Reimbursement Policy Treatment Rooms
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Governs reporting and reimbursement rules for treatment room revenue codes 0760, 0761, and 0769 on outpatient facility claims for Anthem Blue Cross and Blue Shield Medicare Advantage lines in listed states; affects facility providers submitting outpatient claims.
No material clinical or coverage changes in this revision.
Treatment Room Reporting and Reimbursement Rules
Treatment room reporting and reimbursement criteria
Covered when ALL of the following are met:
AND the following exclusions apply
- New or established evaluation and management (E/M) services reported on the same claim with revenue codes 0760, 0761, or 0769 are not reimbursed.
- HCPCS code G0463 (hospital outpatient clinic visit) reported on the same claim with revenue codes 0760, 0761, or 0769 is not reimbursed.
- Revenue codes 0760, 0761, and 0769 are not permitted on the same claim with emergency room (045X), outpatient surgery (036X), recovery room (071X), observation (0762), clinic (051X), or freestanding clinic (052X) revenue codes.
Codes, Reporting Requirements, and Disallowed Codes
| 0760 | Treatment room revenue code - requires accompanying CPT or HCPCS codes; not reimbursed with E/M services or G0463 on same claim. |
| 0761 | Treatment room revenue code - requires accompanying CPT or HCPCS codes; not reimbursed with E/M services or G0463 on same claim. |
| 0769 | Treatment room revenue code - requires accompanying CPT or HCPCS codes; not reimbursed with E/M services or G0463 on same claim. |
| G0463 | Hospital outpatient clinic visit - not reimbursed when reported along with revenue codes 0760, 0761, or 0769. |
Prior Authorization and Claim Submission Expectations
Prior authorization and claim submission expectations for treatment room revenue codes
Do not report new or established evaluation and management (E/M) services or HCPCS code G0463 on the same claim as treatment room revenue codes 0760, 0761, or 0769. Report the required CPT or HCPCS procedure codes with revenue codes 0760, 0761, and 0769 on outpatient facility claims unless provider, state, or federal contracts/mandates indicate otherwise.
- E/M services reported with revenue codes 0760, 0761, or 0769 are not reimbursed.
- HCPCS G0463 reported with revenue codes 0760, 0761, or 0769 is not reimbursed.
- CPT or HCPCS codes must be reported for revenue codes 0760, 0761, and 0769 on outpatient facility claims unless overridden by contract or mandate.
- Follow authorization and medical necessity guidelines; improper coding may result in claim rejection, denial, recovery, or adjusted reimbursement.
Policy Definitions
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