be reported on the same day.
• may be reported once per day
• Cannot be reported on the same day as an evaluation and management service
performed by the same individual
Psychotherapy - insight oriented, behavior modifying and/or supportive - in an office,
home or outpatient setting
Code Description
90832 Psychotherapy – 30 minutes with patient and/or family member
90833 Psychotherapy – 30 minutes with patient and/or family member when performed
with an E & M service
90834 Psychotherapy – 45 minutes with patient and/or family member
90836 Psychotherapy – 45 minutes with patient and/or family member when performed with
an E & M
90837 Psychotherapy – 60 minutes with patient and/or family member
90838 Psychotherapy – 60 minutes with patient and/or family member when performed with
an E & M
90839 Psychotherapy for crisis first 60 minutes and 90840 each additional 30 minutes.
Codes 90839 and 90840 • are used to report the total duration of face-to-face services with patient and/or family
o even if the time spent on that date is not continuous
• The patient must be present for all or some of the visit.
• Do not report 90839 or 90840 in conjunction with 90791, 90792, psychotherapy codes
9083290838 or other psychiatric services 90785-90899.
Pharmacologic management • includes prescription and review of medications when performed with psychotherapy
services
• can be billed with 90863 or the appropriate E & M code (99201-99238, 99304-99337,
9934199350), using key components.
• Code 90863 can be billed in conjunction with 90832, 90834, or 90837
Code 90785 - interactive complexity • is an add-on code
• refers to specific communication factors that complicate the delivery of a psychiatric
procedure • Common factors include:
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o more difficult communication with discordant or emotional family members
engagement of young and verbally undeveloped or impaired patients
o Typical patients are those who have third parties, such as parents, guardians, other family members, interpreters, language translators, agencies, court offices, or schools involved in their care.
• Can be reported with 90791, 90792, 90832, 90833, 90834,90836, 90837, 90838, 90853,
9920199238, 99304-99337, 99341-99350 when appropriate.
• Cannot be reported with 90839, 90840, 90846, 90847, 90849 or in conjunction with an E &
M service when no psychotherapy is also reported.
Family Psychotherapy (90846 and 90847) Family Psychotherapy is billed under the patient’s name and diagnosis whether the patient is
present. Units will always be one.
Group Psychotherapy (90853) Group Therapy services must be billed with 90853 and Place of Service 11 for one unit for
each member in the group. The claim should be billed under the individual provider’s name and
NPI.
Psychological Testing (96130-96139) Billing is based on who administers the test and how long it takes.
Testing codes - reflect who is doing the testing: a psychologist/medical doctor or qualified
health care professional, a technician or a computer.
Units - the amount of time that was spent administering the test and interpreting and reporting
the results.
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Units Bill units in hourly increments when testing conducted by psychologist/medical physician the
units will include the number of hours spent administering the test and interpreting and
reporting the results. If you go into the next hour, you may bill for the whole hour.
Testing conducted by a technician is based on the number of hours the technician spends
administering the test.
It is important to note in the client’s record who administered the test and for how
long. The following scenarios offer examples for how to bill under the testing codes.
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Billing Example 1:
If a psychologist conducts five hours of psychological or neuropsychological testing and three
hours of interpreting and reporting the test results, he or she would bill for eight units of the
psychologist- based code.
Billing Example 2:
If a technician conducts two hours of testing and a psychologist conducts 3.5 hours of testing
and 2.5 hours of interpretation and reporting, he or she would bill for two units of the
technician-based code and six units of the psychologist-based code or two units of 96119
and six units of 96118.
Billing Example 3:
If a patient completes two hours of computerized testing and a psychologist conducts two hours of testing and one hour of interpretation and reporting, he or she would bill for the computer-based code (which is a single, flat-payment rate that is not measured in units) and three units of the psychologist-based code.
Additional information:
The time a technician is with the patient, administering tests, or supervising the patient as he or
she completes the tests, is considered billable under the technician-based code. The
technician must be with the patient, face-to-face, during the testing for the psychologist to be
able to bill for the time.
A Provisionally Licensed Provider or an LMHP (who is also a Provisionally Licensed Psychologist) doing testing and interpretation and feedback would bill under 96102 or 96119 since they are not yet fully licensed Psychologists.
