Provider Payment Policies

What are Payment Policies

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:

  • 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.

New Payment Policies (published within last 30 days)

Blue KC has recently made changes to the following payment policies.

Never Events never,events

Updated Payment Policies (updated within last 30 days)

Blue KC has recently made changes to the following payment policies.
Durable Medical Equipment durable,equipment,DME,supplies,HCPCS,rental,
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
Allergy Testing and Immunotherapy allergy,allergic,reaction,immunotherapy,95004,95012,95017,95018,95024,95027,95028,95044,95052,95056,95060,95065,95071,95076,95079
Preventive Medicine Services preventive,medicine,evaluate,health,screening,99381,99382,99383,99384,99385,99386,99387,99391,99392,99393,99394,99395,99396,99397

All Provider Payment and Coding Policies

List of all Payment and Coding Policies (A-Z).

2021 Office and Other Outpatient Evaluation and Management Services 99202,99203,99204.99204,99205,99211,99212,99213,99214,99215,E/M,time, mdm,,office,visit,outpatient
Additional Supplies, Materials and Clinical Staff supplies,99072,materials,clinical, staff,time,PPE
Advance Care Planning Planning,advanced,directive,will,99497,99498,proxy,attorney,
Allergen Testing Allergen,allergy Ige,82784,82785,82787,83520,86001,86003,86005,86008,88184,88185,0165U,0178U,
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,
ANA ENA Testing ANA,ENA,antinuclear,autoantibodies,antigens,86038,86039,86225,86235,81599,0039U,0062U
APN ARNP and CRNA APN,APRN,CRNA,nurse,anesthetists,advanced,registered
B-Hemolytic Streptococcus Testing streptococcus,b-hemolytic,gram-positive,infection,83789,86060,86215,86317,86318,87040,87070,87071,87077,87081,87430,87650,87651,87653,87797,87798,87799,87802,87880,pneumoniae,pyogenes,agalactiae,dysgalactiae,equisimilis,hemolytic,faecalis,faecium
Bone Turnover Markers Testing BTM,markers,hydroxyproline,osteocalcin,phospatase,alkaline,isoenzymes,82523,83500,83505,83937,84080,0172U
Cardiac Biomarkers for Myocardial Infarction biomarkers,infarction,cardiac,troponin,82250,82552,82553,82554,82725,83615,83625,83874,84450,84484,84512,84588,86140,84999,myoglin,vasopressin,deydrogenase
Cardiovascular Disease Risk Assessment cardiovascular,lipid,CHD,atheroclerosis,hypertension,obesity,hypertriglyceridemia,dyslipidemia,coronary,lipoprotein,cholesterol,0111T,80061,81402,81403,81404,81405,81406,81407,81408,81479,81493,81599,82172,82465,82610,82725,82726,83090,83695,83698,83700,83701,83704,83718,83719,83721,83722,83880,84478,84484,84512,85384,85415,86141,0052U,CAD
Cardiac Rehabilitation rehabilitation, cardiac,assessment,93797,93798,G0422.G0423,exercise,modification,heart
Celiac Disease Testing celiac,autoimmune,gluten,81376,81377,81382,81383,82784,83516,86255,86256,86828,86829,86831,86833,88305,88346,88350
Cervical Cancer Screening cervical,cancer,screening,87623,87624,87625,88141,88142,88143,88147,88148,88150,88152,88153,88164,88165,88166,88167,88174,88175,88175,0500T,G0123,G0124,G0141,G0143,G0144,G0145,G0147,G0148,G0476,P3000,P3001,Q0091,papanicolaou,papillomavirus,vaginal,cytopathology
Chiropractic Care chiropractic,manipulation,manipulative,spinal,muskuloskeletal,extraspinal,therapeutic,98940,98941,98942,98943,98925,98926,98927,98928,98929,97110,97012
Cloning of Documentation cloning,copy,paste,cut,template,default,cloned
Consultations consult,request,opinion,advice,referral,99241,99242,99243,99244,99245,99251,99252,99253,99254,99255
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
Dental Services and Procedures dental,dentist,pedodontists,orthodontists,peridontists,endodontists,prosthodontists,ADA,CDT
