CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Coding and payment guidelines for professional and hospital outpatient claims

Governs BCBSRI coding and payment rules for Medicare Advantage and commercial products, aligning with CMS/NCCI/AMA CPT standards for claim processing and reimbursements.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCoding and payment guidelines for professional and hospital outpatient claims

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 11, 2023

Next Review DateN/A

Key ActionWhen a claim requires review, send clinical documentation to the Individual Consideration Unit at Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI 02903-2699.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Med Advantage & CommercialPlan types governed

100% / 50% / 60.4%Typical payment levels

QuarterlyOPPS/packaged updates

Follows CMSMUEs

60.4%Radiology subsequent

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Coverage and Payment Rules

Primary payment and coding criteria

Key coverage and payment rules

BCBSRI follows NCCI/CCI edits; some edits are modifier-overridable (e.g., 59/XE/XS/XP/XU) while others are not reported together.

BCBSRI follows CMS OPPS for outpatient hospital packaged services: codes with status indicator 'N' on Addendum B are covered but not separately reimbursed (bundled); packaged code lists are updated quarterly per CMS OPPS.

BCBSRI follows the CMS Physician Fee Schedule (PFS RVU file) for global periods, assistant surgeon and co-surgeon indicators, bilateral surgery treatment, and multiple procedure reduction status.

Assistant surgeon payment: BCBSRI will only pay assistant surgeons for procedures with PFS indicator 2; these are not medical necessity determinations and are not reviewed for medical necessity if appealed. Participating physicians may not balance-bill members for assistant surgeon fees when payment is not permitted.

Co-surgeon payment: BCBSRI utilizes MPFS indicators to determine co-surgeon payment rules. Indicator 0 = co-surgeons not permitted (claims deny); Indicator 1 = co-surgeons may be paid but supporting documentation required; Indicator 2 = co-surgeon permitted and may pay when specialty requirement met; Indicator 9 = concept does not apply. Operative notes must be submitted when claims require review.

Bilateral surgery: BCBSRI follows CMS policies and PFS bilateral indicators (0,1,2,3,9). Where CPT and CMS differ on modifier 50 use, BCBSRI follows CPT guidance and may deny incorrectly filed bilateral modifiers.

Multiple procedure reductions (surgical): BCBSRI follows CMS multiple procedure indicators—highest-paying surgical procedure reimbursed at 100% and additional separate procedures typically reimbursed at 50% unless exempt (add-on codes or modifier-51 exempt codes).

Diagnostic imaging MPPR: For multiple radiology services by the same provider/group to the same member on the same date, the highest-allowance service is paid at 100% and all subsequent services are paid at 60.4%. There is no reduction when services are filed with modifier 26.

Technical component (TC) billing: Use the TC modifier only for services with a '1' in the PC/TC field on the National RVU file; BCBSRI follows CMS guidance for appropriate TC use.

Billing and coverage criteria

Key billing and coverage rules in this section include:

Multiple radiology services: For multiple radiology services by the same provider (same Group NPI) to the same member on the same date, the highest-allowance service is paid at 100% and all subsequent services at 60.4%; no reduction when services are filed with modifier 26.

Outpatient hospital bundling: BCBSRI follows CMS OPPS—codes with status indicator 'N' are covered but not separately reimbursed (bundled); BCBSRI updates packaged code lists quarterly per CMS OPPS.

Modifier 25 impact: Claims submitted with an E/M (99201-99215) or ophthalmology E/M (92002-92014) billed with a procedure having a 0, 10 or 90 postoperative period will have the E/M reduced by 50% (except when the E/M is reimbursed under a per diem or all-inclusive arrangement). Documentation must support that the E/M is significant and separate.

Split/shared E/M visits: Effective January 1, 2022, split/shared E/M visits in facility settings are billed by the practitioner who provided the substantive portion; required modifiers (FR, FQ, FS, FT) must be used, documentation must identify both individuals, and the substantive provider must sign and date the medical record.

Modifier payment and claim handling rules

Modifier-specific payment and claim handling rules

AS (Assistant surgeon): BCBSRI will only pay for an assistant surgeon for procedures with PFS indicator 2; claims may require review and payment may be based on a percentage of contracted rate. BCBSRI does not review AS for medical necessity when Medicare requires review.

GP / GO (Outpatient therapy plan of care): When reported, payment is provided; if the modifier is missing, the claim may deny as provider liability.

Anesthesia modifiers QK/QX/QY/QZ: Certain anesthesia/CRNA direction or medical direction modifiers have specified percentage payment rules (e.g., QK/QX/QY may be paid at 50% in certain contexts; QZ may be paid at 100% allowable).

GY (Not covered): GY indicates an item or service is not covered; claims marked GY have payment/denial implications per the modifier definition.

Documentation and review: For any claim requiring review, clinical documentation must be submitted to the Individual Consideration Unit, Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI 02903-2699.

Coding, Modifiers, and Payment Percentages

Billing, Documentation, and Submission Actions

Prior Authorization

Prior authorization is not applicable for the services referenced in this policy.

Billing Rule

Modifier submission and review

Submit applicable modifiers with procedure codes following current industry-standard coding guidelines. Incorrect or inappropriate modifier submission may result in claim line denial or a claim review requirement. Absence or presence of a required modifier can affect claim adjudication.