Psychological testing is reviewed if more than four hours of psychological testing is billed in a
calendar year. A letter of medical necessity and the records to support the additional
psychological testing should be sent with the original claim. If the claim has already been
submitted and the extra hours denied, then you can appeal the denial. The provider should
submit an appeal using the appeal form with a letter of medical necessity and the reason
additional testing was needed.
Section 5: Drug Reimbursement Policy
Description: Therapeutic, prophylactic or diagnostic injections may be subcutaneous, intramuscular, intra-
arterial or intravenous. These codes do not include injections for allergen immunotherapy or
immunizations.
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Definitions: J Code Drugs HCPCS J codes include drugs that ordinarily cannot be self-administered, chemotherapy
drugs, immunosuppressive drugs, inhalation solutions and other miscellaneous drugs and
solutions J0120-J9999
Therapeutic, prophylactic or diagnostic injection administration
96372-96377
Injectable Drug Submit the HCPCS Level II code that best describes the injection given in terms of the drug
and dosage. Codes for injections include the charge for the drug only. The administration
charge should be submitted separately. When the dosage given is greater than the HCPCS
Level II code definition, use the units field to specify the appropriate number of units.
Example: The patient received 8 mg. of haloperidol. The common dosage for haloperidol (J1630) is “up to 5 mg” 2 units of service (UOS) should be submitted. The dosage is rounded up to the next unit.
Codes 96379 and J3490 are for unlisted therapeutic injections. The drug name and dosage
must be included on each claim, as well as the National Drug Code (NDC) number. All
unlisted or unclassified drug codes ending in 99 must include the drug name and dosage on
each claim in addition to the NDC number.
Report the drug name, dosage and NDC starting in the loop 2400/NTE segment narrative field
for electronic claims.
Administration Choose the appropriate administration code for the route of administration (96372-96377).
Administration codes should be appropriate to the drug(s) injected.
Supplies used in conjunction with therapeutic, prophylactic or diagnostic injection
administrations Syringes, needles or other supplies (e.g., A4206-A4209) used in conjunction
with administering any injection, including therapeutic, prophylactic or diagnostic, are
considered integral to that administration and will be denied as incidental to the
administration.
Surgical injections When performed as stand-alone procedures/services, surgical injections should be submitted
with the appropriate CPT code for the administration of the injection and the HCPCS Level II
code for the drug. If no specific HCPCS code exists for the drug, submit J3490 with a
narrative indicating the drug name, dosage and NDC.
When performed as part of a surgical procedure, the surgical injection should be submitted
with the HCPCS Level II code for the drug. The administration of the injection is considered
part of the surgical procedure itself and should not be submitted separately.
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Reconsideration of Unlisted Code Allowances Unlisted drug codes, such as J3490, should only be submitted if there is no other code that
describes the drug given. All unlisted drugs must be submitted with a narrative, dosage and
NDC, and will be manually priced. There may be times when the invoice cost of the drug is
significantly higher than our allowance. In this case, the provider may submit a
reconsideration for additional reimbursement using the normal reconsideration process
described in the In-network Health Care Professionals and
Facilities General Policies and Procedures Manual, Section 12, Member Benefit Appeal and
Reconsideration. To facilitate the review, the drug invoice must be submitted with the
reconsideration form. Additional reimbursement will not be considered without the invoice.
BCBSNE reserves the right to determine a cost threshold for any reconsiderations requested
to be cost efficient for providers and members. Effective June 1, 2019, the current threshold
for calendar year 2019 is $25.00 based on current costs of claims handling.
Injection Place of Service Restrictions
BCBSNE will not allow professional 837P charges for therapeutic, prophylactic, or diagnostic
injections when rendered in certain places of service. Professional services (837P) submitted
with a facility place of service will deny as provider liability.
Section 6: Inpatient Inclusive Billing Policy
Overview This policy is for inpatient billing only and does not pertain to outpatient, observation
or emergency department charges, unless specifically stated.
In the event of a conflict between a clinical payment and coding policy and any plan document
under which a member is entitled to covered services, the plan document will govern. Plan
documents include but are not limited to, certificates of health care benefits, benefit booklets,
summary plan descriptions and other coverage documents.
In the event of a conflict between a clinical payment and coding policy and any provider
contract under which a provider participates and/or provides covered services to eligible
member(s) and/or plans, the provider contract will govern.