Diagnosis of Idiopathic Environmental Intolerance idiopathic,environmental,intolerance,sensitivity,organic,amino,82127,82136,82139,82379,82380,82441,82495,,2507,82525,8254282656,82715,82978,83150,83497,83918,83919,83921,84134,84255,84585,84600,84630,84999,86001,86353,88348,83015,83018,82108,82300,83735,83885,83785,82726,89125,82710,84590,84446,83655,91065,lead,nickel,manganese,cadmium,aluminim,arsenic,barium,beryllium,bismuth,antimony,mercury,selenium,prealbuminvolatiles,hydroxyindolacetic,glutathione,copper,citrate,chromium,caroten,carnitine,chromatography
Diagnosis of Vaginitis Including Multi-Target PCR Testing vaginitis,multi-target,pH,culture,candida,gardnerella,trichomonas,infectious
Diagnostic Testing of Common Sexually Transmitted Infections sexually,transmitted,infections,STI,syphilis,chlamydia,herpes,treponema,trachomatis,neisseria,gonorrhoeae,papillomavirus,HPV,trichomonas,syphilis,86592,96593,96631,86632,86694,86695,86696,86780,87081,87110,87181,87490,87491,97492,87528,87529,87530,87590,87591,87592,87623,87624,87625,87660,87661,87797,87798,87799,87808,88341,88342,88344,0500T,0064U,0065U,0096U
Diagnostic Testing of Iron Homeostasis and Metabolism Iron,homeostasis,metabolism,hemoglobin,hemotocrit,hemochromatosis,anemia,HLH,deficiency,,82728,83540,83550,84466,84999,0024U
DNA Ploidy Cell Analysis DNA,ploidy,SPF,UIHC,s-phase,cytometry,88182
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
Electronic Funds Transfer money,deposit,EFT,payment,reimbursement,
Emergency Care emergency,ED,99281,99282,99283,99284,99285,G0380,G0381,G0382,G0383,G0384
Epithelial Cell Cytology in Breast Cancer Risk Assessment epithelial, cytology,breast,cancer
Erectile Dysfunction erectile,dysfunction,ED,80061,80076,81002,81003,81005,81400,81479,82565,82570,82947,83036,83550,84066,84153,84402,84403,84410,84520,84540,84439,84443,85025,85027,testosterone
Evaluation and Management E/M, guidelines,history,exam,MDM,consultations,initial,subsequent,admit,documentation
Evaluation of Dry Eyes eye,dry,82785,83516,83520,83861,82785,83516,83520,83861
Excision of Benign and Malignant Lesions lesions,benign,malignant,excision,skin,margins,11600,11601,11602,11603,11604,11606,11620,11621,11622,11623,11624,11626,11640,11641,11642,11643,11644,11646,11400,11401,11402,11403,11404,11406,11420,11421,11422,11423,11424,11426,11440,11441,11442,11443,11444,11446,11450,11451,11462,11463,11470,11471
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
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis fecal,dysbiosis,intestinal,82239,82542,82710,82715,82725,82784,83520,83630,83986,84311,87045,87046,87075,87102,87177,87209,87328,87329,87336,87500,87641,87798,89160,87493,87798,87045
Fecal Calprotectin Testing calprotectin,fecal,83993,bowel
Flow Cytometry flow,cytometry,immunophenotyping,88182,88184,88185,88187,88188,88189,86355,86356,86357,86359,86360,86361,86367,markers
Folate Testing folate,B9,anemia,megaloblastic,macrocytic,82746,82747
General Coding and Billing coding,billing,CPT,HCPCS,ICD-10
General Inflammation Testing inflammation,reactants,CRP,ESR,85651,85652,86140,sedimentation,erythrocyte
Genetic Testing for Adolescent Idiopathic Scoliosis idiopathic,scoliosis,genetic,AIS,0004M,adolescent
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
Helicobacter Pylori Testing helicobacter pylori,H.pylori,gram-negative,bacteria,83009,83013,83014,86318,86677,87070,87081,87077,87181,87186,87205,87338,87339,88305,87149,87150,87153,0008U
Hemoglobin A1c hemoglobin,Alc,diabetes,prediabetes,83036,83037,82985
Hepatitis C hepatitis,liver,HCV,blood-borne,86803,86804,87520,87521,87522,87902,G0472
