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| Service Descriptions +----------------------------------------------------------- | All Services | | | | | | | | +----------------------------------------------------------- | Ambulance Services During Inpatient Admission | | +----------------------------------------------------------- | Annual Wellness Visit | | | +----------------------------------------------------------- | Audiology Services, including: audiologic function test, | evaluation and therapeutic services, and special | diagnostic procedures. +----------------------------------------------------------- | Cardiac and Pulmonary Rehabilitation | | | +----------------------------------------------------------- | Clinical Trial Services | | | | | +----------------------------------------------------------- | Corneal Tissue Processing, Preserving and Transporting | | +----------------------------------------------------------- | Digital Breast Tomosynthesis (DBT) (G0279) | | | | | +----------------------------------------------------------- | Donor Services | | | +----------------------------------------------------------- | Emergency Treatment and Labor Act (EMTALA) screening: | | | | +----------------------------------------------------------- | End Stage Renal Disease facility services | | | | | +----------------------------------------------------------- | Federally Qualified Health Center (FQHC) Services | | | | | | | | | | +----------------------------------------------------------- | Home Health | | | +----------------------------------------------------------- | Hospital at Home (CMS Acute Hospital Care at Home) | | | +----------------------------------------------------------- | Hospital Observation Service and Hospital Emergency | Department Visit | | +----------------------------------------------------------- | Hospice Services | | | | | +----------------------------------------------------------- | Outpatient Services During Inpatient Admission | | | +----------------------------------------------------------- | Physical Therapy Assistant (PTA) and Occupational Therapy | Assistant (OTA) Services | | +----------------------------------------------------------- | Professional Services: | | | +----------------------------------------------------------- | Rural health clinic (RHC) services | | | | | | | | | | | | | | | +----------------------------------------------------------- | Self-Administered Drugs | +----------------------------------------------------------- | Skin Substitute Procedures and Products | | +----------------------------------------------------------- | Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) | | | | +-----------------------------------------------------------
Reimbursement Guidance
For services provided to prisoners or members in state or local custody (defined as Condition Code 63), reimbursement will not occur unless modifier QJ is also appended to the codes indicating that certain exception criteria have been met.
Bill types must be reflective of the services received and align with the location where the services were rendered.
Ambulance services for date of service that is after the admission date and prior to the discharge date for any inpatient admission.
Annual wellness visit (AWV) is considered a professional service, and there will be no separate reimbursement for a facility fee. If being provided in a facility setting, the bill type must be reflective of such.
Reimbursement will not occur when these services are performed in an outpatient rehabilitation facility.
Cardiac and pulmonary rehabilitation services will only be eligible for reimbursement when submitted with bill types representing hospital outpatient or critical access center.
Clinical trials that are performed in an outpatient facility, require three items to be included for proper processing of the claim: the appropriate clinical trial modifier (Q0 or Q1), condition code indicating qualifying clinical trial, and the appropriate bill type signifying outpatient hospital.
Corneal tissue processing, preserving and transporting should only be reported when corneal tissue is used in a corneal transplant procedure.
DBT is only eligible for reimbursement in the inpatient hospital, outpatient hospital, inpatient skilled nursing facility (SNF), outpatient SNF, and outpatient critical access center. Bill types must be reflective of this. Additionally, DBT must be billed with the appropriate revenue codes.
Revenue code 0815 (Allogeneic stem cell acquisition/donor services) is only reimbursable when submitted with inpatient hospital, outpatient hospital or Special facilities-critical access hospital bill types.
Reimbursement of revenue code 0452 requires the presence of 0451 on the same date of service. Evaluation and Management services using revenue code 0450 are not separately reimbursable when submitted with 0451 or 0452 on the same date of service.
To be eligible for reimbursement, procedures submitted with bill type 0720-072Z but without condition code 84 must include a principal diagnosis of ESRD.
If submitted with bill type 0720-072Z and condition code 84, then G0491 must be appropriately reported.
Five visit codes (G0466-G0470) were established to be used by FQHC when submitting a claim for services under the prospective payment system (PPS). Only 1 unit of any FQHC visit or up to 3 units if providing a combination of FQHC visits will be eligible for reimbursement if reported on a single date of service. If billing for a combination of FQHC visits, the appropriate modifier must also be appended to the claim line. G0469 (FQHC visit, mental health, new patient) when reported for PPS payment will not be eligible for reimbursement if FQHC new patient visit code G0466 is also present on the claim.
Home health services for date of service that is after the admission and prior to the discharge for any inpatient, skilled nursing facility, or swing bed hospital admission.
Hospital at Home services are not eligible for reimbursement. If these services are provided, Blue Cross NC requires they be submitted with Revenue code 161 and Occurrence Span Code 82.
Reimbursement will not occur if either of these services are billed with Revenue codes 0960-0989 (professional fee) or modifier 26 as the codes are exclusive to facility billing only.
Hospice services (Q5003-Q5008, Q5010) must be billed with an appropriate bill type. Services completed under hospice care will not be eligible for reimbursement if submitted on a hospice bill type indicating late charges. However, hospices may adjust finalized claims to add late charges within the normal timely filing period.
Services, other than ambulance, that are rendered by an outpatient hospital and the date of service is after the inpatient admission date and prior to the discharge date, by any provider
Services administered in whole or in part by a PTA or OTA are only eligible for reimbursement when submitted with modifier CO or CQ. Services are reimbursed at 85% of the allowable amount.
Revenue codes 0960-0989 representing professional services are not eligible for reimbursement on a facility claim. These services are to be submitted on a CMS-1500 professional claim form.
RHCs are required to bill the appropriate revenue code representing a free standing clinic or behavioral health treatment/service and applicable HCPCS/ CPT® code for each qualifying preventive health, behavioral health, or medical service provided. Additional services provided in an RHC will not be eligible for reimbursement when billed with revenue codes other than the ones previously addressed. Only one qualifying medical visit is reimbursed per date of service (unless modifiers are appropriately appended) and, only one qualifying mental health visit is reimbursed per date of service. Additional medical or behavioral health services will not be eligible for reimbursement. A qualifying preventive health service, other than an initial preventive exam (G0402) is not reimbursed in addition to an RHC qualifying medical service, on the same date of service.
Revenue code 0637 (Pharmacy - self-administered drugs) is not reimbursable when submitted without a HCPCS code.
Billing for skin substitute application procedures are required to also include the appropriate high cost or low cost skin substitute products.
Ultrasound screening for AAA is only eligible for reimbursement in the following settings: inpatient hospital, outpatient hospital, inpatient SNF, outpatient SNF, RHC, freestanding clinic, and outpatient critical access center. Bill types must be reflective of this.