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Occupational Therapy Codes Reimbursement Update

As of May 31, 2017, Horizon Blue Cross Blue Shield of New Jersey no longer includes CPT® codes 97532 and 97533 as part of our maximum per-visit reimbursement approach for outpatient therapy services.

CPT codes 97532 and 97533 included on claims submitted for services rendered on and after June 1, 2017 will be reimbursed at the appropriate Horizon BCBSNJ fee schedule.

Our recently posted Outpatient Therapy Daily Maximum reimbursement policy outlines our approach to reimbursing certain physical therapy and occupational therapy services on a maximum per-visit basis. This policy lists the CPT and HCPCS codes for outpatient therapy services that are reimbursed at a limited maximum allowed amount per member, per day.

If you have questions, please contact your Network Specialist.


Fee Schedule Inquiry Tool

Fee schedule information is available on our online Fee Schedule Inquiry tool. To access this information, please log into NaviNet.net, select Horizon BCBSNJ from the My Health Plans menu and:

  • Mouse over Claim Management
  • Select Fee Request Inquiry

To view allowances for specific codes:

  • Select your Billing Provider number, County and Specialty
  • Enter the desired CPT® and/or HCPCS codes
  • Select Submit

Reimbursement of E&M services

Please note that significant, separately identifiable Evaluation & Management (E&M) services may be eligible for separate reimbursement if:

  • The appropriate level of E&M service is billed.
  • The appropriate modifier is appended to the E&M service, which is above and beyond the other services provided.
  • The reason for the E&M service is clearly documented in the member’s medical record and this documentation supports that the member’s condition required the significantly, separate E&M service.
  • The services in question have not been specifically identified as part of an impacted code pair combination in our claim processing logic that prevents separate reimbursement (even if the E&M code is appended with a modifier).

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

Published on: July 24, 2017, 15:06 p.m. ET
Last updated on: July 24, 2017, 15:08 p.m. ET