Providers are responsible for accurately, completely, and legibly documenting the services
performed, including any preoperative workup. The billing office is expected to submit claims
for services rendered using valid codes from Health Insurance Portability and Accountability
Act (HIPAA)-approved code sets. Claims should be coded appropriately according to industry
standard coding guidelines including, but not limited to:
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• Uniform Billing (UB) Editor
• American Medical Association (AMA)
• Current Procedural Terminology (CPT®)
• CPT® Assistant
• Healthcare Common Procedure Coding
System (HCPCS)
• National Drug Codes (NDC)
• Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (CCI) Policy Manual
• CCI table edits
• other CMS guidelines
• Diagnosis Related Group (DRG)
guidelines
Claims are subject to the code auditing protocols for services/procedures billed.
Description The purpose of the Inpatient Inclusive Billing policy is to document a payment policy for
covered medical and surgical services and supplies. Health care providers (facilities,
physicians, and other health care professionals) are expected to exercise independent
medical judgment in providing care to patients. The Inpatient Inclusive Billing policy is not
intended to impact care decisions or medical practice.
Reimbursement Information A claim review conducted on an itemized statement involves an examination of that
statement and the associated medical records for unbundling of charges and/or inappropriate
charges, whether the patient’s status is outpatient or inpatient.
Routine services are those included by the provider in a daily service charge. Routine
services are composed of two broad components: (1) general routine service, and (2) special
care units (SCU), including coronary care units (CCU) and intensive care units (ICU). Included
in routine services are the regular room, dietary services, nursing services, minor medical and
surgical supplies, medical social services, psychiatric social services and the use of certain
equipment and facilities for which a separate charge is not applicable.
Equipment commonly available to patients in a setting or ordinarily furnished to patients
during a procedure, even though the equipment is rented by the hospital, is considered
routine and not billed separately. Special Care Units (SCU) must be equipped or have
available for immediate use, life-saving equipment necessary to treat critically ill patients.
The equipment necessary to treat critically ill patients may include, but is not limited to:
• respiratory and cardiac monitoring equipment
• respirators
• cardiac defibrillators
• wall or canister oxygen and compressed air
Routine services and supplies are included by the provider in the general cost of the room
where services are being rendered or the reimbursement for the associated surgery or other
procedures or services. A separate payment is never made for routine bundled services and
supplies, and therefore cannot be billed separately. These are considered floor stock and are
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generally available to all patients receiving services. Examples include drapes and reusable
items. As such, these items should not be billed separately.
The following guidelines may assist hospital personnel in identifying items, supplies
and services that are not separately billable. This is not an all-inclusive list.
• Any supplies, items and services that are necessary or otherwise integral to the
provision of a specific service and/or the delivery of services in a specific location are
considered routine and not separately billable in the inpatient and outpatient
environments.
• All items and supplies, including DME and beginning January 1, 2022, also
medications, that may be purchased over the counter are not separately billable.
• All reusable items, supplies and equipment provided to all patients during an inpatient
or outpatient admission.
• All reusable items, supplies and equipment, such as pulse oximeter, blood pressure
cuffs, bedside table, etc., that are provided to all patients in a given inpatient/outpatient
treatment area or unit.
• All reusable items supplies and equipment that are provided to all patients receiving
the same service.
Routine Supplies - The hospital’s basic room and critical care area room (cardiac, medical,
surgical, pediatric, respiratory, burn, neonate (level III and IV), neurological, rehabilitative,
post-anesthesia or recover and trauma) daily charge shall include all the following services,
personal care and supply items and equipment:
The list below provides examples of routine items and services that should be inclusive.
Please note that the list is not all-inclusive.
