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.

All Provider Payment and Coding Policies

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

Last Updated:
30 Day Readmissions 05/01/2025 admission,subsequent,readmission,criteria,related,hospital,related
Advance Care Planning 09/01/2024 Planning,advanced,directive,will,99497,99498,proxy,attorney,
Advanced Practice Provider Billing 01/01/2025 Advanced,Nurse,Midwives,asistants,anesthesia,CRNA,APRN,PA
Allergy Testing and Immunotherapy 09/01/2024 allergy,allergic,reaction,immunotherapy,95004,95012,95017,95018,95024,95027,95028,95044,95052,95056,95060,95065,95071,95076,95079
Ambulatory Continuous Glucose Monitoring 12/01/2024 glucose,blood,sugar,CGM,95249,95250,95251,sensor,diabetes,99091,monitoring
Anesthesia Processing 07/01/2024 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,
Bariatrics and B12 Injections 12/01/2024 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 06/01/2024 bilateral,indicator,modifier,descriptor,reimbursement,left,right,allowable,procedure
Cardiac Rehabilitation 09/01/2024 rehabilitation, cardiac,assessment,93797,93798,G0422.G0423,exercise,modification,heart
Chiropractic and Osteopathic Manipulative Services 12/01/2024 chiropractic,manipulation,manipulative,spinal,muskuloskeletal,extraspinal,therapeutic,98940,98941,98942,98943,98925,98926,98927,98928,98929,97110,97012
Clinical Trials 07/15/2024
Cloning of Documentation 03/01/2025 cloning,copy,paste,cut,template,default,cloned
Codes Inclusive to Imaging Services 04/01/2025 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 10/01/2024 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 12/01/2024 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 01/01/2025 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 09/01/2024 critical,illness,injury,deterioration,time,life-threatening,organ-failure,99291,99292
Cryosurgery for Benign Lesions 08/09/2024 cryosurgery,cryo,acne,warts,dermatofibroma,hemangioma,keloid,molluscum,contagiosum,myxoid,cyst,pyogenic,granuloma,sebborrheic,keratoses,skin,tags,actinic,lesion,benign
Dental Services and Procedures 03/01/2025 dental,dentist,pedodontists,orthodontists,peridontists,endodontists,prosthodontists,ADA,CDT
Durable Medical Equipment 11/01/2024 durable,equipment,DME,supplies,HCPCS,rental,
Echocardiography 11/01/2024 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 02/01/2025 electroencephalogram, eeg,diagnostic,epilepsy,seizures,data,monitoring,veeg,video,intractable,anticonvulsant
Emergency Care 11/01/2024 emergency,ED,99281,99282,99283,99284,99285,G0380,G0381,G0382,G0383,G0384
Esketamine (SPRAVATO) 08/01/2024
Excision and Biopsy of Benign and Malignant Lesions 11/11/2024 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 03/01/2025 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 Observation G0379, G0379 07/01/2025 facility,supplies,equipment,materials,supplements,remedies
Facility Routine Supplies and Services 09/01/2024 facility,supplies,equipment,materials,supplements,remedies
Fracture Care 04/01/2025 fracture, dislocation, treatment, open, closed, cast, splint, reduction, strapping, supplies, global, restorative, repair
Gastrointestinal Endoscopies and Related Services 08/09/2024 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 07/01/2024 coding,billing,CPT,HCPCS,ICD-10
Global Surgical 07/01/2024 surgery,global,pre-operative,post-operative,-54,-55,-56,-57,99024,surgical
Health Behavior Assessment and Intervention 03/01/2025 behavior,assessment,intervention,96156,96158,96159,96164,96165,96167,96168,96170,96171
Hemodialysis Services 08/01/2024 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
Hemodialysis, Home Hemodialysis, and Peritoneal Dialysis Services 07/01/2025
Hypoglossal Nerve Stimulation 10/01/2024 hypoglossal,apnea,sleep,obstructive,0466T,64568,61886,61888,64569,64570,0467T,0468T,95970,95976,95977
ICD-10 Manifestation and Sequela Diagnosis Codes 03/01/2025 manifestation,diagnosis,icd10,underlying,disease,primary,disease,principle
IOP, PHP, and Inpatient Treatment Services for Substance Abuse and Psychiatric Care 01/01/2025 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 10/01/2024 immunization,vaccine,component, antigen,conjugates,adjuvants,90460,90461,99071,90472,9473,90474,toxoid
Implants - Inpatient Facility 09/01/2024 Implants, Inpatient, Facility, inserted, material, tissue, implantable, durable, medical, equipment
Increased Procedural Service (Modifier 22) 02/01/2025 22, increased, service, greater, intensity, difficult, above, time. Effort
JW and JZ Modifiers 09/01/2024 JZ,waste,drug, dose, SDV, biological, unused, discarded, administered, vial, smallest, FDA
Knee Orthotics 10/01/2024 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 04/01/2025 gastric,banding,restrictive,injection,saline,fill,adjustment,port,band,fluoroscopy,
Lyric (formerly ClaimsXten) Editing 06/01/2024 lyric, reimbursement, claim, denial, accurate, edit,editing, adjudicate,software, guidelines, policies, rules, programs, CPT, HCPCS, procedure, validation, OCE, NCCI
Maternity Services 07/01/2024 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 07/01/2024 quantity, units, allowed,excess, MUE, NCCI, MAI, inappropriate, maximum,edits, unlikely
Modifiers 08/25/2024 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 02/01/2025 Modifiers
Modifier SU 08/13/2024
Modifiers 59, XE, XP, XS, & XU 59, XE,XP,XP,XS,XU,separate,distinct,unusual, NCCI,edit,conflict 06/01/2024
MOHs Micrographic Surgery 10/01/2024 MOHS, Micrographic, Carcinoma, Dermatofibrosarcoma, Melanoma, malignant, Squamous, Cell, histiocytoma, microcystic, Sebaceous, 17311, 17312, 17313, 17314, 17315
Multiple Surgery Reduction 03/01/2025 Multiple, Reduction, Bilateral
National Correct Coding Initiative (NCCI) 02/15/2025 ncci,guidelines,edit,mue,addon,exclusive,extensive,standards,separate,rationale
Negative Pressure Wound Therapy (NPWT) 08/09/2024 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 11/01/2024 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 03/01/2025 Office, Facility, Fees, Place, Service, Clinic, Equipment, E/M
Organ Acquisition Costs 01/01/2025 transplant,organ,acquisition,facility
Pass Through Billing 03/01/2025 pass,billing
Physician Fee Schedule Status Indicator Policy 07/01/2024 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 09/01/2024 new, FDA,pharmaceutical,therapies,devices,approved,exclusion
Post Service Claim Review 12/01/2024 review,post-service,claim,reimbursed,fraud,waste,abuse,documentation
Preventive Medicine Services 02/01/2025 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 03/01/2025 prolonged,99354,99355,99356,99357,99358,99359,99417
Proton Beam Therapy 11/01/2024 proton, beam, therapy, particle, cancer, photon, gamma, rays, linear, accelerator, tumor, 77520, 77522, 77523, 77525
Revenue Codes Requiring HCPCS Codes 02/01/2025
Risk Adjustment and Acute Inpatient Diagnosis 01/02/2025 oig,risk,adjustment,acute,diagnosis,resolved,outpatient,history,inspector,general,conditions
Robotic and Computer Assisted Surgery 03/01/2024 robot,robotic,surgery,s2900,surgical,procedure
SBRT, SRS, FSRT 11/01/2024 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 07/09/2024 serious, never,HAC,POA,adverse,infection,falls,wrong, PA, PB, PC
Skilled Nursing Facility Gold Card 07/15/2024
Status Indicator B Codes 12/01/2024 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 07/01/2024 telehealth,interactive,video,telecommunication
Therapeutic, Prophylactic, and Diagnostic Injections and Infusions 10/01/2024 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 10/01/2024 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 10/01/2024 trigger,injection,corticosteroid,myofascial,20552,20553
Tumor Treatment Field Therapy 10/01/2024 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 10/01/2024 midnight,inpatient,admission,hospital,MCG,physician,admitting,CMS,criteria,two
Unlisted and Miscellaneous Codes 11/01/2024 unlisted
Vasopneumatic Device 11/01/2024 Vasopneumatic, Device, Therapy, Lymphadema, 97016,97139,97140,97150,97530,97532,97535,97537,97542,G0237,G02389

