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Medical Policy Revision: Observation Care

Effective February 25, 2015, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider claims for services provided to members in an observation care setting based on the guidelines of our revised medical policy, Observation Care.

Claims submitted for care provided on or after February 25, 2015 to a member who has remained in an observation care setting for more than 48 hours and include one or more of the CPT® codes listed below will pend while information required for us to determine medical necessity of the service(s) is requested and reviewed.

CPT Codes: 99217, 99218, 99219, 99220, 99224, 99225, 99226, 99234, 99235 or 99236

Following our review, the codes above will be allowed if our medical criteria are met, or denied as "not medically necessary" if our medical criteria are not met.

Review this revised policy in our online Medical Policy Manual.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after February 25, 2015.

CPT® is a registered mark of the American Medical Association.

Published on: November 26, 2014, 09:00 a.m. ET
Last updated on: November 24, 2020, 23:15 p.m. ET