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.

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
Physician Fee Schedule Status Indicator Policy physician,fee,schedule,indicator,medicare,status,bundled,active,excluded,valid,invalid,measurement,noncovered,restricted,statutory,exclusion,cms

Updated Payment Policies (updated within last 30 days)

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

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,
Advanced Practice Provider Billing
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
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
COVID 19 Billing and Coding
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
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
Gastrointestinal Endoscopies and Related Services gastrointestinal,endoscopy,colonoscopy,screening,colorectal,polyp,preventive,biopsy,diagnostic,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 CM Manifestation Codes manifestation,diagnosis,icd10,underlying,disease,primary,disease,principle
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) modifier,22,increased,greater,difficult,additional,effort
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,
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
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
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 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
Physician Fee Schedule Status Indicator Policy physician,fee,schedule,indicator,medicare,status,bundled,active,excluded,valid,invalid,measurement,noncovered,restricted,statutory,exclusion,cms
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
Proton Beam Therapy Proton,beam,therapy,treatment,delivery,photon,77520,77522,77523,77525
Revenue Codes Requiring CPT of HCPCS Codes revenue,codes,cpt,hcpcs,facility,outpatient,claims,uniform,billing,editor,hospital
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 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
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
Vasopneumatic Device Vasopneumatic, Device, Therapy, Lymphadema, 97016,97139,97140,97150,97530,97532,97535,97537,97542,G0237,G02389
Weight Management, Stress Management, and Exercise Classes weight,stress,exercise,S9449,S9454,S9451,management,class

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