Hormonal Testing in Females hormonal,hormones,estrogen,estradiol,FSH,LH,AMH,E2,testosterone,82024,82397,82642,82670,82679,83001,83002,83003,83520,84146,84402,84403,84410,84443,S3650,S3652
Hormonal Testing in Males hormonal,hormone,testosterone,hypogonadism,gynecomastia,FSH,LH,GH,TSH,ACTH,hypopituitarism,82024,82040,82642,82670,83001,83002,83003,84146,84270,84402,84403,84410,84443
Hypoglossal Nerve Stimulation hypoglossal,apnea,sleep,obstructive,0466T,64568,61886,61888,64569,64570,0467T,0468T,95970,95976,95977
Identification of Microorganisms using Nucleic Acid Probes microorganism,8747187472,87480,87481,87482,87485.87486,87487,87493,87495,87496,87498,87500,87516,87517,87525,87526,87527,87531,87532,87533,
Immune Cell Function Assay immune,cell,assay,lymphocyte,86372
Immunizations-Vaccines immunization,vaccine,component, antigen,conjugates,adjuvants,90460,90461,99071,90472,9473,90474,toxoid
Immunohistochemistry immunohistochemistry, biochemical, immunological, IHC, cells, tissues, organisms, monoclonal, antibodies, immunocytochemistry, 88341, 88342, 88344
Implants - Inpatient Facility Implants, Inpatient, Facility, inserted, material, tissue, implantable, durable, medical, equipment
Intracellular Micronutrient Analysis Intracellular, Micronutrient, Analysis, inorganic, organic, testing, panel, 82128, 82136, 82180, 82310, 82379, 82495, 82525, 82607, 82652, 82725, 82746, 82978, 83735, 83785, 84207, 84252, 84255, 84425, 84446, 84590, 84591, 84597, 84630, 84999, 86353, 88348
In Vitro Chemoresistance and Chemosensittivity Assays In, Vitro, Chemoresistance, Chemosensitivity, Assay, chemotherapy, histoculture, cytoprint, fluorescent, drug, resistance, 81535, 81536, 86849, 88104, 88199, 88305, 88313, 88358, 89050, 89240, 0083U.
Lyme Disease Lyme, inflammatory, spirochetes, Borreliaceae, Ixodes, Serologic, immunofluorescence, EIA, Sensitive, enzyme, immunossay, erythema, migrans, Borrelia, burgdorferi, 86617, 86618, 87475, 87476, 0041U, 0042U.
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
Measurement of Thromboxane Metabolites for ASA Resistance Measurement, Thromboxane, Metabolites, Resistance, ASA, prostaglandin, vasoconstriction, 82570, 84431
Medical Team Conference Team, Conference, E/M, 99366, 99367
Modifiers Modifiers
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
Nerve Fiber Density Testing Nerve, Fiber, Density, neuropathy, epidermal, Sensory, 88305, 88314, 88342, 88341, 88344, 88346, 88350, 88356
Never Events never,events
Newborn and Neonatal Intensive Care Unit (NICU) 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
Observation Care Observation, short-term, assessment, reassessment, monitoring 99217, 99218, 99219, 99220, 99224, 99225, 99226, 99241, 99242, 99243, 99244, 99245, 99234, 99235, 99236, G0379, G0378
Office Facility Fees Office, Facility, Fees, Place, Service, Clinic, Equipment, E/M
Onchomycosis Testing Onychomycosis,fungal,82542,87101,87149,87150,87153,87205,87206,87220,87480,87481,87482,87798,87800,87801,88312,88749
Oral Screening Lesion Identification Systems and Genetic Screening 81599,82397,87623,87624,87625,oral,cancer,carcinoma
Pancreatic Enzyme Testing for Acute Pancreatitis pancreatic,pancreatitis,82150,83519,83520,83690,84145,86140
Parathyroid H Phosphorus Calcium and Magnesium Testing parathyroid,hormone,phosphorus,calcium,magnesium,82310,82330,82340,83735,83970,84100,84105
Pass Through Billing pass,billing
Pathogen Panel Testing pathogen,PCR,87483,87505,87506,87507,87631,87632,87633
Pediatric Preventative Screening pediatric,screening,preventative,children,80061,82247,82248,82465,83655,83718,84439,84443,84478,85014,85018,85660,86480,86580,96592,86593,86631,86632,86689,86701,86702,86703,86704,86705,86706,86780,86850,87110,87270,87320,87340,87341,87390,laboratory
