October 1, 2015
To provide guidelines for the reimbursement of procedure codes for knee arthroscopy when submitted 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 shall not separately reimburse for a procedure codes 29874, 29875 and 29876 when submitted with 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.
Procedure codes 29870, 29875, 29876 and 29877 will not be considered for separate reimbursement, but will be included within the primary procedure code, as follows:
- Deny 29870 when billed with 29874, regardless of the use of modifier 59
- Deny 29870 when billed with 29877, regardless of the use of modifier 59
- Deny procedure code 29875 when billed with 29880-29881, regardless of the use of modifier 59
- Deny procedure code 29876 when billed with 29880, regardless of the use 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.