Lab Payment Policies

Last Updated:
Allergen Testing 07/01/2025
β-Hemolytic Streptococcus Testing 07/01/2025
Biomarker Testing for Autoimmune Rheumatic Disease 07/01/2025
Biochemical Markers of Alzheimer Disease and Dementia 07/01/2025
Biomarkers for Myocardial Infarction and Chronic Heart Failure 07/01/2025
Bone Turnover Markers Testing 07/01/2025
Cardiovascular Disease Risk Assessment 07/01/2025
Celiac Disease Testing 07/01/2025
Cervical Cancer Screening 07/01/2025
Colorectal Cancer Screening 07/01/2025
Coronavirus Testing in the Outpatient Setting 07/01/2025
Diabetes Mellitus Testing  07/01/2025
Diagnosis of Idiopathic Environmental Intolerance 07/01/2025
Diagnosis of Vaginitis 07/01/2025
Diagnostic Testing of Common Sexually Transmitted Infections 07/01/2025
Diagnostic Testing of Influenza 07/01/2025
Diagnostic Testing of Iron Homeostasis and Metabolism 07/01/2025
Epithelial Cell Cytology in Breast Cancer Risk Assessment 07/01/2025
Evaluation of Dry Eyes 07/01/2025
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing 07/01/2025
Fecal Calprotectin Testing in Adults 07/01/2025
Flow Cytomerty 07/01/2025
Folate Testing 07/01/2025
Gamma-Glutamyl Tranferase Testing In Adults 07/01/2025
General Inflammation Testing 07/01/2025
Helicobacter Pylori Testing 07/01/2025
Hepatitis Testing 07/01/2025
Human Immunodeficiency Virus (HIV) 07/01/2025
Identification of Microorganisms using Nucleic Acid Probes 07/01/2025
Immune Cell Function Assay 07/01/2025
Immunohistochemistry 07/01/2025
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies 07/01/2025
In Vitro Chemoresistance and Chemosensitivity Assays 07/01/2025
Intracellular Micronutrient Analysis 07/01/2025
Lyme Disease Testing 07/01/2025
Metabolite Markers of Thiopurines Testing 07/01/2025
Nerve Fiber Density Testing 07/01/2025
Parathyroid Hormone, Phosphorus Calcium, and Magnesium Testing 07/01/2025
Pathogen Panel Testing 07/01/2025
Pediatric Preventive Screening 07/01/2025
Prenatal Screening (Nongenetic) 07/01/2025
Prescription Medication and Illicit Drug Testing 07/01/2025
Prostate Biopsy Specimen Analysis 07/01/2025
Prostate Specific Antigen (PSA) Testing 07/01/2025
Salivary Hormone Testing 07/01/2025
Serum Testing for Evidence of Mild Traumatic Brain Injury 07/01/2025
Serum Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases 07/01/2025
Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease 07/01/2025
Serum Tumor Markers for Malignancies 07/01/2025
Testosterone 07/01/2025
Testing for Autism Spectrum Disorder and Developmental Delay 07/01/2025
Testing for Diagnosis of Active or Latent Tuberculosis 07/01/2025
Testing for Vector-Borne Infections 07/01/2025
Therapeutic Drug Monitoring for 5-Fluorouracil 07/01/2025
Thyroid Disease Testing 07/01/2025
Urinary Tumor Markers for Bladder Cancer 07/01/2025
Urine Culture Testing for Bacteria 07/01/2025
Vitamin B12 and Methylmalonic Acid Testing 07/01/2025
Vitamin D Testing 07/01/2025