CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

Facility Billing Guidelines

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Outpatient facility claims editing and reimbursement rules applied by Blue Cross and Blue Shield of North Carolina for commercial, ASO, and Blue Card Host members; describes scenarios, bill types, revenue code and modifier requirements that affect facility claim payment.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyFacility Billing Guidelines

Policy CodePolicy N/A

Change TypeMaterial updates — additions, clarifications, and reimbursement adjustments

Effective DateApr 3, 2026

Last ReviewApr 3, 2026

Next Review DateApr 1, 2026

Key ActionProviders must bill services using appropriate CPT®, HCPCS, and/or revenue codes supported by documentation in the medical record; follow CPT, HCPCS, UB-04, and ICD-10 guidance and industry coding edits.

SourceLink

POLICY UPDATE CHANGES

End Stage Renal Disease (ESRD) bill type requirements added.

PTA and OTA modifier CO and CQ reimbursement reduction added (services reimbursed at 85% of allowable).

Clarification that Hospital at Home services are not eligible for reimbursement unless submitted with revenue code 161 and Occurrence Span Code 82.

Recovery room services are not eligible for separate reimbursement if anesthesia or moderate sedation is not performed during the primary procedure.

multipledistinct non-reimbursable scenarios

85%PTA/OTA reimbursement rate w/ CO/CQ

Rev Code 161 + Occ Span 82Hospital at Home required submission

Rev Code 0637non-reimbursable without HCPCS

Non-reimbursable Scenarios & Billing Requirements

Non-reimbursable scenarios and billing requirements

Outpatient facility services are not eligible for reimbursement unless the specific billing elements or situational exceptions listed below are met:

Prisoner or member in state or local custody (Condition Code 63) claims require modifier QJ to be appended to codes to indicate exception criteria have been met; bill types must reflect the location of services.

Digital Breast Tomosynthesis (G0279) is eligible only in specified facility settings and must be billed with appropriate revenue codes and bill types reflecting the setting (inpatient hospital, outpatient hospital, inpatient SNF, outpatient SNF, outpatient critical access).

Clinical trial services performed in an outpatient facility require all three of the following for proper processing: appropriate clinical trial modifier (Q0 or Q1), a condition code indicating qualifying clinical trial, and an outpatient hospital bill type.

Donor services reported with revenue code 0815 (allogeneic stem cell acquisition/donor services) are reimbursable only when submitted with inpatient hospital, outpatient hospital, or special facilities‑critical access hospital bill types.

EMTALA screening and related ED evaluation coding: reimbursement of revenue code 0452 requires presence of 0451 on the same date; E/M services using revenue code 0450 are not separately reimbursable when submitted with 0451 or 0452 on the same date of service.

End Stage Renal Disease (ESRD) facility services billed with bill type 0720–072Z must include condition code 84 or, if submitted without condition code 84, must include a principal diagnosis of ESRD; when bill type 0720–072Z is submitted with condition code 84, G0491 must be appropriately reported.

Federally Qualified Health Center (FQHC) visit codes (G0466–G0470): only 1 unit of any FQHC visit or up to 3 units for a combination of FQHC visits are eligible for reimbursement on a single date of service; when billing combinations, appropriate modifiers must be appended; G0469 (FQHC mental health new patient) is not eligible for PPS reimbursement if G0466 (FQHC new patient) is also present on the claim.

Home health services provided on a date of service that is after an inpatient, skilled nursing facility, or swing‑bed hospital admission date and prior to discharge are not eligible for reimbursement.

Hospital at Home (CMS Acute Hospital Care at Home) services are not eligible for reimbursement unless submitted with Revenue code 161 and Occurrence Span Code 82.

Hospital observation services and hospital emergency department visit facility billing: reimbursement will not occur if these services are billed with revenue codes 0960–0989 (professional fee) or with modifier 26, as those codes/modifier are exclusive to professional billing and not eligible on a facility claim.

Outpatient services rendered during an inpatient admission (date of service after admission and prior to discharge) are not eligible for reimbursement on a facility claim, except ambulance services as noted separately.

Services administered in whole or in part by a Physical Therapy Assistant (PTA) or Occupational Therapy Assistant (OTA) are eligible for reimbursement only when submitted with modifier CO or CQ; such services are reimbursed at 85% of the allowable amount.

Revenue codes 0960–0989 representing professional services are not eligible for reimbursement on a facility claim and must be submitted on a CMS‑1500 professional claim form.

Recovery room services are not eligible for separate reimbursement if anesthesia or moderate sedation is not performed during the primary procedure.

Rural Health Clinic (RHC) services must be billed with the appropriate revenue code representing a free‑standing clinic or behavioral health treatment/service and an applicable HCPCS/CPT code; only one qualifying medical visit and one qualifying mental health visit are reimbursed per date of service unless modifiers justify additional units; preventive services (other than G0402 initial preventive exam) are not reimbursed in addition to an RHC qualifying medical service on the same date of service.

Self‑administered drugs billed with revenue code 0637 are not reimbursable when submitted without an appropriate HCPCS code.

Skin substitute application procedures must be billed together with the appropriate high‑cost or low‑cost skin substitute product codes to be eligible for reimbursement.

