Updated Coding Requirements for Provider Reimbursement

Effective April 28, 2021, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will limit reimbursement of Current Procedural Terminology (CPT^®) and Healthcare Common Procedure Coding System (HCPCS) codes to the time spans described in their definition.

Some code descriptions, CPT^® and HCPCS, specify a time parameter for which the code should and can be reported (e.g., weekly, yearly). This is a reminder that Blue Cross NC will reimburse CPT and HCPCS codes based on the time span given in the description.

Key Details

• Claims will have different look-back periods based on the code definition.

  • Example: Code such as 93241 External electrocardiographic recording for more than 48 hours up to 7 days - this description states that it can only be filed every 7 days.
  • For a claim received on 5/14/2021, with date of service 4/28/2021, Blue Cross NC will review claim history 7 days prior to 4/28/2021.

• If a provider submits a code more frequently than the standardized code definition, it will be denied.

• These coding requirements apply to all commercial, Administrative Services Only (ASO), State Health Plan (SHP) and Blue Card Inter-Plan Program Host members.

To ensure accurate coding and reimbursement, please report during the designated time period.

Below are two example codes which contain date span limitations in their definition:

• 99421, Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
• 93271, External patient and, when performed, auto activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attended monitoring; transmission and analysis

Please reference the most current American Medical Association (AMA) CPT or HCPCS Coding Book for code descriptions.