We have completed our review of the 20 de outubro23 CPT code changes, including any category II performance measurement tracking codes and category II temporary codes for emerging technology. These updates will be added to our claims processing system and are effective 1 de outubro, 2023. The list includes codes that have special coverage or payment rules for standard products. (Some employers may customize their benefits.) We have included codes for services that are:
- “Not Covered" – This includes services not covered in the main member certificate (e.g., covered as a prescription drug).
- “Not Medically Necessary" – This indicates services where there is insufficient evidence to support it.
- “Not Separately Reimbursed" – Services that are not separately reimbursed are generally included in payment for another service or are reported using another code and may not be billed to your patient.
- “Subject to Medical Review" – Preauthorization is recommended for commercial products and required for BlueCHiP for Medicare.
- “Invalid" – Use alternate procedure codes, such as a CPT or HCPCS code.
- “Medicare Lab Network" – Codes that are reimbursed to a hospital laboratory outside of the laboratory network, physicians, or urgent care center providers for BlueCHiP for Medicare.
- “Pending CMS determination" – For BlueCHiP for Medicare Category III codes.
Please submit your comments and concerns regarding coverage and payment designations to:
Email: Medical.Policy@bcbsri.org
Mail:
Blue Cross & Blue Shield of Rhode Island
Attention: Medical Policy, CPT Review
500 Exchange Street
Providence, Rhode Island 02903
Please note that as a participating provider, it is your responsibility to notify members about non-covered services prior to rendering them.
CPT is a registered trademark of the American Medical Association.
20 de outubro23 CPT Updates:
Please note: Coverage and/or payment rules for code(s) below may be subject to change for Medicare Advantage plans and/or commercial products.
The following code(s) are covered and are separately reimbursed for professional and institutional providers for Medicare Advantage plans and commercial products:
0402U 0403U 0404U 0405U 0406U 0407U 0409U 0410U 0413U 0414U 0415U 0416U 0418U 0019M
The following code(s) are covered under the pharmacy benefit only and are separately reimbursed for professional and institutional providers for Medicare Advantage plans and commercial products:
0408U 0411U 0419U
The following codes are not medically necessary for professional and institutional providers for both Medicare Advantage plans and commercial products:
0412U
The following codes are subject to medical review for professional and institutional providers for both Medicare Advantage plans and commercial products:
0417U