Blue KC has developed Provider Payment Policies to provide guidance on payment methodologies as they pertain to submitted claims. These policies are written following industry standard recommendations from sources such as:
Coverage of any service is determined by date of service, a member's eligibility and benefit limits for the service or services rendered, all terms of the Provider Service Agreement, and other standards of coding rules and guidelines. Final payment is subject to the application of claims adjudication and edits common to the industry. For confirmation of which services may be eligible for coverage and description of when medical services are considered medically necessary, not medically necessary or investigational. In the event of a conflict between any policies, the Member's coverage document will govern.
| 2 Midnight Rule midnight,inpatient,admission,hospital,MCG,physician,admitting,CMS,criteria,two |
Blue KC has recently made changes to the following payment policies.
| Modifier SU |
| Clinical Trials |
| Skilled Nursing Facility Gold Card |
| Lyric (formerly ClaimsXten) Editing lyric, reimbursement, claim, denial, accurate, edit,editing, adjudicate,software, guidelines, policies, rules, programs, CPT, HCPCS, procedure, validation, OCE, NCCI |
| Modifiers 59, XE, XP, XS, & XU 59, XE,XP,XP,XS,XU,separate,distinct,unusual, NCCI,edit,conflict |
| Medically Unlikely Edits quantity, units, allowed,excess, MUE, NCCI, MAI, inappropriate, maximum,edits, unlikely |
| Fracture Care fracture, dislocation, treatment, open, closed, cast, splint, reduction, strapping, supplies, global, restorative, repair |
| Preventive Medicine Services preventive,medicine,evaluate,health,screening,99381,99382,99383,99384,99385,99386,99387,99391,99392,99393,99394,99395,99396,99397,99459 |
| Gastrointestinal Endoscopies and Related Services gastrointestinal,endoscopy,colonoscopy,screening,colorectal,polyp,preventive,biopsy,diagnostic,45378,45380,43232,43202,43216,43217,45385,polyp,00812,00811,flexible,tumor,mass,lesion |
| Critical Care Services critical,illness,injury,deterioration,time,life-threatening,organ-failure,99291,99292 |
| Emergency Care emergency,ED,99281,99282,99283,99284,99285,G0380,G0381,G0382,G0383,G0384 |
| Prolonged Service and Visit Complexity prolonged,99354,99355,99356,99357,99358,99359,99417 |
| Revenue Codes Requiring HCPCS Codes |
List of all Payment and Coding Policies (A-Z).
| 30 Day Readmissions admission,subsequent,readmission,criteria,related,hospital,related |
| 2023 CPT Evaluation and Management Guidelines observation,deletion,revision,hospital,office,inpatient,G0378,G0379,88221,99222,99223,99231,99232,99233,99238,99239,99234,99235,99236,99242,99243,99244,99245,99251,99252,99253,99254,99255,99202,99203,99204,99205,99212,99213,99214,99215 |
| Advance Care Planning Planning,advanced,directive,will,99497,99498,proxy,attorney, |
| Advanced Practice Provider Billing Advanced,Nurse,Midwives,asistants,anesthesia,CRNA,APRN,PA |
| Allergy Testing and Immunotherapy allergy,allergic,reaction,immunotherapy,95004,95012,95017,95018,95024,95027,95028,95044,95052,95056,95060,95065,95071,95076,95079 |
| Ambulatory Continuous Glucose Monitoring glucose,blood,sugar,CGM,95249,95250,95251,sensor,diabetes,99091,monitoring |
| Anesthesia Processing anesthesia,epidural,sedation,PCA,01960,01961,01967,01969,01968,01996,31500,36563,36557,36558,36560,36561,36565,36566,36570,36571,36575,36576,36578,36581,36582,36583,36584,36585,36589,36590,62350,62351,62360,62361,62362,94002,94003,94004,ventilator, |
