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Outpatient Facility Code Edits: Bundling and Revenue Codes

Reimbursement Policy:
Outpatient Facility Code Edits: Bundling and Revenue Codes

Effective Date:
August 1, 2021

End Date:
December 31, 2021

Purpose:
To provide billing guidelines for Bundling and Revenue Code policy on outpatient acute care and ancillary facility claims.

Scope:
All products are included, except

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
  • Horizon NJ Health
  • Flex Link
  • ITS Home Par
  • ITS Host Medicare Advantage (PPO OON)
  • MPL
  • COB

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

Policy:
Horizon BCBSNJ shall start to apply the following code editing concepts. Bundling is a coding concept and packaging is a payment concept. Also Horizon will require revenue codes to be billed with the corresponding CPT/HCPCS code when billed on an OP Facility claims (UB-04). Our guidelines are outlined below.

Bundled Services
Will not be considered for separate reimbursement when submitted on outpatient claims. These codes will not be considered for separate reimbursement if they are the only services billed for a date of service or if they are billed with other services for the same date of service.

Typically packaged codes
May not be considered for separate reimbursement when submitted on outpatient claims if other non-laboratory procedure codes are billed for the same date of service. These codes will only be considered for separate reimbursement if they are the only services billed for a date of service or if they are billed with clinically unrelated services for the same date of service.

Lab codes when billed with other services
May not be considered for separate reimbursement when submitted on outpatient claims if other non-laboratory procedure codes are billed for the same date of service. These codes will only be considered for separate reimbursement if they are the only service billed for a date of service or if they are billed ONLY with other laboratory procedure codes for the same date of service.

Revenue codes requiring HCPCS code
These revenue codes will only be considered for reimbursement on outpatient claims if billed with appropriate HCPCS code(s).

Procedure:
Horizon BCBSNJ shall deny procedure codes when services are always or conditionally bundled as indicated in this policy.

Horizon BCBSNJ shall deny the revenue codes listed within this policy when they are not submitted with a CPT/HCPCS code.

Horizon BCBSNJ shall deny CPT/HCPCS codes that do not match the associated revenue code.

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.

Resources:
American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

History:

06/09/2021: Policy approved

12/31/2021: Policy end dated

Policy146_v1.0_06092021