CurrentBlue Cross Blue Shield - New MexicoPolicy CPCP002

Inpatient/Outpatient Unbundling Policy - Facility

Defines BCBSNM facility reimbursement rules about unbundling, bundled/routine supplies and services, incidental services, contaminated/waste items, mutually exclusive procedures, and examples of non-reimbursable facility charges; applies to providers submitting facility claims to Blue Cross Blue Shield of New Mexico.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyInpatient/Outpatient Unbundling Policy - Facility

Policy CodePolicy CPCP002

Change TypeNo material change

Effective DateDecember 27, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide supporting documentation upon request; claims are subject to review and code edit protocols.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5.0policy version

2023-12-27effective date

2023-12-21approval date

disposable supplies not reimbursedcoverage stance example

oxygen not reimbursableexplicit exclusion

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4implant revenue codes

Facility Unbundling and Billing Rules

Facility unbundling and bundling criteria

Criteria for non-reimbursement or bundled services (facility):

Contaminated/Not Utilized/Waste: Items that are contaminated, wasted and/or not utilized during the provisioned services on the member are not eligible for reimbursement, including but not limited to: items prepared or opened during a procedure but not used or implanted; non-utilized supplies or DME (e.g., crash carts, emergency drugs); items opened by mistake; change of mind by the surgeon; equipment failure/technical difficulties; surgery case cancellation; and large packages when smaller packaging is appropriate. Disposable supplies (e.g., syringes, needles, testing supplies, sheaths, bags, bandages, gauze, replacement batteries) are ineligible for separate reimbursement.

Incidental Services: Costs of incidental services that are clinically integral to the primary procedure (including technical charges for equipment purchase, rental, and maintenance) may not be billed separately by the provider or another entity.

Routine Bundled Services and Supplies: Routine services/supplies and reusable items provided to members or integral to the service/location are included in the provider's general location or procedure charge and are not separately reimbursable (examples include drapes, saline for flush/irrigation, reusable items, pulse oximeters, blood pressure cuffs, bedside tables). These floor-stock items and items necessary or integral to a specific service or location should not be billed separately.

Routine Supplies, Medical Equipment, and Facility Basic Charges: Daily room and critical care area charges (e.g., ED, observation, treatment room, cardiac, medical, surgical, pediatric, burn, neonate, neuro, rehabilitative, post-anesthesia, trauma) include personal care and supplies, ancillary personnel providing nursing/technical services, equipment and respiratory supplies and services; examples of non-separately billable items include admission/hygiene kits, needles, oxygen masks, linens, drapes, gloves, gowns, bedside equipment, monitors, pumps, and other listed reusable equipment.

Surgical Rooms and Services: Charges for surgical suites and services (major/minor surgical suites, endoscopy, cath labs, procedural rooms) include nursing personnel services, supplies, and equipment as part of the basic/critical care daily room charges and should not be billed separately.

Respiratory/Ventilator/Oxygen Charges: Ventilator and respiratory therapy charges (including respiratory assessment, intubation/extubation, manual ventilation during transport, endotracheal tube care, Ambu bag, ventilator machine(s), breathing/IMV circuits, PEEP, technician time, water, and disposable supplies) and related respiratory services/equipment are included in facility charges. Oxygen charges (including oxygen, water, respiratory therapy technician time, distribution/delivery supplies or equipment such as flow meters, humidifiers, croupette, disposable supplies, nasal cannula/catheter, masks, tent/hood, T-piece, isolette(s)) are not eligible for separate reimbursement and should not be billed separately.

Coding and Claim Review: Claims must be coded using valid HIPAA-approved code sets and follow code edit protocols; providers are responsible for submission of accurate documentation and may be asked to submit additional documentation upon request.

Billing and reimbursement criteria

Billing and reimbursement guidance and restrictions

Oxygen charges are not eligible for separate reimbursement and should not be billed separately.

Implant revenue codes 0274, 0275, 0276, and 0278: If separately reimbursable, billed charges may require a vendor invoice to support supplies used. Vendor invoices must clearly indicate units that match the billed units; if units do not match or are not noted, the revenue codes will be denied unless otherwise agreed upon. If supplies are purchased in bulk, the units applicable to the billed claim must be noted on the invoice or the revenue codes will be denied unless otherwise agreed upon.

Revenue code 0278 should not be billed for item(s) that may be considered supplies. Billing 0278 for supply items may be ineligible for separate reimbursement and considered unbundled under this policy.

Coding and Use of Unlisted Codes: When billing drugs, supplies, services or procedures, select the CPT or HCPCS code that accurately describes the service. Use unlisted codes only if no appropriate code exists; submission of an unlisted code must include supporting documentation.

Codes, Revenue Codes, and Code Set Requirements

Policy identifiermixed

CPCP002

Inpatient/Outpatient Unbundling Policy - Facility

Implant revenue codesRevenueCovered

0274	Pros/Ortho devices revenue code
0275	Pacemaker revenue code
0276	Intraocular Lens revenue code
0278	Other Implants revenue code (should not be billed for items considered supplies)

Code set requirements — valid HIPAA-approved code sets and industry edits

Required code setsClaims must be submitted using valid HIPAA‑approved code sets (CPT, HCPCS, ICD‑10 CM/PCS, NDC, UB, DRG)

Coding guidelines and editsCode selection and claim coding must follow industry standard coding guidelines and CMS edits (e.g., AMA CPT, UB Editor, CMS NCCI/CCI table edits)

Claim review and documentationClaims are subject to code edit protocols and claim review; providers may be asked to submit additional documentation upon request

Provider responsibilityProviders are expected to submit claims using valid code combinations and to code appropriately per standards

Discretion and governanceIf policy conflicts with plan documents or provider contracts, the plan document or contract governs; BCBSNM may exercise reasonable discretion in application

Documentation, Billing Guidance, and Invoicing Requirements

Documentation Required

Documentation and Claim Review — Provider Responsibility

Providers are responsible for submission of accurate documentation of services performed. Providers are expected to submit claims for services rendered using valid code combinations from HIPAA-approved code sets and to code claims appropriately according to industry standard coding guidelines (including but not limited to UB Editor, AMA CPT, CPT Assistant, HCPCS, ICD-10-CM/PCS, NDC, DRG guidelines, CMS NCCI policy manual and CCI table edits). Claims are subject to code edit protocols and claim review for benefit coverage, provider contract language, medical policies, clinical payment and coding policies, and coding software logic. Upon request, the provider must submit any additional documentation to support the services billed.