| APN ARNP and CRNA APN,APRN,CRNA,nurse,anesthetists,advanced,registered |
| Bariatrics and B12 Injections Bariatrics, bariatric,B12,holotranscolbalamin,methylmalonic,screening,global,post-operative,90,vitamni,injectino,J3420,96372,43775,43770,43645,43644,43847,43842,43843,43845,43846 |
| Bilateral Procedures bilateral,indicator,modifier,descriptor,reimbursement,left,right,allowable,procedure |
| Cardiac Rehabilitation rehabilitation, cardiac,assessment,93797,93798,G0422.G0423,exercise,modification,heart |
| Chiropractic and Osteopathic Manipulative Services chiropractic,manipulation,manipulative,spinal,muskuloskeletal,extraspinal,therapeutic,98940,98941,98942,98943,98925,98926,98927,98928,98929,97110,97012 |
| Clinical Trials |
| Cloning of Documentation cloning,copy,paste,cut,template,default,cloned |
| COVID 19 Billing and Coding COVID,19,Vaccine,Pfizer,Moderna,Jansen,booster,coronavirus,91300,91305,91307,91301,91306,91303,0001A,0051A,0071A,0011A,0031A,0002A,0052A,0072A,0012A,0003A,0053A,0013A,0004A,0054A,0064A,0034A,86328,86413,86769,87426,87635,U0001,U0002,U0003,U0004,U0005,guidelines,symptoms,suspected,exposure,testing,99072,S8031,99211,G2023,G2024,99000,99001,SARSCoV,CDC,AMA |
| CPAP Durable Medical Equipment CPAP,DME,equipment,sleep,apnea,hypercapnia,breathing,hypoventilation,obstructive,A4604,A7027,A7028,A7029,A7030,A7031,A7032,A7033,A7034,A7035,A7036,A7037,A7038,A7039,A7046,E0562,E0601,E1390,E0470,E0471,E0472,rented,pressure |
| Critical Care Services critical,illness,injury,deterioration,time,life-threatening,organ-failure,99291,99292 |
| Cryosurgery for Benign Lesions cryosurgery,cryo,acne,warts,dermatofibroma,hemangioma,keloid,molluscum,contagiosum,myxoid,cyst,pyogenic,granuloma,sebborrheic,keratoses,skin,tags,actinic,lesion,benign |
| Dental Services and Procedures dental,dentist,pedodontists,orthodontists,peridontists,endodontists,prosthodontists,ADA,CDT |
| Durable Medical Equipment durable,equipment,DME,supplies,HCPCS,rental, |
| Echocardiography Echo,sonogram,heart,doppler,ultrasound,transthoracic,-,transesophageal,transcatheter,93303,93304,93306,93307,93308,93312,93313,93314,93315,93316,93317,93318,93320,93321,93325,93350,93351,93352,93355,A9700,C1759,C8921,C9822,C8923,C8924,C8925,C8926,C8927,C8928,C8929,C8930 |
| Electroencephalogram (EEG) Video Monitoring electroencephalogram, eeg,diagnostic,epilepsy,seizures,data,monitoring,veeg,video,intractable,anticonvulsant |
| Emergency Care emergency,ED,99281,99282,99283,99284,99285,G0380,G0381,G0382,G0383,G0384 |
| Esketamine (SPRAVATO) |
| Excision and Biopsy of Benign and Malignant Lesions lesions,benign,malignant,excision,skin,margins,11600,11601,11602,11603,11604,11606,11620,11621,11622,11623,11624,11626,11640,11641,11642,11644,11646,11400,11401,11402,11043,11404,11406,11420,11421,11422,11423,11424,11426,11440,11441,11442,11443,11444,11446,11450,11451,1462,11463,11470,11471 |
| Extracorporeal Membrane Oxygenation extracorporeal,oxygenation,membrane,ECMO,ECLS,33946,33947,33948,33949,33951,33952,33953,33954,33955,33956,33957,33958,33959,33962,33963,33964,33965,33966,33969,33984,33985,33986,33987,33988,33989 |
| Facility Routine Supplies and Services facility,supplies,equipment,materials,supplements,remedies |
| Fracture Care fracture, dislocation, treatment, open, closed, cast, splint, reduction, strapping, supplies, global, restorative, repair |
| Gastrointestinal Endoscopies and Related Services gastrointestinal,endoscopy,colonoscopy,screening,colorectal,polyp,preventive,biopsy,diagnostic,00812,00811,45378,45380,43232,43202,43216,43217,45385,polyp,flexible,tumor,mass,lesion |
