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Reimbursement Policy Revisions Posted June 1, 2022

Reimbursement Policy Revision
Add-on Codes New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Anesthesia, Professional and Facility New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Bundling Guidelines Policy language updated throughout. Added topics: Care Plan Oversight and Coordination Services, Injection and Infusion, and Outpatient Therapies. G0500 added to Moderate Sedation section. Removed topic Correct Coding Initiative, moved to new policy titled NCCI. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Co-Surgeon, Assistant Surgeon, Team Surgeon and Assistant-At-Surgery Guidelines Policy language updated throughout. Modifier 62, Modifier 66, and Obstetrical Deliveries added to Billing and Coding section. Instructions on usage of 80, 81, 82 and AS added to Reimbursement Guidelines. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Consistency guidelines Policy language updated throughout. Age group definitions updated. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Diagnosis validity & code guidelines New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Evaluation and Management Services Policy language updated throughout. Added “Blue Cross NC may verify whether services are related or truly separate and significant. Review criteria includes, but is not limited to, diagnoses, claim history, and medical records.” to Description section. Reimbursement Guidelines Modifier 25 section updated, including “Blue Cross NC interprets the definition of 99211, which includes, “minor” to be incompatible with the definition of Modifier 25, which includes “significant”.” Hospital Discharge, Preventative Medicine, and Observation Care Services sections added to Reimbursement Guidelines. Medical Director approved. Policy noticed 3/31/2022 for effective date 6/1/2022.
Facility Billing Guidelines New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Global Surgery New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Guidelines for Global Maternity Reimbursement O82 added to Routine Maternity Diagnosis table. “The removal of any cerclage within one (1) calendar day of the delivery and in the same place of service will not be eligible for separate reimbursement as it is incorporated into the delivery reimbursement.” Added to Reimbursement Guidelines section. Clarified Antenatal Care “E/M services submitted with a routine maternity diagnosis on the claim are considered part of the global allowance and not separately reimbursable.” Medical Director approved. Notification given 3/31/2022 for effective date of 6/1/2022.
Immunization Guidelines Policy language updated throughout. Billing and Coding section updated to include G0008-G0010, Q2034-Q2039, and “Counseling related to administered vaccines is incidental to the administration codes (G0008-G0010, 90460-90461).” Added language for SHINGRIX in patients over 19 with special conditions as specified by the CDC. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Maximum Units of Service Policy language updated throughout. Specific Unit Limits added to Reimbursement Guidelines section. IgE testing limit updated from 36 to 20. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Modifier Guidelines Policy language updated throughout. Policy section restated as Blue Cross NC utilizes modifiers in determining reimbursement and eligibility. Services billed with inappropriate modifiers or that lack the appropriate modifier according to this policy will not be eligible for reimbursement. Reimbursement Guidelines updated with instructions for Modifier 59, Repeat or Unplanned Procedures, Modifier 90, Modifier 92, Modifier SL, Combined Mammography, Anesthesia Modifiers, and Professional and Technical Components. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
NCCI Editing New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Observation New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Once in a Lifetime Policy language updated throughout. Added “When a “Once in a Lifetime” procedure is reported, subsequent services specific to that removed body part or organ will not be reimbursable.” to Reimbursement Guidelines section. Deleted code 57112 removed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Opioid Treatment Program Clarified Reimbursement Guideline related to usage of multiple drugs in a week and added claim filing instructions for take-home injectable naloxone. Medical Director approved.
Outpatient Code Editor (OCE) Edits Policy language updated throughout. Added “Blue Cross Blue Shield North Carolina (Blue Cross NC) has adopted OCE edits and will use these in processing outpatient facility claims.” and “Sample of OCE Edits (not all inclusive)” to Reimbursement Guidelines. Clarified modifier usage pertains to code pair, not just column two code. Medical Director approved. Notification 3/31/2022 for effective date 6/1/2022.
Partial Hospitalization and Intensive Outpatient Programs Policy language updated throughout. Reimbursement Guidelines updated with “PHP services will be denied when:…“. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Place of Service New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Pricing and Adjudication Principles Policy renamed from “Pricing and Adjudication Principles for Professional Providers” to “Pricing and Adjudication Principles”. Policy language updated throughout. Principle 3 updated to include “Claims may be processed according to same provider or same group practice. Same group practice is defined as a physician and/or other qualified health care professional of the same group and same specialty with the same Federal Tax ID number.” Principle 11 removed language “after the implementation of a software update”. Principle 13 and 14 added. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Radiation Therapy Services Policy language updated throughout. Multi-lead collimator added to Reimbursement Guidelines. Listing of “Radiology Maximum Units/Frequency” added to Reimbursement Guidelines. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Revenue Codes Requiring Procedure Codes, Facility New policy developed. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Split Surgical Package Language updated throughout policy. “Claims may be processed according to same provider or same group practice….” added to Description section. “All providers submitting split surgical care modifiers should use the same procedure code and use the actual surgery date as the date of service.” added to Reimbursement Guidelines. Language related to services appended with 54, 55, or 56 billed on same day as global added to Reimbursement Guidelines. Language related to services appended with 55 or 56 and also 78 added to Reimbursement Guidelines. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Status Codes Policy language updated throughout. Status “P” added to Reimbursement Guidelines section. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.
Supply and Equipment Reimbursement Policy language updated throughout. Added “Medical, Surgical Supplies and DME in a Facility Setting” and “Devices, Implants, Blood Products, & Imaging Agents“ to Reimbursement Guidelines. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022.