Plasma HIV-a and HIV-2 RNA Quantification for HIV Infection plasma,HIV,quantification,retrovirus,infection,87536,87539
Post Service Claim Review review,post-service,claim,reimbursed,fraud,waste,abuse,documentation
Pre-Operative Testing preoperative,surgery,80047,80048,80050,80053,81000,81001,81002,81003,81005,81025,84702,84703,85014,85018,85025,85027,85610,85730,86904,86920,87086,87088
Prescription Medication and Illicit Drug Testing in the Outpatient Setting prescription,medication,illicit,drugs,testing,80305,80306,80307,G0480,G0481,G0482,G0483,G0659,0007U,0011U,0051U,0054U,0082U,0093U,0143U,0144U0145U,0146U,0147U,0148U,0149U,0150U
Preventive Medicine Services preventive,medicine,evaluate,health,screening,99381,99382,99383,99384,99385,99386,99387,99391,99392,99393,99394,99395,99396,99397
Preventive Screening in Adults prevetative,preventive,screening,adult,laboratory,81327,82270,82274,82974,82947,82950,82951,82952,83540,84443,86689,86701,86702,86703,86704,86705,86706,86707,86803,86804,87340,87341,87389,87390,87391,87806,G0328,G0432,G0433,G0435,G0499,G0472,G0475,S3645
Prolonged Services prolonged,99354,99355,99356,99357,99358,99359,99417
Prostate Biopsies prostate,biopsy,88305,G0416
Salivary Hormone Testing salivary,hormone,saliva,82530,82533,82626,82627,82670,82671,82672,82677,82679,84144,84402,84403,84410,S3650
Skin Biopsy skin,biopsy,lesions,tangential,punch,incisional,11102,11103,11104,11105,11106,11107
ST2 Assay for Congestive Heart Failure ST2,failure,heart,83006,congestive
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
Telehealth Originating Site Fee telehealth,originating,site,Q3014
Testing for Diagnosis of Active or Latent Tuberculosis tuberculosis,mycobacterium,pulmonary,81099,81425,81426,81479,82945,83520,83615,84157,84311,86480,86481,87070,87077,87116,87149,87150,87153,87181,87184,87185,87186,87187,87188,87190,87206,87550
Testing for Mosquito or Tick Related Infections mosquito,tick,arthropod,zika,chikungunya,denguemalaria,babesiosis,ehrlichiosis,anaplasmosis,lyme,86757,87040,87798,86280,86753,86666,86619,85060,87207,87254,86750,86753,86788,86789,86790,87449,87899,0043U,0044U,
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,
Thyroid Disease Testing thyroid,hypothyroidism,goiter,thyroiditis,80438,80439,83519,84432,84436,84437,84439,84442,84443,84445,84479,84480,84482,86376,86800
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
Transplant Rejection Testing transplant,rejection,immune,organ,81479,81595,0085T,0055U,0087U,0088U,0018U,
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 Procedure unlisted
Urgent Care Urgent,clinic,walk-in,99202,99203,99204,99205,99211,99212,99213,99214,99215
Urinary Tumor Markers for Bladder Cancer cancer,bladder,tumor,biomarkers,86294,86316,86386,88120,88121,0012M,0013M,
Urine Culture for Bacteria urine,culture,bacteria,UTI,cystitis,pyelonephritis,urosepsis,urethritis,epididymitis,81000,81001,81002,81003,81005,81007,81015,81020,87077,87088,87140,87149,87147,urinalysis
Vasopneumatic Device Vasopneumatic, Device, Therapy, Lymphadema, 97016,97139,97140,97150,97530,97532,97535,97537,97542,G0237,G02389
Vectra DA Blood Test Rheumatoid Arthritis Vectra, Blood, Test, Rheumatoid, Arthritis, MBDA, 81490
Vitamin B12 and Methylmalonic Acid Testing Vitamin, B12, Methylmalonic, Acid, Cobalamin, Holotranscobalamin, deficiency, Methylmalonic, acid, Homocysteine, 82607, 83090, 83921, 84999
Vitamin D Testing Vitamin, D, Ergocalciferol, Cholecalciferol, Ultraviolet, radiation, sunlight, 25-hydroxyvitamin, Deficiency, 82306, 82652, 0038U
ZIKA Virus Risk Assessment ZIKA, Virus, Risk, Assessment, Mosquitoes, amniocentesis, 86794, 87662

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