| Global Surgical surgery,global,pre-operative,post-operative,-54,-55,-56,-57,99024,surgical |
| Health Behavior Assessment and Intervention behavior,assessment,intervention,96156,96158,96159,96164,96165,96167,96168,96170,96171 |
| Hemodialysis Services hemodialysis,renal,end,stage,esrd,dialyzing,cycle,90935,90937,90951,90952,90953,90954,90955,90956,90957,90958,90959,90960,90961,90962,90967,90968,90969,90970,90999,professional,facility,urea,reduction,ratio,frequency,cg,kx,g1,g2.g3,g4,g5,g6,kx |
| Hypoglossal Nerve Stimulation hypoglossal,apnea,sleep,obstructive,0466T,64568,61886,61888,64569,64570,0467T,0468T,95970,95976,95977 |
| ICD-10 Manifestation and Sequela Diagnosis Codes manifestation,diagnosis,icd10,underlying,disease,primary,disease,principle |
| IOP, PHP, and Inpatient Treatment Services for Substance Abuse and Psychiatric Care treatment,psychiatric,evauation,multidisciplinary,intensive,outpatient,h0015,s0201,h0035,h0018,h0010,90853,g0410,90791,90792,99484,therapy,group,inpatient,residential,psychiatrist,psycho,logist,facility,intervention |
| Immunizations-Vaccines immunization,vaccine,component, antigen,conjugates,adjuvants,90460,90461,99071,90472,9473,90474,toxoid |
| Implants - Inpatient Facility Implants, Inpatient, Facility, inserted, material, tissue, implantable, durable, medical, equipment |
| Increased Procedural Service (Modifier 22) 22, increased, service, greater, intensity, difficult, above, time. Effort |
| JZ Modifier JZ,waste,drug, dose, SDV, biological, unused, discarded, administered, vial, smallest, FDA |
| Knee Orthotics knee,orthotic,braces,injury,sprain,prefabricated,custom,osteoarthritis,L1834,L1840,L1844,L1846,L1860,L2320,L2330,L2755L2800,L2961,L1810,L1812,L1820,L1832,L1833,L1834,L1844,L1845,L1846,L1847,L1848,L1850,L1851,L1852,L1860, |
| Lyric (formerly ClaimsXten) Editing lyric, reimbursement, claim, denial, accurate, edit,editing, adjudicate,software, guidelines, policies, rules, programs, CPT, HCPCS, procedure, validation, OCE, NCCI |
| Maternity Services Maternity, Obstetrical, Antepartum, fetal, Delivery, Pregnancy, Gestation, Cesarean, Vaginal, Birth, VBAC, Postpartum, Newborn, Umbilical, 59400, 59409, 59410, 59412, 59414, 59425, 59426, 59530, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620, 59622, 59899, 99460, 99461, 99462, 99463, 99464, 99465, 99477, 99478, 99479, 99480 |
| Medically Unlikely Edits quantity, units, allowed,excess, MUE, NCCI, MAI, inappropriate, maximum,edits, unlikely |
| Modifiers modifier, 22, 23, 24, 25, 26, 32, 33, 47, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 62, 63, 66, 76, 77, 78, 79, 80, 81, 82, 90, 91, 99 AA, AD, AS, AT, CC, CO, CQ, CT, E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F5, F6, F7,F8, F9,GN, GP, LT, RT, P1, P2, P3, P4, P5, P6, QK, QS, QX, QY, QZ, RR, SH, SJ, TA, T1, T2, T2, T3, T4, T5, T6, T7, T8, T9, TC |
| Modifier AS Assistant Surgeon Modifiers |
| Modifier SU |
| Modifiers 59, XE, XP, XS, & XU 59, XE,XP,XP,XS,XU,separate,distinct,unusual, NCCI,edit,conflict |
| MOHs Micrographic Surgery MOHS, Micrographic, Carcinoma, Dermatofibrosarcoma, Melanoma, malignant, Squamous, Cell, histiocytoma, microcystic, Sebaceous, 17311, 17312, 17313, 17314, 17315 |
| Multiple Surgery Reduction Multiple, Reduction, Bilateral |
| National Correct Coding Initiative (NCCI) ncci,guidelines,edit,mue,addon,exclusive,extensive,standards,separate,rationale |
| Negative Pressure Wound Therapy (NPWT) wound, negative,ulcer,delayed,npwt,diabetic,surgical,traumatic.pressure,therapy,E2402,A6550,A7000,A7001,K0743,K0744,K0745,K0746,97605,97606 |
