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.

Codes Inclusive to Imaging Services contrast,radiopharmaceuticals,isotopes,inclusive,mri,pet,scan,ct,radiology,diagnostic,osmolar,supplies,imaging
Laparoscopic Adjustable Gastric Banding (LAGB) Gastric Band Adjustment gastric,banding,restrictive,injection,saline,fill,adjustment,port,band,fluoroscopy,
Two-Midnight Benchmark midnight,inpatient,admission,hospital,MCG,physician,admitting,CMS,criteria,two

Updated Payment Policies (updated within last 30 days)

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

Lab Payment Policies

Allergen Testing
β-Hemolytic Streptococcus Testing
Biomarker Testing for Autoimmune Rheumatic Disease
Biochemical Markers of Alzheimer Disease and Dementia
Biomarkers for Myocardial Infarction and Chronic Heart Failure
Bone Turnover Markers Testing
Cardiovascular Disease Risk Assessment
Celiac Disease Testing
Cervical Cancer Screening
Colorectal Cancer Screening
Coronavirus Testing in the Outpatient Setting
Diabetes Mellitus Testing 
Diagnosis of Idiopathic Environmental Intolerance
Diagnosis of Vaginitis
Diagnostic Testing of Common Sexually Transmitted Infections
Diagnostic Testing of Influenza
Diagnostic Testing of Iron Homeostasis and Metabolism
Epithelial Cell Cytology in Breast Cancer Risk Assessment
Evaluation of Dry Eyes
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing
Fecal Calprotectin Testing in Adults
Flow Cytomerty
Folate Testing
Gamma-Glutamyl Tranferase Testing In Adults
General Inflammation Testing
Helicobacter Pylori Testing
Hepatitis Testing
Human Immunodeficiency Virus (HIV)
Identification of Microorganisms using Nucleic Acid Probes
Immune Cell Function Assay
Immunohistochemistry
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies
In Vitro Chemoresistance and Chemosensitivity Assays
Intracellular Micronutrient Analysis
Lyme Disease Testing
Metabolite Markers of Thiopurines Testing
Nerve Fiber Density Testing
Onychomycosis Testing
Oral Cancer Screening and Testing
Pancreatic Enzyme Testing for Acute Pancreatitis
Parathyroid Hormone, Phosphorus Calcium, and Magnesium Testing
Pathogen Panel Testing
Pediatric Preventive Screening
Prenatal Screening (Nongenetic)
Prescription Medication and Illicit Drug Testing
Prostate Biopsy Specimen Analysis
Prostate Specific Antigen (PSA) Testing
Salivary Hormone Testing
Serum Testing for Evidence of Mild Traumatic Brain Injury
Serum Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases
Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
Serum Tumor Markers for Malignancies
Testosterone
Testing for Autism Spectrum Disorder and Developmental Delay
Testing for Diagnosis of Active or Latent Tuberculosis
Testing for Vector-Borne Infections
Therapeutic Drug Monitoring for 5-Fluorouracil
Thyroid Disease Testing
Urinary Tumor Markers for Bladder Cancer
Urine Culture Testing for Bacteria
Vitamin B12 and Methylmalonic Acid Testing
Vitamin D Testing

All Provider Payment and Coding Policies

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

30 Day Readmissions admission,subsequent,readmission,criteria,related,hospital,related
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
Codes Inclusive to Imaging Services contrast,radiopharmaceuticals,isotopes,inclusive,mri,pet,scan,ct,radiology,diagnostic,osmolar,supplies,imaging
Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BIPAP) Devices 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
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
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
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
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
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
JW and JZ Modifiers 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,
Laparoscopic Adjustable Gastric Banding (LAGB) Gastric Band Adjustment gastric,banding,restrictive,injection,saline,fill,adjustment,port,band,fluoroscopy,
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
Two-Midnight Benchmark midnight,inpatient,admission,hospital,MCG,physician,admitting,CMS,criteria,two
Unlisted and Miscellaneous Codes unlisted
Vasopneumatic Device Vasopneumatic, Device, Therapy, Lymphadema, 97016,97139,97140,97150,97530,97532,97535,97537,97542,G0237,G02389