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 organizations 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.

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,
Modifiers Modifiers
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
Preventive Medicine Services preventive,medicine,evaluate,health,screening,99381,99382,99383,99384,99385,99386,99387,99391,99392,99393,99394,99395,99396,99397
Telehealth telehealth,interactive,video,telecommunication

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
Advance Care Planning Planning,advanced,directive,will,99497,99498,proxy,attorney,
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
Cardiac Rehabilitation rehabilitation, cardiac,assessment,93797,93798,G0422.G0423,exercise,modification,heart
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
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
Evaluation and Management E/M, guidelines,history,exam,MDM,consultations,initial,subsequent,admit,documentation
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
General Coding and Billing coding,billing,CPT,HCPCS,ICD-10
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
Hypoglossal Nerve Stimulation hypoglossal,apnea,sleep,obstructive,0466T,64568,61886,61888,64569,64570,0467T,0468T,95970,95976,95977
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
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
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
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
Pass Through Billing pass,billing
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
Prolonged Services prolonged,99354,99355,99356,99357,99358,99359,99417
Serious Adverse Events, formerly Never Events never,events
Skin Biopsy skin,biopsy,lesions,tangential,punch,incisional,11102,11103,11104,11105,11106,11107
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
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 Procedure unlisted
Urgent Care Urgent,clinic,walk-in,99202,99203,99204,99205,99211,99212,99213,99214,99215
Vasopneumatic Device Vasopneumatic, Device, Therapy, Lymphadema, 97016,97139,97140,97150,97530,97532,97535,97537,97542,G0237,G02389

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