Treatment Rooms - Facility
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Defines Anthem's reimbursement policy for reporting and reimbursing treatment room revenue codes in outpatient facility settings; applies to facility providers submitting claims to Anthem commercial plans, with specific state exceptions noted.
Added language to not allow reimbursement for revenue code 0760, 0761, and 0769 when billed with Emergency Room (045X), Outpatient Surgery (036X), Recovery Room (071X), Observation (0762), and Clinic (051X).
Added Wisconsin exemption allowing revenue code 0760/0761/0769 when billed with Clinic (051X) or Freestanding Clinic (052X).
Updated title from Treatment rooms with Office Evaluation and Management Services and added language for new or established patient and consultation.
Treatment Room Reimbursement Criteria
Treatment room revenue code reimbursement criteria
Covered when the following reporting and billing requirements are met; exceptions and state-specific rules apply.
Relevant Codes and Claim Line Requirements
| 0760 | Treatment room - general |
| 0761 | Treatment room - dedicated |
| 0769 | Treatment room - other |
| 045X | Emergency Room revenue code range |
| 036X | Outpatient Surgery revenue code range |
| 071X | Recovery Room revenue code range |
| 0762 | Observation |
| 051X | Clinic |
| 052X | Freestanding Clinic |
Billing Rules and Provider Responsibilities
Prior auth | Billing rules for treatment room revenue codes
Providers must report CPT or HCPCS procedure codes on outpatient facility claim lines reporting treatment room revenue codes (0760, 0761, 0769). The facility claim line may be denied or payment recovered if the required CPT/HCPCS code is not submitted. Reimbursement is not allowed for new or established patient office E/M or consultation CPT codes when reported on the same claim with revenue codes 0760, 0761, or 0769. Revenue codes 0760, 0761, and 0769 are not reimbursed when billed on the same claim with Emergency Room (045X), Outpatient Surgery (036X), Recovery Room (071X), Observation (0762), Clinic (051X), or Freestanding Clinic (052X); Wisconsin allows 0760/0761/0769 when billed with 051X or 052X.
- Required: CPT or HCPCS code must accompany revenue codes 0760/0761/0769 on the UB-04/facility claim line or the line may be denied.
- Do not reimburse new or established patient E/M or consultation CPTs when billed with revenue codes 0760, 0761, 0769.
- Do not reimburse revenue codes 0760/0761/0769 when billed on the same claim with room revenue codes 045X, 036X, 071X, 0762, 051X (except Wisconsin allows 051X or 052X).
Definitions
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