| Newborn and Neonatal Critical and Intensive Care Services Newborn, Neonatal, NICU, Intensive, Care, Critical 99460, 99462, 99463, 99464, 99465, 99477, 99478, 99479, 99480, 99468, 99469, 31500, 36000, 36400, 36405, 36406, 36410, 36415, 36420, 36600, 36430, 36440, 36510, 36555, 36591, 36660, 43752, 43753, 51100, 51701, 51702, 71045, 71046, 62270, 92953, 93561, 93562, 94002, 94004, 94375, 94610, 94660, 94662, 94760, 94761, 94762, 94780, 949781 |
| Office Facility Fees Office, Facility, Fees, Place, Service, Clinic, Equipment, E/M |
| Organ Acquisition Costs transplant,organ,acquisition,facility |
| Pass Through Billing pass,billing |
| Physician Fee Schedule Status Indicator Policy physician,fee,schedule,indicator,medicare,status,bundled,active,excluded,valid,invalid,measurement,noncovered,restricted,statutory,exclusion,cms |
| Post FDA Approved Pharmaceutical products, Medical Therapies, and Devices new, FDA,pharmaceutical,therapies,devices,approved,exclusion |
| Post Service Claim Review review,post-service,claim,reimbursed,fraud,waste,abuse,documentation |
| Preventive Medicine Services preventive,medicine,evaluate,health,screening,99381,99382,99383,99384,99385,99386,99387,99391,99392,99393,99394,99395,99396,99397,99459 |
| Prolonged Service and Visit Complexity prolonged,99354,99355,99356,99357,99358,99359,99417 |
| Proton Beam Therapy proton, beam, therapy, particle, cancer, photon, gamma, rays, linear, accelerator, tumor, 77520, 77522, 77523, 77525 |
| Revenue Codes Requiring HCPCS Codes |
| Risk Adjustment and Acute Inpatient Diagnosis oig,risk,adjustment,acute,diagnosis,resolved,outpatient,history,inspector,general,conditions |
| Robotics in Surgery robot,robotic,surgery,s2900,surgical,procedure |
| SBRT, SRS, FSRT SBRT,SRS,FSRT,radiotherapy,radiation,therapy,sterotactic,treatment,77470,77370,77300,77331,77293,77014,77301,77338,77371,77372,77373,77336,77401,OART,orthovoltage,evicore |
| Serious Adverse Events, formerly Never Events serious, never,HAC,POA,adverse,infection,falls,wrong, PA, PB, PC |
| Skilled Nursing Facility Gold Card |
| Status Indicator B Codes bundled,indicator,status,A4262,A4263,A4300,A4550,G0269,G0501,Q3031,R0076,0573T,0538T,0539T,15850,20930,20936,22841,34839,36000,36416,38204,90885,90887,90889,92352,92353,92354,92355,92358,92371,92531,92532,92533,92534,92605,92606,92618,92921,92925,92929,92934,92938,92944,93740,93770,94005,94150,96040,96902,97010,97602,98960,98961,98962,99000,99001,99002,99024,99050,99051,99053,99056,99058,99060,99070,99072,99071,99078,99080,99100,99116,99135,99140,99288,99339,99340,99366,99367,99368,99374,99377,99379,99380,99485,99486 |
| Telehealth telehealth,interactive,video,telecommunication |
| Therapeutic, Prophylactic, and Diagnostic Injections and Infusions injection,infusions,prophylactic,therapeutic,diagnostic,86365,96366,96367,96368,96369,96370,96371,96372,96373,96374,96375,96376,96377,96379,A4211,G0260,G0429,D9610,D9612, |
| Timed Therapeutic Procedures time,therapeutic,therapy,modalities,97032,97034,97035,97036,97039,97110,97112,97113,97116,97124,97139,97140,97150,97530,97532,97535,97537,97542,G0237,G0238,S5100,S5110,S5115,S5125,S5130,S5135,S8950,S9482 |
| Trigger Point Injections trigger,injection,corticosteroid,myofascial,20552,20553 |
| Tumor Treatment Field Therapy tumor,field,treatment,glioblastoma,temozolomide,77299,E0766,A4555,C71.0,C71.1,C71.2,C71.3,C71.4,C81.5,C71.6,C71.7,C71.8,C71.9,malignant,neoplasm |
| Unlisted and Miscellaneous Codes unlisted |
| Vasopneumatic Device Vasopneumatic, Device, Therapy, Lymphadema, 97016,97139,97140,97150,97530,97532,97535,97537,97542,G0237,G02389 |