Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

Always Bundled Procedure Codes

Notification Issue Date:

This version of the policy will become effective 3/06/2023. This policy has been updated to communicate The Company's reimbursement position for the following procedures/services:

The Company's reimbursement position has changed from Eligible to Not Eligible for Separate reimbursement for the following codes:

99091

The Company's reimbursement position has changed from Not Eligible for Reimbursement to Not Eligible for Separate reimbursement for the following codes:

99453, 99454, 99457, 99458, 98975, 98976, 98977, 98980, 98981

Title:

Always Bundled Procedure Codes

Policy #:

MA00.026r

Please refer to the NewsFlash: 
Coverage of Interprofessional Internet Consultation

Policy

This policy applies to professional and outpatient facility claims.

The procedure codes listed in Attachment A are considered 'always bundled', based on the Medicare Physician Fee Schedule database (MPFSD) Status B Indicator. These procedure codes are 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.

The procedure codes listed in Attachment B may be covered by the Company; however, are not eligible for separate reimbursement consideration whether billed alone or in conjunction with other services. Participating providers may not bill members for these services.

The procedure codes listed in Attachment C may be covered by the Company; however, they are not eligible for reimbursement consideration. Participating providers may not bill members for these services.

Guidelines

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

Description

The intent of this policy is to communicate services that are not eligible for reimbursement or not eligible for separate reimbursement consideration by the Company.

The Company takes into consideration the Medicare Physician Fee Schedule Database (MPFSD), the American Medical Association Current Procedure Technology (CPT) Manual, Centers for Medicare and Medicaid Services (CMS) guidelines, Company policies, and other appropriate sources, when determining services listed in this policy.

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 December 04, 2020.

Centers for Medicare & Medicaid Services Medicare Claims Processing Manual. Chapter 23 - Fee Schedule Administration and Coding. Requirements. Table of Contents. (Rev. 4188, 12-28-18). Available at:http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf. Accessed December 04, 2020.

Company Benefit Contracts.

Coding

CPT Procedure Code Number(s)

Attachment A: Always Bundled Procedures/Services (MPFSD) Status B Indicator

Attachment B: Procedures/Services Not Eligible for Separate Reimbursement

Attachment C: Procedures/Services Not Eligible for Reimbursement

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

Attachment A: Always Bundled Procedures/Services (MPFSD) Status B Indicator

Attachment B: Procedures/Services Not Eligible for Separate Reimbursement

Attachment C: Procedures/Services Not Eligible for Reimbursement

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

7/1/2023

Version Issued Date:

7/6/2023

Version Reissued Date: