October 1, 2015
Last Revised Date:
January 25, 2017
To provide guidelines for the reimbursement of procedure codes for hip arthroscopy when billed with modifier 59.
All plans, products and accounts are included, except
- Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
- Coordination Of Benefits (COB) situations when Horizon BCSNJ is not the primary carrier
All Insured and Administrative Services Only (ASO) accounts are included.
Horizon BCBSNJ shall not separately reimburse for procedure codes 29916, 29862 and 29863 when submitted with a modifier 59.
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.
Reimbursement for procedure codes 29916, 29862 and 29863 will not be considered for separate reimbursement, but will be included within the primary procedure code, even if billed with modifier 59, as follows:
- Deny procedure codes 29916 when billed with 29914 or 29915 regardless of modifier 59
- Deny procedure code 29862 when billed with 29914, 29915 or 29916 regardless of modifier 59
- Deny procedure code 29863 when billed with 29914, 29915 or 29916 regardless of modifier 59
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.
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.
CPT ® is a registered mark of the American Medical Association.