Treatment Rooms - Facility
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Governs reporting and reimbursement rules for treatment room revenue and associated CPT/HCPCS coding in outpatient facility claims for Anthem commercial lines; applies unless overridden by provider, state, or federal mandates.
Added language disallowing reimbursement for new or established patient office E/M or consultation service codes when reported with revenue codes 0760, 0761 or 0769.
Specified that revenue codes 0760, 0761, and 0769 are not allowed when billed on the same claim with certain room revenue codes (Emergency Room 045X, Outpatient Surgery 036X, Recovery Room 071X, Observation 0762, Clinic 051X/Freestanding Clinic 052X).
Updated title and clarified scope to include new or established patient and consultation services.
Treatment Room Billing — Coverage Criteria
Treatment room billing criteria
Criteria for when facility reimbursement is allowed or disallowed:
ALL of the following
- Policy may be superseded by provider, state, federal contracts or mandates; follow applicable mandates where present.
- Facility claims that include treatment room revenue codes (0760, 0761, 0769) must report an accompanying CPT or HCPCS code on the UB-04; absence may result in denial or recoupment.
ALL of the following
- Deny reimbursement for new or established patient office E/M or consultation CPT/HCPCS codes when reported with revenue codes 0760, 0761, or 0769.
ALL of the following
- Emergency Room (045X)
- Outpatient Surgery (036X)
- Recovery Room (071X)
- Observation (0762)
- Clinic (051X)
- Freestanding Clinic (052X)
ALL of the following
- If appropriate coding/billing guidelines or current reimbursement policies are not followed, the plan may reject or deny the claim, and may recover or recoup payments.
Restricted Revenue Code Combinations & Required Coding
| 045X | Emergency Room |
| 036X | Outpatient Surgery |
| 071X | Recovery Room |
| 0762 | Observation |
| 051X | Clinic |
| 052X | Freestanding Clinic |
Billing and Authorization Guidance
Billing and authorization guidance — report CPT/HCPCS and follow authorization/medical necessity
Report CPT® or HCPCS codes on outpatient facility claims that include treatment room revenue codes (0760, 0761, 0769); follow applicable authorization and medical necessity guidelines and member benefit or regulatory mandates. Failure to include required CPT/HCPCS coding or to follow authorization/medical necessity requirements may result in claim denial, rejection, or recoupment.
- Facility claim lines with revenue codes 0760, 0761, 0769 must include an accompanying CPT or HCPCS code on the UB-04 or may be denied.
- Policy may be superseded by provider, state, federal contracts and/or mandates — follow applicable mandates where present.
- Noncompliance with billing/submission or authorization/medical necessity guidelines may lead to claim rejection, denial, or recovery/recoupment.
Treatment Room Revenue Code Definitions
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