CurrentBlue Cross Blue Shield - NevadaPolicy C-15004

Facility Guidelines for Claims Related to Professional Services - Facility

Governs how professional services should be billed (CMS-1500 vs UB-04) for facility-related outpatient and emergency services for Blue Cross Blue Shield - Nevada commercial lines and specifies when facility claim modifiers apply.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyFacility Guidelines for Claims Related to Professional Services - Facility

Policy CodePolicy C-15004

Change TypeMaterial updates to modifier use and coding clarifications

Effective DateApr 1, 2026

Next Review Date

Key ActionDo not bill professional services on a UB-04; bill on CMS-1500 for E/M and preventive counseling services or append PN/PO/ER modifiers on outpatient UB-04 when applicable.

SourceLink

POLICY UPDATE CHANGES

Modifiers PN, PO, and ER must be appended on outpatient UB-04 claim lines when services are not billed on a CMS-1500, with specific meanings for off-campus non-contracted, off-campus contracted, and off-campus emergency department services.

Updated Definitions by adding 'Provider-based off-campus emergency department'.

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

960-989Revenue codes (professional fees) disallowed on UB-04

99281-99285Emergency Room E&M codes reimbursed

PN/PO/ERModifiers required on outpatient UB-04

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Billing and Reimbursement Criteria

Billing and reimbursement criteria

Claims and billing requirements for professional services related to facilities:

The health plan does not allow professional services when billed on a UB-04 claim form unless provider, state, federal contracts and/or mandates indicate otherwise.

ALL of the following

Evaluation and Management services rendered in an office, professional building, medical office building, clinic or a space owned by a hospital or an institutional provider, other than the primary structure on the campus of the hospital or institutional provider, or rented by a professional from the hospital or an institutional provider.
Evaluation and Management services rendered within a primary structure of a facility.
Preventive Counseling services rendered in an outpatient setting of a facility.

ALL of the following

Modifier PN — must be appended for services, procedures and/or surgeries provided at an off‑campus location that is not contracted as part of the hospital agreement (PN reimbursed at 40% of the allowable).
Modifier PO — must be appended for services, procedures and/or surgeries provided at any off‑campus provider‑based outpatient departments that are specifically contracted under the hospital agreement.
Modifier ER — must be appended for outpatient hospital services furnished in an off‑campus provider‑based emergency department.

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

Emergency Room E/M codes (99281–99285, G0380, G0384) will be reimbursed when billed under the appropriate revenue codes; however, professional services for the Emergency Room must be billed on a CMS‑1500 claim form.

Key Codes and Revenue Guidance

Covered CPT/HCPCS and modifier codesmixedCovered

99281-99285	Emergency Room Evaluation and Management codes (reimbursed when billed under the appropriate revenue codes)
G0380	ER visit code (reimbursed when billed under the appropriate revenue codes)
G0384	ER visit code (reimbursed when billed under the appropriate revenue codes)
PN	Nonexcepted service provided at an off-campus, outpatient, provider-based department of a hospital; reimbursed at 40% of the allowable
PO	Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
ER	Items and services furnished by a provider-based, off-campus emergency department

Revenue code prohibition range

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

Action required if billed on UB-04Do not submit professional fees under revenue codes 960-989 on UB-04; instead bill the professional component on a CMS-1500 claim form.

Exception basisExceptions apply only if provider, state, or federal contracts and/or mandates indicate otherwise.

Required Billing Submission Actions

Billing Rule

Billing submission actions — use CMS-1500 for professional services; append PN/PO/ER if on UB-04

Do not bill professional services on a UB-04 claim form unless provider, state, federal contracts and/or mandates indicate otherwise. Evaluation and Management services (as listed) and preventive counseling rendered in outpatient facility settings must be billed on a CMS-1500. If professional services are submitted on a UB-04 outpatient claim instead of CMS-1500, append modifier PN for off-campus non-contracted provider-based departments, PO for off-campus contracted provider-based outpatient departments, or ER for off-campus provider-based emergency department services on each applicable claim line.

Bill E/M services rendered in office, professional building, clinic, or space owned/rented by a hospital on CMS-1500.
Bill E/M services rendered within the primary structure of a facility on CMS-1500.
Bill preventive counseling services rendered in an outpatient facility setting on CMS-1500.
If billing these professional services on UB-04, append PN, PO, or ER as defined for each claim line.

Key Definitions

Evaluation and Management Services (E/M)

DefinitionEvaluation and Management (E/M) services use CPT codes from the range 99202-99499 to represent services provided by a physician or other qualified healthcare professional for evaluating and managing patient health.

Typical settingsE/M services rendered in office, professional building, medical office building, clinic, or a space owned or rented by a hospital should be billed on a CMS-1500.

Related billing guidanceWhen E/M services are submitted on an outpatient UB-04 instead of CMS-1500, append PN/PO/ER modifiers as applicable per policy.

Provider-based off-campus emergency department

DefinitionProvider-based off-campus emergency department: any department or facility of the hospital that meets at least one of these: state-licensed as an emergency room/department; held out to the public as providing urgent emergency care without scheduled appointments; or, in the prior calendar year, at least one-third of outpatient visits were for emergency medical conditions on an urgent basis without scheduled appointments.