Medical Policy Updates

Reimbursement Policy Update Posted December 30, 2021

Reimbursement Policy	Reason for Update
Discontinued Procedures	Blue Cross NC will reduce payment by 50% when services were discontinued, as indicated by modifier 53 or 73.
Split Surgical Package	Blue Cross NC will provide reimbursement for components of the surgical package according to the criteria outlined in this policy.
Unplanned Return to Surgery	Blue Cross NC will reduce payment by 30% for unplanned return to surgery services, as indicated by modifier 78.
Advanced Illness / Advance Directives	Routine policy review. Medical Director approved.
Bundling Guidelines	Routine policy review. Grammatical errors corrected. Remote Monitoring of Physiologic Parameter(s) section renamed to Remote Physiologic and Therapeutic Monitoring, newly created codes 98975, 98976, 98977, 98980, and 98981 added. Newly created codes 63052 and 63053 added to Lumbar Spine section. Newly created codes 99424-99427 and 99437 added to Care Management Services section. Urgent Care Services section clarified to include S9083. Medical Director approved.
Consistency Guidelines	Routine policy review. Medical Director approved.
Co-Surgeon, Assistant Surgeon, Team Surgeon and Assistant-At-Surgery Guidelines	Clarification added in Policy section “Understanding that CMS does not advise on all codes, Blue Cross NC reserves the right to edit “S” codes for assistant surgery benefits as deemed appropriate.” Routine policy review. Medical Director approved.
Developmental Delay Screening and Testing Guidelines	Routine policy review. Medical Director approved.
Documentation Requirements for Treatment of End Stage Renal Disease	Routine policy review. Medical Director approved.
Drug and Biological Wastage	Routine policy review. “Drug” clarified as “drug or biological” and “lower quantity” clarified as “equal or lower quantity” in Reimbursement Guidelines. Medical Director approved.
ECG Reimbursement	Routine policy review. Medical Director approved.
Evaluation and Management Services	Routine policy review. Grammatical corrections. Medical Director approved.
Group Visit (Shared Medical Appointment) Guidelines	Routine policy review. Medical Director approved.
Guidelines For Global Maternity Reimbursement	Routine policy review. Grammatical corrections. Medical Director approved.
Immunization Guidelines	Routine policy review. Billing and Coding section updated with new codes expanding range from 90460-90756 to 90460-90759. Guidance in Billing and Coding section updated that Modifier 52 is not recognized to represent state-supplied vaccines. State-supplied vaccines are now to be submitted with Modifier SL. Medical Director approved.
Maximum Units of Service	Routine policy review. Medical Director approved.
Modifier Guidelines	Routine policy review. Modifiers 53, 73, and 78 added to policy statement. Added related policies for Split Surgical Package, Discontinued Procedures, and Unplanned Return to Surgery. Medical Director approved.
Multiple Procedure Payment Reduction on the Technical Component (Tc) of Diagnostic Cardiovascular and Ophthalmology Procedures	Routine policy review. Medical Director approved.
Multiple Surgical Procedure Guidelines for Professional Providers	Clarification added in Reimbursement Guidelines section specific to “S” codes. Routine policy review. Medical Director approved.
Nonpayment for Serious Adverse Events	Routine policy review. Medical Director approved.
Once in a Lifetime	Routine policy review. Deleted code 59135 removed. Medical Director approved.
Outpatient Code Editor (Oce) Edits	Routine policy review. Medical Director approved.
Preadmission and Preoperative Services	Routine policy review. Medical Director approved.
Pricing and Adjudication Principles for Professional Providers	Routine policy review. Grammatical corrections. Medical Director approved.
Radiation Therapy Services	Routine policy review. Medical Director approved.
Radiology Services Reimbursement Policy	Routine policy review. Grammatical corrections. Medical Director approved.
Removal of Impacted Cerumen	Routine policy review. Medical Director approved.
Services Bundled Into Inpatient / Outpatient Stays	Routine policy review. Medical Director approved. Based on existing provider manual language, “Cardiac rehabilitation (during inpatient stay)” added to routine service list.
Status Codes	Routine policy review. Clarification added to status B codes “whether billed alone or with another service.” Medical Director approved.
Supply and Equipment Reimbursement	Supply Billing Requirements clarification added to Reimbursement Guidelines. Routine policy review. Medical Director approved.
Ambulatory Surgical Center (ASC) Reimbursement	Content extracted from provider manual and developed into policy to clarify and summarize DME reimbursement in an ASC.
Opioid Treatment Program Reimbursement	Blue Cross Blue Shield North Carolina (Blue Cross NC) will provide reimbursement for opioid treatment programs as outlined in this policy.
Telehealth	Routine policy review. Newly created place of service 10 added throughout policy. Medical Director approved.