Routine Supplies
Admission, hygiene, and or
comfort kits
IV (intravenous) arm
boards
Shampoo
Alcohol swabs Kleenex tissues Sharps containers
Arterial blood gas kits Lemon glycerin swabs
(flavored swabs)
Shaving cream
Baby powder Lotion Skin cleansing liquid
Band-aids Lubricant Jelly Soap
Bariatric Beds and
Supplies
Masks used by patients or
staff
Socks/Slippers
Basin Meal trays Specipan
Bathing supplies Measuring pitcher Syringes
Bedpan, regular or fracture
pan
Mid-stream urine kits Tape
Blood tubes Mouth care kits Thermometers
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Chucks absorbent pads Mouthwash Toilet tissue
Cotton balls, sterile or
nonsterile
Needles Tongue depressors
Deodorant Odor eliminator/ Room
deodorizer
Toothettes, oral swabs
Diapers, any age Oral Swabs Toothbrush
Drapes Oxygen masks Toothpaste
Emesis Basin PICC (peripherally inserted
central catheter) line
supplies
Trap sputum
Gloves used by patients or
staff
Pillows Urinal
Gowns used by patents or
staff
Preparation kits Water pitcher
Heat light or heating pad Razors
Heel warmers Restraints
Ice packs Reusable sheets, blankets,
pillowcases, draw sheets,
underpads, washcloths and
towels
Medical Equipment - The hospital’s daily charge for basic and critical care area rooms
(cardiac, medical, surgical, pediatric, respiratory, burn, neonate (level III and IV), neurological,
rehabilitative, post- anesthesia or recover and trauma) shall include all the following services,
personal care and supply items and equipment.
The allowed amount for daily charges for equipment usage such as oxygen, ventilator or
CPAP will be prorated based on the total number of hours the equipment and/or supply was in
use.
The list of medical equipment below provides examples of items that should be inclusive.
Please note that the list is not all-inclusive.
Medical Equipment
Ambu bag Emerson pumps Oximeters/Oxisensors-
single use or continuous
Aqua pad motor Fans Patient room furniture;
manual, electric, semi-
electric beds
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Arterial pressure monitors (inclusive of critical care room charge only)
Feeding pumps and supplies
(including syringes)
PCA pump
Auto syringe pump Flow meters Penlight or another flashlight
Automatic thermometers
and blood pressure
machines
Footboard PICC line (reusable
equipment associated with
PICC line placement)
Bariatric beds/supplies Glucometers Pill pulverizer
Bed scales Gomco pumps Pressure bags or pressure
infusion equipment
Bedside commodes Guest beds Radiant warmer
Blood pressure cuffs Heating or cooling pumps Sitz baths
Blood warmers Hemodynamic monitors
(inclusive of critical care
room charge only)
Specialty beds
Cardiac monitors Humidifiers Stethoscopes
Cerebral saturation
monitoring and supplies
Infant warmer Telephone
CO2 monitors Injections (Therapeutic,
prophylactic, or diagnostic)
Telemetry electrodes
Commode, including
bedside
Isolettes, cribs Temporary pacemaker unit
Cooling/warming units IV pumps; single and
multiple lines; tubing
Televisions
Crash cart MRI/CT syringes Traction equipment
Defibrillator and paddles Nebulizers Transport isolette
Digital recording equipment
and printouts
Overhead frames Tube feeding, fortifiers
and/or supplements an
associated supplies,
including syringes
Dinamap Over-bed tables Wall suction, continuous or
intermittent
Facility Basic Charges
The hospital’s daily charge for basic and critical care area rooms (cardiac, Surgical, pediatric,
respiratory, burn, neonate (Level III and IV), neurological, rehabilitative, post-anesthesia or
recovery and trauma) shall include all the following services, personal care and supply items
and equipment. The list of medical equipment below provides examples of items that should
be inclusive. Please note that the list is not all-inclusive.
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Facility Basic Charges
Administration of blood or any blood product by
nursing staff (does not include tubing, blood bank
preparation, etc.)
Monitoring of cardiac monitors; CVP (central
venous pressure) lines; SwanGanz
lines/pressure readings; arterial lines/
readings; pulse oximeters; cardiac output;
pulmonary arterial pressure
Administration or application of any medicine,
chemotherapy, and/or IV fluids
Neurological status checks
Assisting patient onto bedpan, bedside commode, or into the bathroom
Nursing care
Assisting physician or other licensed personnel in
performing any type of procedure in the patient’s
room, treatment room, surgical suite, endoscopy
suite, cardiac catheterization lab; or x-ray. TC code
is appropriate.
