Reimbursement Policy — Treatment Rooms
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Governance of reporting and reimbursement rules for treatment room revenue codes 0760, 0761, and 0769 on outpatient facility claims for Anthem Blue Cross Medicare Advantage providers in California.
No material clinical or coverage changes in this revision.
Treatment Room Coverage Criteria
Treatment room coverage criteria
Reimbursement stance for services billed with treatment room revenue codes
ALL of the following
- Report appropriate CPT or HCPCS codes for treatment room revenue codes 0760, 0761, and 0769 on an outpatient facility claim unless provider, state, or federal contracts or mandates indicate otherwise.
- Policy applies regardless of reimbursement methodology.
Non-reimbursable when billed with treatment room revenue codes
- New or established evaluation and management (E/M) services reported with revenue codes 0760, 0761, or 0769 are not reimbursable.
- HCPCS code G0463 (hospital outpatient clinic visit) reported with revenue codes 0760, 0761, or 0769 is not reimbursable.
Disallowed same-claim revenue code combinations
- Emergency room (045X)
- Outpatient surgery (036X)
- Recovery room (071X)
- Observation (0762)
- Clinic (051X)
- Freestanding clinic (052X)
Treatment Room and Related Codes
| 0760 | Treatment room revenue code |
| 0761 | Treatment room revenue code |
| 0769 | Treatment room revenue code |
| G0463 | Hospital outpatient clinic visit |
| 045X | Emergency room |
| 036X | Outpatient surgery |
| 071X | Recovery room |
| 0762 | Observation |
| 051X | Clinic |
| 052X | Freestanding clinic |
Claim Reporting and Provider Responsibilities
Report CPT/HCPCS when billing treatment room revenue codes; consequences for noncompliance
Report the appropriate CPT or HCPCS codes on outpatient facility claims when billing treatment room revenue codes 0760, 0761, or 0769, unless provider, state, or federal contracts/mandates state otherwise. Failure to follow coding/billing guidelines may result in claim rejection or denial, recovery/recoupment of payment, or adjustment of reimbursement to reflect appropriate services performed.
- Report CPT or HCPCS codes on outpatient facility claims when using revenue codes 0760, 0761, or 0769 unless overridden by contract or mandate.
- Noncompliance may result in claim rejection or denial, recovery/recoupment of claim payment, or adjustment of reimbursement.
Referenced Definitions
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