CurrentBlue Cross Blue Shield - MainePolicy C-20005

Treatment Rooms with Office Evaluation and Management Services - Facility

Defines billing and reimbursement rules for treatment room revenue codes and co-reported office E/M or consultation codes in outpatient facility settings for Blue Cross Blue Shield - Maine.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyTreatment Rooms with Office Evaluation and Management Services - Facility

Policy CodePolicy C-20005

Change TypeRevised (material)

Effective DateApr 1, 2026

Next Review Date

Key ActionReport a CPT® or HCPCS code on the UB-04 when billing revenue codes 760, 761, or 769 to avoid denial or recoupment.

SourceLink

POLICY UPDATE CHANGES

Policy expanded to include revenue codes 760 and 769 when billed with office E/M codes and denies facility claim lines if revenue codes 760, 761 or 769 are not billed with an accompanying CPT® or HCPCS code on a UB-04.

3revenue codes explicitly called out (760, 761, 769)

UB-04required form

CMS, EncoderProreferences

Coverage and Billing Rules

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The plan requires reporting CPT® or HCPCS codes when billing treatment room revenue codes in an outpatient facility unless provider, state, federal contracts and/or mandate indicate otherwise.

Office evaluation and management (E/M) and office consultation services are not reimbursable when reported along with revenue codes 760, 761, or 769.

Revenue codes 760, 761, or 769 must be billed with an accompanying CPT® or HCPCS code on the UB-04; if billed without an accompanying CPT® or HCPCS code, the facility claim line may be denied and payment may be recovered or recouped.

Relevant Codes and Billing Requirements

Treatment room revenue codes referencedRevenueCovered

760	Treatment room revenue code (facility)
761	Treatment room revenue code (facility)
769	Treatment room revenue code (facility)

Required accompanying code on UB-04

RequirementRevenue codes 760, 761, or 769 must be billed with an accompanying CPT® or HCPCS code on the UB-04; failure to do so may result in the facility claim line being denied or payment recouped.

Applicable formsUB-04 is the required claim form for submitting facility lines with revenue codes 760, 761, or 769.

Operational changePolicy was updated to expand requirements to include revenue codes 760 and 769 when billed with office E/M codes (effective 01/01/2024; review approved 10/01/2023).

Consequence of noncomplianceIf revenue codes 760, 761, or 769 are not billed with an accompanying CPT® or HCPCS code, the facility claim line may be denied and payment may be recouped.

Authorization and Billing Compliance

Documentation Required

Authorization, coding, and documentation compliance

Ensure services meet authorization and medical necessity guidelines and follow applicable provider, state, and federal mandates. Use proper CPT/HCPCS and revenue codes on all claim submissions; services must be fully supported in the medical record and/or office notes. Failure to follow appropriate coding/billing guidelines or current reimbursement policies may result in claim rejection or denial, and the plan may recover or recoup payment.

Report CPT® or HCPCS codes when billing treatment room revenue codes in an outpatient facility unless overridden by provider, state, or federal mandates.
Ensure documentation in the medical record and/or office notes supports billed CPT/HCPCS and revenue codes.
Be aware that noncompliance with coding/billing guidelines may lead to rejection, denial, or recoupment of payment.

Policy Definitions

Definitions and key reimbursement terms

DefinitionsGeneral reimbursement policy definitions (see policy for full definitions).

Reporting requirementThe health plan requires reporting of CPT® or HCPCS codes for treatment room revenue codes in an outpatient facility setting unless provider, state, or federal contracts/mandates indicate otherwise.

Non‑reimbursable servicesOffice evaluation and management services are not reimbursable when reported along with revenue codes 760, 761, or 769.

Policy basisPolicy developed with reference to CMS and Optum EncoderPro 2024; effective dates and revision history are documented in References and Research Materials.