Enhancement to CMS Always Bundled Edit

Reimbursement Policy:
Enhancement to CMS Always Bundled Edit

Effective Date:
October 1, 2015

Purpose:
The purpose of this policy is to document our enhancement of the current CXT rule logic to deny status “B” codes (bundled procedures) regardless of whether they are billed alone or in conjunction with other services for the same. member, for the same provider, on the same date of service.

Scope: 
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • COB
  • FEP
  • Flex Link
  • ITS Home In – Network
  • ITS Host MA non-PPO
  • ITS Host MA PPO Non-Par
  • MPL

All Insured and Administrative Services Only (ASO) accounts are included.

Policy: 
Horizon BCBSNJ shall not separately reimburse for certain codes that CMS has identified as status "B" codes (bundled procedures). Status B Codes shall not be reimbursed regardless of whether they are billed alone or in conjunction with other services for the same member, for the same provider, on the same date of service. This policy will apply to participating and non-participating professional providers.

As per CMS guidelines, status “B” codes are bundled. Payment for these services is always included in payment for other services not specified. There are no RVUs or payment amounts for these codes, and separate payment is not made.

In denied instances where the provider is participating, there shall be no member liability.

In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association.  In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure: 
Deny procedure codes identified as status “B” (Bundled Codes) when billed alone or in conjunction with other services for the same member, for the same provider, on the same date of service.

Limitations and Exclusions: 
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

Policy 087_v1.0_06032015