Refer to up-to-date coding guidance for proper modifier use.
If a modifier is submitted incorrectly with the procedure code, BCBSRI may deny the claim line for incorrect use of the modifier.
Some modifiers trigger a claims review for additional payment (for example, modifier 22 — Unusual procedural services — may require claim review).

Key Terms and Definitions

Technical Component

Definition of Technical Component (TC)The TC modifier identifies the technical component of a service that has separate physician and technical components

Appropriate usageTC should be used only for codes with a '1' in the PC/TC field on the CMS National RVU file

Follow CMS guidanceBCBSRI follows CMS guidelines for correct usage of the TC component

Global Period

Global period designationsProcedures on the Medicare PFS are assigned a global period of 000, 010, or 090 (major vs minor surgical procedures)

BCBSRI alignmentBCBSRI follows the surgical global periods as designated by CMS on the RVU files

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyCoding and payment guidelines for professional and hospital outpatient claims

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 11, 2023

Next Review DateN/A

Key ActionWhen a claim requires review, send clinical documentation to the Individual Consideration Unit at Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI 02903-2699.

SourceLink

On This Page

MUE adherence: BCBSRI follows CMS-published Medically Unlikely Edits (MUEs) for facilities, physicians and DME.

Modifier correctness: Incorrectly submitted modifiers, or absence/presence of modifiers, may result in denial or altered claim processing and payment review.

340B reporting: For CY2023, 340B providers must report JG or TB modifiers as appropriate on OPPS claims for informational purposes.

Informational modifiers: Many HCPCS modifiers are informational or indicate payment allowed based on a percentage of contracted rate; providers should follow specific modifier definitions for payment/claim outcomes.

Documentation Required

Split/shared E/M modifier and documentation

For split (or shared) E/M visits in the facility setting, the visit must be billed by the practitioner (physician or non-physician practitioner) who provided the substantive portion of the visit. Documentation must identify both individuals who participated and must clearly indicate and be signed and dated by the individual who provided the substantive portion. These rules do not apply to E/M services provided in an office setting (Place of Service 11).

Substantive portion for 2022 and thereafter may be defined as history, physical exam, medical decision-making, or more than half of the total time spent.
Split/shared visits may be reported for new and established patients, initial and subsequent visits, and prolonged services.
Modifiers related to split/shared E/M visits include: FR (supervising practitioner present via two-way audio/video), FQ (audio-only communication), FS (Split/shared E/M visit), FT (Unrelated E/M visit during a postoperative period or same day as a procedure).
Medical record must identify both individuals and include signature and date of the individual furnishing the substantive portion.

Note

Claims requiring review — submission address

When a claim line requires clinical review, send the supporting clinical documentation to BCBSRI at the address below. Claims for which review is required will note that clinical documentation must be submitted for individual consideration.

Send clinical documentation to: Individual Consideration Unit of Basic Claims Administration, Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI 02903-2699.

Impact on E/M billingGlobal period determines postoperative days and interactions with E/M services (e.g., modifier 25 rules)

NCCI / CCI

NCCI / CCI edits overviewBCBSRI follows the National Correct Coding Initiative (NCCI) edits to prevent reporting code combinations that should not be reported together

Edit typesThere are edits that are modifier-overridable (indicator allowing modifier, e.g., 59/XE/XS/XP/XU) and edits that are never to be reported together (0 indicator)

Exception modifiersException modifiers considered include global surgery modifiers (24,25,57,58,78,79) and other modifiers (27,59,91,XE,XS,XP,XU)

TC modifier meaningTC identifies the technical component of a combined service (technical vs professional components)

Relation to imaging reductionsTC-flagged services are subject to diagnostic imaging multiple-service rules when indicated on the RVU file

Use per RVU fileOnly use TC when the National RVU file has the PC/TC field indicating a technical component

Split/shared E/M visit

DefinitionSplit (or shared) E/M visit: a facility visit provided by a physician and/or non-physician practitioner in the same group where the substantive portion determines billing

Modifiers requiredA modifier is required on the claim to identify split/shared services (examples: FS, FR, FQ, FT)

Documentation requirementMedical record must identify the two individuals who performed the visit and the substantive provider must sign and date the record

Assistant surgeon / Assistant

Assistant surgeon payment criteriaBCBSRI will only pay for an assistant surgeon for procedures with MPFS assistant surgeon indicator 2; payment may be based on a percentage of contracted rate and claim review may be required

Claim reviewAS modifier may trigger claim review and percentage-based payment; BCBSRI does not perform medical necessity review in instances where Medicare requires review

Indicator-drivenAssistant surgeon payment and requirements are determined by Medicare Physician Fee Schedule indicators and may require operative notes on review

Modifier GP/GO

GP / GO meaningGP indicates services delivered under an outpatient physical therapy plan of care; GO indicates outpatient occupational therapy plan of care

Payment and denial implicationsWhen GP/GO present, payment is allowed; if the modifier is missing the claim may deny as provider liability

Modifier usageBCBSRI follows CMS-designated modifier meanings and applies payment/claim adjudication accordingly