Submit claims using valid HIPAA-approved code sets and industry-standard coding guidance.
Be prepared to provide additional documentation upon request to support billed services.

Billing Rule

Key Definitions

Unbundling

DefinitionUnbundling occurs when charges are billed that may be represented by or are included in the description of another billed service

Examples and scopePolicy pertains to medical/surgical services, supplies and equipment; routine, incidental or integral items should not be billed separately

ConsequencesCharges determined to be unbundled may be denied as not separately reimbursable under this policy

Mutually Exclusive

DefinitionProcedures that cannot reasonably be performed together or on the same member on the same day based on code definitions or anatomy

ApplicationMutually exclusive coding edits will be applied when procedures meet these criteria to prevent inappropriate multiple billing

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyInpatient/Outpatient Unbundling Policy - Facility

Policy CodePolicy CPCP002

Change TypeNo material change

Effective DateDecember 27, 2023

Next Review Date

Key ActionProviders must submit accurate documentation and may be asked to provide supporting documentation upon request; claims are subject to review and code edit protocols.

SourceLink

On This Page

Use of unlisted codes and supporting documentation

When to use unlisted codesUse an unlisted CPT/HCPCS code only if no appropriate code exists; unlisted codes are a last resort

Supporting documentation requiredSubmission of an unlisted code must include supporting documentation describing the service or item

Vendor invoice units for implant revenue codesFor revenue codes 0274, 0275, 0276, and 0278, vendor invoices may be required and must clearly indicate units that match the billed claim

Bulk purchasesIf supplies are purchased in bulk, the invoice must note the units that apply to the billed claim or revenue codes 0274–0276 and 0278 may be denied

Accuracy of code selectionSelect the CPT/HCPCS code that accurately describes the administered drug(s), service(s) or procedure(s)

Coding and Billing Guidance

When billing for a drug, supply, service, or procedure, select the CPT or HCPCS code that most accurately describes the administered drug(s), service(s), or procedure(s). Use unlisted codes only when no specific CPT/HCPCS code exists; unlisted codes are a last resort and must be submitted with supporting documentation. Ensure coding follows CMS/NCCI edits and other applicable payer rules to avoid denials or downcoding.

Report the most specific CPT/HCPCS code available that describes the service or item.
Use unlisted codes only if no appropriate code exists and include supporting documentation with the claim.
Follow CMS NCCI/CCI and other applicable code-edit protocols to ensure correct code combinations.

Billing Rule

Implant Revenue Code Invoicing (0274, 0275, 0276, 0278)

For inpatient/outpatient hospital claims that include implant revenue codes 0274 (Prosthetic/Orthotic devices), 0275 (Pacemaker), 0276 (Intraocular Lens), and 0278 (Other Implants), providers may be required to submit a vendor invoice supporting the supplies used that correspond to the services rendered. The vendor invoice must clearly indicate the units that apply to the claim; if units are missing or do not match the billed units, those revenue codes may be denied unless otherwise agreed upon. If supplies were purchased in bulk, the invoice must note the specific units applied to the billed claim. Revenue code 0278 should not be used for items appropriately billed as supplies; such charges may be ineligible for separate reimbursement and considered unbundled under this policy.

Vendor invoices may be required to support billed revenue codes 0274, 0275, 0276, and 0278.
Invoice must clearly state units matching billed units; mismatched or missing units may result in denial.
If supplies purchased in bulk, invoice must note units applied to the claim.
Do not bill revenue code 0278 for items that are properly considered supplies; such charges may be ineligible for separate reimbursement.

Provider expectationProviders should not report mutually exclusive procedures as separately payable on the same date of service

Point-of-Care Testing (POC or POCT)

DefinitionPoint‑of‑Care Testing (POC/POCT) is testing performed near or at the site of the member with results that may change care

Coding guidanceSelect CPT/HCPCS codes that accurately describe the POC test performed; follow standard coding rules for laboratory and POC services

DocumentationDocument test performed, location, and how results impacted care; submit supporting documentation if requested

Ventilator charges

Included componentsVentilator charges include respiratory assessment, intubation/extubation, manual ventilation during in‑hospital transport, and endotracheal tube care

Equipment and disposablesComponents include Ambu bag, ventilator machine(s), breathing circuit, IMV circuit, PEEP, water, and disposable ventilator supplies

Personnel timeTechnician time associated with ventilator services is included in ventilator charges

Oxygen charges

Policy stanceOxygen charges are not eligible for separate reimbursement

Included componentsOxygen charges include oxygen, water, respiratory therapy technician time, distribution/delivery supplies or equipment (e.g., flow meter, humidifier, croupette)

Disposable supplies and interfacesAll disposable supplies (nasal cannula, nasal catheter), associated masks, tent/hood, T‑piece, and isolette(s) are part of oxygen charges

Billing instructionDo not bill oxygen components separately; such charges are not separately reimbursable under this policy