Notification



Notification Issue Date:



Claim Payment Policy


Title:Always Bundled Procedure Codes

Policy #:00.01.52g

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

This policy applies to providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all Company products.

The procedure codes listed in Attachment A of the policy are always considered bundled into the reimbursement for other services and, therefore, are not eligible for separate reimbursement, whether billed alone or in conjunction with other services. Participating providers may not bill members for these services.
Guidelines

This policy does not contain an all-inclusive list of procedure codes that may have editing applied to them. Procedure codes not listed in this policy continue to be subject to Company claims adjudication logic, eligibility, benefits, limitations, exclusions, pre-certification/referral requirements, provider contracts, and Company policies.

Description

The Company takes into consideration the Medicare Physician Fee Schedule database (MPFSD) and other appropriate sources.

The MPFSD identifies procedure codes with the status B indicator. The Status B Indicator is used when the reimbursement for certain procedure codes is always considered bundled into the reimbursement for other services.
References


Centers for Medicare & Medicaid Services (CMS). National Physician Fee Schedule Relative Value File. [CMS Web site]. Available at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html. Accessed September 26, 2018.

Centers for Medicare and Medicaid Services Medicare Claims Processing Manual.Chapter 23-Fee Schedule Administration and Coding.Requirements. Table of Contents. (Rev. 3876, 10-06-17). Available at:http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf. Accessed Accessed September 26, 2018.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

See Attachment A.


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

See Attachment A.


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Always Bundled Procedure Codes
Description: CPT Codes and HCPCS Codes


 Policy: 00.01.14q:Reporting and Documentation Requirements for Anesthesia Services

 Policy: 00.01.25ar:PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services

 Policy: 00.03.06e:Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products

 Policy: 00.10.03i:Criteria for Reimbursement of Emergency Room Services

 Policy: 00.10.31c:Medical Team Conferences

 Policy: 00.10.39j:Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus

 Policy: 05.00.32i:Speech and Non-Speech Generating Devices

 Policy: 06.00.01e:Computer Analysis and Generation of Automated Data in Conjunction with Diagnostic Studies

 Policy: 07.08.03d:Medical and Surgical Treatment of Temporomandibular Joint Disorder

 Policy: 10.02.02i:Chiropractic Spinal and Extraspinal Manipulation Therapy

 Policy: 10.03.01j:Physical Medicine, Rehabilitation, and Habilitation Services

 Policy: 11.07.01s:Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)

 Policy: 12.05.01i:Outpatient Diabetes Education and Self-Management Training

 Policy: 00.06.02y:Preventive Care Services (Independence)

 Policy: 11.02.27:Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound


Policy History

00.01.52g:
01/01/2019This version of the policy will become effective 01/01/2019.

The following CPT codes has been deleted from this policy: 99090

The following CPT codes have been added to this policy: 0537T, 0538T, 0539T


REVISIONS FROM 00.01.52f
11/26/2018This version of the policy will become effective 11/26/2018.

This policy has been updated as a result of the quarterly update to the Medicare Physician Fee Schedule.

The following Procedure codes have been added to Attachment A of the policy: 34839, G0501

The following Procedure codes have been deleted from Attachment A of the policy: 99091, 99487, 99488, 99489


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2019
Version Issued Date: 01/16/2019
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.