Provider Payment and Coding Policies

Blue KC has developed Provider Payment and Coding 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:

  • Current Procedural Terminology
  • Centers for Medicare and Medicaid
  • American Medical Association
  • National Correct Coding Initiative
  • Other professional organziations and societies

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.

2021 Office and Other Outpatient Evaluation and Management Services
Additional Supplies, Materials and Clinical Staff
Advance Care Planning
Allergen Testing
Allergy Testing and Immunotherapy
Ambulatory Continuous Glucose Monitoring
Anesthesia Processing
ANA ENA Testing
B-Hemolytic Streptococcus Testing
Bone Turnover Markers Testing
Cardiac Biomarkers for Myocardial Infarction
Cardiovascular Disease Risk Assessment
Cardiac Rehabilitation
Celiac Disease Testing
Cervical Cancer Screening
Chiropractic Care
Cloning of Documentation
CPAP Durable Medical Equipment
Critical Care Services
Dental Services and Procedures
Diagnosis of Idiopathic Environmental Intolerance
Diagnosis of Vaginitis Including Multi-Target PCR Testing
Diagnostic Testing of Common Sexually Transmitted Infections
Diagnostic Testing of Iron Homeostasis and Metabolism
DNA Ploidy Cell Analysis
Durable Medical Equipment
Electronic Funds Transfer
Emergency Care
Epithelial Cell Cytology in Breast Cancer Risk Assessment
Erectile Dysfunction
Evaluation and Management
Evaluation of Dry Eyes
Excision of Benign and Malignant Lesions
Extracorporeal Membrane Oxygenation
Facility Routine Supplies and Services
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis
Fecal Calprotectin Testing
Flow Cytometry
Folate Testing
General Coding and Billing
General Inflammation Testing
Genetic Testing for Adolescent Idiopathic Scoliosis
Global Surgical
Health Behavior Assessment and Intervention
Helicobacter Pylori Testing
Hemoglobin A1c
Hepatitis C
Hormonal Testing in Females
Hormonal Testing in Males
Hypoglossal Nerve Stimulation
Identification of Microorganisms using Nucleic Acid Probes
Immune Cell Function Assay
Implants - Inpatient Facility
Intracellular Micronutrient Analysis
In Vitro Chemoresistance and Chemosensittivity Assays
Lyme Disease
Maternity Services
Measurement of Thromboxane Metabolites for ASA Resistance
Medical Team Conference
MOHs Micrographic Surgery
Multiple Surgery Reduction
Nerve Fiber Density Testing
Newborn and Neonatal Intensive Care Unit (NICU) Services
Observation Care
Office Facility Fees
Onchomycosis Testing
Oral Screening Lesion Identification Systems and Genetic Screening
Pancreatic Enzyme Testing for Acute Pancreatitis
Parathyroid H Phosphorus Calcium and Magnesium Testing
Pass Through Billing
Pathogen Panel Testing
Pediatric Preventative Screening
Plasma HIV-a and HIV-2 RNA Quantification for HIV Infection
Post Service Claim Review
Pre-Operative Testing
Prescription Medication and Illicit Drug Testing in the Outpatient Setting
Preventive Medicine Services
Preventive Screening in Adults
Prolonged Services
Prostate Biopsies
Salivary Hormone Testing
Skin Biopsy
ST2 Assay for Congestive Heart Failure
Status Indicator B Codes
Telehealth Originating Site Fee
Testing for Diagnosis of Active or Latent Tuberculosis
Testing for Mosquito or Tick Related Infections
Therapeutic, Prophylactic, and Diagnostic Injections and Infusions
Thyroid Disease Testing
Timed Therapeutic Procedures
Transplant Rejection Testing
Trigger Point Injections
Tumor Treatment Field Therapy
Unlisted Procedure
Urgent Care
Urinary Tumor Markers for Bladder Cancer
Urine Culture for Bacteria
Vasopneumatic Device
Vectra DA Blood Test Rheumatoid Arthritis
Vitamin B12 and Methylmalonic Acid Testing
Vitamin D Testing
ZIKA Virus Risk Assessment

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