Ultrasound screening for abdominal aortic aneurysm (AAA) is reimbursable only in specified settings (inpatient hospital, outpatient hospital, inpatient SNF, outpatient SNF, RHC, freestanding clinic, outpatient critical access center) and bill types must reflect the setting.

HCPCS/CPT References, Billing Constraints, and Code-Specific Rules

FQHC Visit Units per Date of Service

FQHC visit units per date of serviceOnly 1 unit of any FQHC visit is eligible for reimbursement on a single date of service, or up to 3 units when providing a combination of FQHC visit codes (G0466–G0470) with the appropriate modifier appended.

Modifier requirement for combinationsWhen billing a combination of FQHC visits (to reach up to 3 units), the appropriate modifier must be appended to the claim line.

G0469 exclusion with G0466G0469 (FQHC mental health new patient) reported for PPS payment is not eligible for reimbursement if G0466 (FQHC new patient visit) is also present on the claim.

Claim Coding and Documentation Requirements

Documentation Required

Claim coding and documentation requirements

Providers must bill services using appropriate CPT®, HCPCS, and/or revenue codes supported by documentation in the medical record; follow CPT, HCPCS, UB-04, and ICD-10 guidance and industry coding edits (NCCI, OCE, MUE). Failure to follow correct coding or reimbursement guidelines may result in claim review, denial, or recovery of payment.

Maintain medical records and standards of care consistent with scope of practice, regulatory, and licensure requirements.
Include and retain any AI-generated content, recordings, or transcripts when applicable as part of the medical record.
Adhere to coding guidance from CPT®, HCPCS, UB-04, ICD-10 and industry edits (NCCI, OCE, MUE).

Definitions and Specific Conditions

Prisoner or Member in State or Local Custody (Condition Code 63)

DefinitionPrisoner or member in state or local custody is represented by Condition Code 63.

Reimbursement ruleReimbursement will not occur for services provided to prisoners or members in state or local custody unless modifier QJ is appended indicating certain exception criteria have been met.

Bill type requirementBill types must reflect the services received and align with the location where the services were rendered.

Services Provided Under CMS Acute Hospital Care at Home

DefinitionHospital at Home refers to services provided under CMS Acute Hospital Care at Home.

General reimbursement stanceHospital at Home services are not eligible for reimbursement unless specific billing elements are submitted.

Required submission elementsTo be processed for reimbursement, Hospital at Home services must be submitted with revenue code 161 and Occurrence Span Code 82.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyFacility Billing Guidelines

Policy CodePolicy N/A

Change TypeMaterial updates — additions, clarifications, and reimbursement adjustments

Effective DateApr 3, 2026

Last ReviewApr 3, 2026

Next Review DateApr 1, 2026

SourceLink

On This Page

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Facility Billing Guidelines

Customize your policy alerts

Sign up for all Blue Cross Blue Shield - North Carolina policy alerts

Know when Blue Cross Blue Shield - North Carolina releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Non-reimbursable Scenarios & Billing Requirements

Non-reimbursable scenarios and billing requirements

Outpatient facility services are not eligible for reimbursement unless the specific billing elements or situational exceptions listed below are met:

Hospital at Home (CMS Acute Hospital Care at Home) services are not eligible for reimbursement unless submitted with Revenue code 161 and Occurrence Span Code 82.

Revenue codes 0960–0989 representing professional services are not eligible for reimbursement on a facility claim and must be submitted on a CMS‑1500 professional claim form.

Recovery room services are not eligible for separate reimbursement if anesthesia or moderate sedation is not performed during the primary procedure.

Self‑administered drugs billed with revenue code 0637 are not reimbursable when submitted without an appropriate HCPCS code.

Skin substitute application procedures must be billed together with the appropriate high‑cost or low‑cost skin substitute product codes to be eligible for reimbursement.

HCPCS/CPT References, Billing Constraints, and Code-Specific Rules

FQHC Visit Units per Date of Service

Modifier requirement for combinationsWhen billing a combination of FQHC visits (to reach up to 3 units), the appropriate modifier must be appended to the claim line.

G0469 exclusion with G0466G0469 (FQHC mental health new patient) reported for PPS payment is not eligible for reimbursement if G0466 (FQHC new patient visit) is also present on the claim.

Claim Coding and Documentation Requirements

Documentation Required

Claim coding and documentation requirements

Maintain medical records and standards of care consistent with scope of practice, regulatory, and licensure requirements.
Include and retain any AI-generated content, recordings, or transcripts when applicable as part of the medical record.
Adhere to coding guidance from CPT®, HCPCS, UB-04, ICD-10 and industry edits (NCCI, OCE, MUE).

Definitions and Specific Conditions

Prisoner or Member in State or Local Custody (Condition Code 63)

DefinitionPrisoner or member in state or local custody is represented by Condition Code 63.

Bill type requirementBill types must reflect the services received and align with the location where the services were rendered.

Services Provided Under CMS Acute Hospital Care at Home

DefinitionHospital at Home refers to services provided under CMS Acute Hospital Care at Home.

General reimbursement stanceHospital at Home services are not eligible for reimbursement unless specific billing elements are submitted.

Required submission elementsTo be processed for reimbursement, Hospital at Home services must be submitted with revenue code 161 and Occurrence Span Code 82.