CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPO34

Unbundling Policy-Professional Providers

Governs reimbursement for professional provider services, equipment and supplies that may be bundled or ineligible for separate payment; applies to in-network and out-of-network professional/ancillary providers under BCBSOK plan documents.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyUnbundling Policy-Professional Providers

Policy CodePolicy CPCPO34

Change TypeNo material change

Effective DateApr 5, 2022

Next Review Date

Key ActionProvider may be required to submit supporting documentation upon request; claims may be reviewed and denied if not supported or not adhering to coding/billing guidelines.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

listexamples

includedglobal package

IN and OONapplies to

4/5/2022plan effective

Coverage Criteria for Bundling and Reimbursement

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ALL of the following

ONE of
- Services and supplies included in the global surgical package are not eligible for separate reimbursement.
- Incidental services and technical charges that are clinically integral to the primary procedure are excluded from separate payment.
- Procedures defined as mutually exclusive (cannot reasonably be performed together on the same patient on the same day based on code definitions or anatomic considerations) are not separately reimbursable.
- Routine equipment and supplies that are commonly furnished or are a usual part of a surgical/medical procedure, office visit or office procedure (examples include exam room items, disposable minor supplies, drapes, saline, gloves, syringes, needles, bandages, IV pumps/tubing, oximeters, etc.) should not be billed separately and are ineligible for separate reimbursement.
- Supplies that were prepared/opened but not used, considered contaminated or waste (including change of mind, opened by mistake, equipment failure/technical difficulties, cancellation, or oversized packaging) are not eligible for reimbursement.

ALL of the following

Appropriate HIPAA‑approved codes that describe services and supplies actually performed or utilized must be submitted; submission should be fully supported in the medical record.
Modifiers may be appended only when clinically supported and the correct modifier‑to‑procedure code combination is used; modifiers must not be used to circumvent NCCI PTP edits.
The plan reserves the right to request supporting documentation; failure to provide documentation or unsupported coding/modifier use may result in claim denial.

ALL of the following

The global surgical package applies across settings (inpatient, outpatient, ASC, office) and includes related services and supplies routine and necessary before, during and after a procedure.
Examples of commonly bundled items are illustrative and not all‑inclusive; providers should not bill those items separately when they are incorporated into an E/M or procedure code in a non‑facility setting.

ALL of the following

Claims containing inappropriate modifier‑to‑procedure combinations or lacking clinical support may be denied.
The plan may review claims and request medical records; unsupported claims may be denied per plan review.

References

Required Codes, Modifiers, and Bundling Rules

Required code sets and modifier rulesmixed

HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, DRG)

Claims must use valid HIPAA-approved code sets and follow industry coding guidelines; correct modifier-to-procedure combinations required and must be clinically supported.

Bundling rule — mutual exclusivity, integral/incidental, global period ineligibility

RuleServices considered mutually exclusive, integral, incidental, or within the global period of a primary service are not eligible for additional reimbursement.

Mutual ExclusivityProcedures that cannot reasonably be performed together on the same patient on the same day are bundled and not separately reimbursable.

Integral/IncidentalServices or technical charges that are clinically integral to the primary procedure (including equipment purchase, rental and maintenance) are excluded from separate payment.

Global Period IneligibilityAny service within the global period of a primary procedure is not eligible for additional reimbursement.

Documentation, Claims Review, and Provider Responsibilities

Documentation Required

Documentation and claim review — keep records and respond to requests

Providers must maintain and submit accurate supporting documentation and medical records when requested; failure to provide documentation or when claims do not adhere to coding/billing guidelines may result in claim denial.

Submit claims using valid HIPAA‑approved code sets (CPT, HCPCS, ICD‑10, NDC, DRG) and follow industry coding guidelines.
Upon request, promptly provide any additional documentation supporting the codes billed; the plan reserves the right to request documentation and to deny claims not supported or not adhering to coding/billing guidelines.
Claims are subject to code edit protocols and claim review against benefit terms, provider contract language, medical policies, CPCPs and coding software logic.

Definitions

Global surgical package

DefinitionThe global surgical package includes all related services and supplies that are routine and necessary for a provider or by another same-specialty provider within the same group before, during and after a procedure.

ScopeApplies across settings including inpatient hospital, outpatient hospital, Ambulatory Surgery Center (ASC) and professional provider offices.

ProvidersIncludes services performed by the same provider or another same-specialty provider within the same group.

Incidental services

DefinitionIncidental services are costs excluded when performed with the primary procedure and are clinically integral to the successful outcome of the primary procedure.

Included ChargesIncludes technical charges for equipment and its purchase, rental and maintenance.

BillingCompensation for incidental services may not be billed separately by the performing provider, another provider, or other entity.

Mutually exclusive procedures

DefinitionMutually exclusive procedures are those that cannot reasonably be performed together on the same patient on the same day based on code definitions or anatomic considerations.

ImplicationWhen procedures are mutually exclusive they are not eligible for separate reimbursement in the same encounter/date of service.

BasisDeterminations are made using code definitions and anatomic considerations.

Contaminated / not utilized / waste supplies

DefinitionSupplies prepared or opened but not used, supplies opened by mistake, or items considered contaminated or waste are generally not eligible for reimbursement.

ExamplesIncludes surgical trays opened but unused, change of mind by the provider, items opened by mistake, equipment failure/technical difficulties, and cancellations.

PackagingLarge packages of items, supplies, or implants when more appropriate packaging could be purchased are considered not reimbursable.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyUnbundling Policy-Professional Providers

Policy CodePolicy CPCPO34

Change TypeNo material change

Effective DateApr 5, 2022

Next Review Date

Key ActionProvider may be required to submit supporting documentation upon request; claims may be reviewed and denied if not supported or not adhering to coding/billing guidelines.

SourceLink

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