Medical record documentation
Bathing of patients Obtaining and recording of blood pressure,
temperature, respiration, pulse, pulse
oximetry
Bedside glucose monitoring Obtaining: finger-stick blood sugars; blood
samples from any type of central line
catheter or PICC line; urine specimens; stool
specimens; sputum specimens; or body fluid
specimen
Body preparation of deceased patients Oral care
Changing of dressing, bandages and/or ostomy
appliances
Patient and family education and counseling
Changing linens and patient gowns, chest tube
maintenance, dressing change, discontinuation
PICC line supplies
Enemas Preoperative care
Enterostomal services Set up and/or take-down of: IV pumps,
suctions, flow meters, heating or cooling
pumps, overbed frames; oxygen; feeding
pumps; TPN; traction equipment; monitoring
equipment
Feeding of patients Shampoo hair
Gowns and gloves Start and/or discontinue IV lines
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Incontinent care Suctioning or lavage of patients
Injections (therapeutic, prophylactic, or diagnostic) Telemetry
Insert, discontinue, and/or maintain nasogastric
tubes
Tracheostomy care and changing of
cannulas
Intubation Transporting, ambulating, range of motion,
transfers to and from bed or chair
Maintenance and flushing of J-tubes; PEG tubes;
and feeding tubes of any kind
Turning and weighing patients
Monitoring and maintenance of peripheral or
central IV lines and sites – to include site care,
dressing changes, and flushes
Urinary catheterization
Ancillary Personnel Providing Nursing or Technical Services
The list below provides examples of items and services that should be inclusive. Please
note that the list is not all-inclusive.
Ancillary Personnel Providing Nursing or Technical Services
Bedside Glucose monitoring, i.e.
Accucheck
No separate charges will be allowed for callback, emergency, standby, urgent attention, as soon as
possible (ASAP), stat, or portable fees
Maintenance of oxygen administration
equipment
Single determination or continuous pulse
oximetry monitoring
Mixing, preparation, or dispensing of
any medications, IV fluids, total
parenteral nutrition (TPN), or tube
feedings
Critical Care Units
The list below provides examples of items and services that should be inclusive. Please note
that the list is not all-inclusive.
Critical Care Units
All services listed in the above sections PICC line supplies
Personal and supply items and equipment, if post-operative
surgical or procedural recovery services are performed in any
critical care room setting other than the post-anesthesia recovery
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room), the critical care daily room charge will cover recovery
service charges.
Intensive care nursing
Inpatient and Outpatient Surgical rooms and services
Includes surgical suites (major and minor), treatment rooms, endoscopy labs, cardiac cath
labs, X-ray, pulmonary and cardiology procedural rooms. The hospital’s charge for surgical
suites and services shall include the entire above-listed nursing personnel services, supplies,
and equipment (as included in the basic or critical care daily room charges).
In addition, the following services and equipment will be included in the surgical rooms and
service charges Please note this list is not all inclusive. Please refer to any state-
specific guidelines.
Surgical Rooms and Services
Air conditioning and filtration
Gowns and gloves, including
surgical
Saline slush machine
All reusable instruments
charged separately
Grounding pads Solution warmer
All services rendered by
RNs, LPNs, scrub
technicians, surgical
assistants, orderlies and
aides
Hemochron Surgeons’ loupes or other
visual assisting devices
Anesthesia equipment and
monitors
Hemoconcentrator Surgical drapes
Any automated blood
pressure equipment
Laparoscopes,
bronchoscopes, endoscopes,
and accessories
Cardiac monitors Lights; light handles; light
cord, fiber optic microscopes
Transport monitor
Cardiopulmonary bypass
equipment
Midas Rex
Video camera and tape
CO2 monitors Monopolar and bipolar
electrosurgical/bovie or
cautery equipment
Wall suction equipment
Crash carts Obtaining laboratory
specimens Packs and surgical
trays
Warming units
Packs and surgical trays
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Digital recording equipment
and printouts
Power equipment
X-ray film
Dinamap Room heating and monitoring
equipment
Fracture tables
Room set-ups of equipment
and supplies
Reference CMS Provider Reimbursement Manual, Determination of Cost of Services to Beneficiaries,
Chapter
22, Section 2202.6 https://www.medicalbillingandcoding.org/health-insurance-guide/understanding-medical-bills/ https://aspe.hhs.gov/report/frequently-asked-questions-about-code-set-standards-adopted-under-hipaa
“Determination of Cost of Services to Beneficiaries.” Medicare Provider Reimbursement Manual (Pub. 15-1). Chapter 22. https://www.cms.gov/regulations-and-guidance/guidance/manuals/paper-based-manuals-items/cms021929.html
Section 7: How to Contact Us
Send an Inquiry You can locate your specific Provider Executive on our website under Provider Contacts or
email us regarding escalated claim questions at [email protected] to reach
our CSC Provider team.