CurrentAnthemPolicy C-15004

Facility Guidelines for Claims Related to Professional Services - Facility

Defines when professional services must be billed on CMS-1500 vs UB-04 and reimbursement stance for facility-related professional services for Anthem commercial plans; applies to providers submitting claims to the plan.

Policy Summary

PayerAnthem

PolicyFacility Guidelines for Claims Related to Professional Services - Facility

Policy CodePolicy C-15004

Change TypeRevision (non-material)

Effective Date04/01/2026

Next Review Date

Key ActionEnsure professional services are billed on CMS-1500 unless provider, state, or federal contracts or mandates indicate otherwise; improper billing may result in rejection, denial, or recoupment.

SourceLink

POLICY UPDATE CHANGES

Policy title and content edited (removed Evaluation and Management from policy title; added guidance on professional services billed under revenue codes 960-989 when submitted on a UB-04 and added Preventive Counseling CPTs when billed in an outpatient setting).

C-15004Policy identifier

04/01/2026Effective date

01/01/2026Last approval

960-989Not allowed on UB-04

99281-99285ER E/M reimbursed

Coverage and Billing Rules

Coverage and billing rules for professional services

Billing and reimbursement stance for professional services in facility contexts:

Professional services are not allowed when billed on a UB-04 claim form unless provider, state, federal contracts and/or mandates indicate otherwise.

Revenue codes 960-989 (professional fees) are not allowed for reimbursement when submitted on a UB-04; these professional services should only be billed with the applicable HCPCS/CPT code on a CMS-1500 claim form.

Evaluation and Management (E/M) services rendered in an office, professional building, medical office building, clinic, or a space owned by or rented from a hospital or institutional provider must be billed on a CMS-1500 claim form.

Evaluation and Management (E/M) services rendered within the primary structure of a facility must be billed on a CMS-1500 claim form.

Policy Summary

PayerAnthem

PolicyFacility Guidelines for Claims Related to Professional Services - Facility

Policy CodePolicy C-15004

Change TypeRevision (non-material)

Effective Date04/01/2026

Next Review Date

SourceLink

On This Page

Relevant CPT / HCPCS and Revenue Codes

Referenced CPT/HCPCS ranges and codesCPT | HCPCS

99202-99499	Evaluation and Management CPT range referenced for E/M services
99281-99285	Emergency Room E/M codes reimbursed when billed under appropriate revenue codes
G0380	ER related HCPCS; reimbursed when billed under appropriate revenue codes
G0384	ER related HCPCS; reimbursed when billed under appropriate revenue codes
99401-99404, 99411-99412	Preventive Counseling CPTs noted as added for outpatient setting per revisions

Revenue codes not allowed on UB-04RevenueNot Covered

960-989

Professional fees — not allowed for reimbursement when submitted on a UB-04; must be billed on CMS-1500 with applicable HCPCS/CPT

Revenue codes not allowed on UB-04

Revenue code range not allowed on UB-04960-989 — professional fees submitted on UB-04 are not allowed for reimbursement; must be billed on CMS-1500 with applicable HCPCS/CPT.

Required billing form for professional servicesProfessional services billed under revenue codes 960-989 should be submitted on a CMS-1500 claim form using the applicable HCPCS/CPT code.

Exception for ER E/M reimbursementEmergency Room E/M codes (99281-99285, G0380-G0384) will be reimbursed when billed under appropriate revenue codes, but ER professional services still must be billed on CMS-1500.

Services rendered off primary hospital structureServices rendered outside the primary structure on a hospital or institutional campus shall not be billed or reimbursed on a UB-04 and must be billed on a CMS-1500 by the rendering provider.

Billing Form Requirements and Compliance Actions

Billing Rule

Submit professional services on CMS-1500; follow billing guidelines to avoid denials/recoupment

Ensure professional services are submitted on the CMS-1500 claim form unless a provider, state, federal contract or mandate requires otherwise; failure to follow form requirements may result in claim rejection, denial, or recovery of payment. Use proper billing and submission guidelines, including industry-standard CPT, HCPCS and revenue codes, and ensure codes are fully supported in the medical record or office notes.

Revenue codes 960-989 (professional fees) are not allowed for reimbursement when submitted on a UB-04 and must be billed on a CMS-1500 with the applicable HCPCS/CPT code.
Evaluation and Management and Preventive Counseling services rendered in facility outpatient settings, outside the primary hospital structure, or in professional/clinic spaces must be billed on CMS-1500.
Emergency Room E/M codes (99281-99285, G0380-G0384) may be reimbursed when billed under appropriate revenue codes, but professional ER services must still be billed on a CMS-1500.
Noncompliance (incorrect form or coding) may lead to claim rejection/denial and/or recovery/recoupment of payments.

Key Definitions

Evaluation and Management Services

E/M CPT code rangeCPT codes 99202-99499 represent Evaluation and Management (E/M) services for visits involving evaluating and managing patient health.

Emergency Room E/M codes reimbursedE/M codes 99281-99285 and HCPCS G0380-G0384 will be reimbursed when billed under the appropriate revenue codes.

Billing form requirement for E/M servicesEvaluation and Management services rendered in offices, clinics, or facility outpatient settings must be billed on a CMS-1500 claim form rather than a UB-04.

Definition of E/M servicesEvaluation and management coding applies to services provided by a physician or other qualified healthcare professional that involve evaluating and managing patient health.