CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Not Separately Reimbursed (NSR) and Use Alternate Code services

This document describes codes and services that BCBSRI considers covered but not separately reimbursable (NSR) or that should be reported using alternate CPT/HCPCS codes; it affects professional and institutional providers and varies by product.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyNot Separately Reimbursed (NSR) and Use Alternate Code services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 6, 2013

Next Review DateJan 7, 2024

Key ActionPrior authorization not applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

quarterlyupdate frequency

Professional & Institutionalprovider types

Medicare Advantage, Commercialproducts noted

excludedCategory II guidance

Coverage Stance and Applicability

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ALL of the following

Applicable settings
- Coverage and reimbursement may differ for Professional and Institutional providers; many services are included in the allowance of another service or are otherwise not separately reimbursed.
- Benefits may vary between groups and contracts; refer to the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for member-specific coverage.
The attached Excel workbook reflects the code status for professional and institutional providers as of January 1, 2024; reimbursement may vary by product.
The list is not all-inclusive and is updated quarterly; providers should consult the attached workbook and contract-specific benefit documents for authoritative coding and reimbursement determinations.
Operational note

Codes: Category II, NSR, OPPS Packaging, and Effective Status

Category II codesCPT | HCPCSNot Covered

Category II (XXXXF, GXXXX, MXXXX)

Category II CPT and HCPCS codes used for performance measurement are not intended for reimbursement and are excluded from this list.

NSR and OPPS packaged codesmixedNot Covered

CMS OPPS status indicator N	Codes with OPPS status indicator 'N' are generally covered but not separately reimbursed (payment packaged into other services).
NSR (Not Separately Reimbursed)	Covered but not separately reimbursable; not billable to the member in many cases; may vary by age or provider type.
Use Alternate Code	When an equivalent CPT/HCPCS exists, services should be reported using the alternate code.

Effective code status date

Effective code status dateAttached workbook reflects code status for professional and institutional providers as of January 1, 2024.

ApplicabilityReimbursement may vary by product (Medicare Advantage and Commercial).

Source fileStatus reflected in the attached Excel workbook used by BCBSRI for code maintenance.

Key Definitions

Not Separately Reimbursed (NSR)

Definition'Not Separately Reimbursed (NSR)' indicates a code is covered but not separately reimbursable; these services are not billable to the member.

Billing implicationProviders should not bill members separately for NSR-coded services; payment is not processed as a separate reimbursable line item.

Conditional exceptionsSome codes may be NSR only for specific patient ages or provider types; check the code listing for details.

Use Alternate Code

Meaning'Use Alternate Code' indicates there is an equivalent CPT or HCPCS code for the service and the service should be reported using that alternate code.

Provider actionReport services using the specified equivalent CPT/HCPCS code rather than the original code indicated as requiring an alternate.

Impact on reimbursementClaims must use the alternate code to ensure accurate processing and adjudication per BCBSRI guidance.

OPPS status indicator N

OPPS status indicator NCodes with OPPS status indicator 'N' are treated by CMS as packaged into other services and not separately payable.

BCBSRI alignmentBCBSRI generally mirrors CMS by setting 'N' codes as covered but not separately reimbursed in its claims system.

Claims processingThese codes are configured so payment is packaged with other services rather than paid as separate line items.