CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Device intensive procedure edit for outpatient facility claims

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This policy governs billing and reimbursement for device-intensive procedures on outpatient facility (UB-04) claims, allowing denial of a device-intensive procedure line if an associated device procedure code is not billed on the same claim, date of service, and by the same provider. It applies to facility outpatient bill types (13X, 76X) for Medicare Advantage and commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDevice intensive procedure edit for outpatient facility claims

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 15, 2026

Next Review DateN/A

Key ActionEnsure the device procedure HCPCS/CPT code is billed on the same claim, same date of service, and by the same provider to avoid denial of the device-intensive procedure line.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13X, 76Xapplicable outpatient bill types

Facilityclaim types subject to edit

Denial recommendedaction when device code missing

CMS OPPSreimbursement methodology

Coverage Criteria

Device intensive procedure billing and denial criteria

Conditions under which the device‑intensive procedure line may be denied or considered for payment:

Device intensive procedure code must be billed with an associated device procedure code on the same claim, same date of service, and by the same provider for outpatient facility claims; absence of the device procedure code may result in denial of the device‑intensive procedure line unless an applicable modifier indicates a reduced, discontinued, or terminated procedure.

Applies to facility outpatient institutional claims submitted on UB‑04 (or electronic equivalent) with bill types 13X (Hospital Outpatient) and 76X.

Does not apply to professional (physician) claims, physician office claims, inpatient facility claims, or claims outside the identified bill types.

When a device intensive procedure code is submitted without the corresponding device procedure code as required, the device intensive procedure line may be denied; the presence of a device procedure code does not guarantee reimbursement.

Applicable device intensive procedures and corresponding device procedure codes are identified per industry‑standard reimbursement methodologies (including CMS OPPS); code lists may be updated periodically in accordance with annual coding and reimbursement updates.

Coding and Claim Requirements

Device procedure codes (HCPCS/CPT)mixedCovered

Device procedure HCPCS or CPT codes corresponding to insertion/implantation/replacement/supply/use of device; see CMS device intensive procedure list for specific codes.

Claim requirements

Same claim and dateDevice intensive procedure code and associated device procedure code must be on the same claim and same date of service.

Same provider requirementBoth codes must be billed by the same provider on the claim.

Applicable bill typesApplies to outpatient facility claims submitted with bill types 13X (Hospital Outpatient) and 76X (Community Mental Health Center when applicable).

Denial outcomeWhen device intensive procedure code is submitted without the corresponding device procedure code as required, the device intensive procedure line may be denied; presence of device code does not guarantee reimbursement.

Provider Actions and Billing Rules

Denial Risk

Device Intensive Procedure Edit — denial condition

Recommend denial of the device-intensive procedure line when a corresponding device procedure code is not billed on the same claim, for the same date of service, and by the same provider; denial may be avoided if an applicable modifier indicates a reduced, discontinued, or terminated procedure.

Applies to outpatient facility claims only (UB‑04 or electronic equivalent) billed on bill types 13X or 76X.
Does not apply to professional, physician office, or inpatient facility claims.

Billing Rule

Required provider billing action

Ensure the device procedure HCPCS/CPT code that identifies insertion, implantation, replacement, supply, or use of the device is billed on the same claim, for the same date of service, and by the same provider as the device‑intensive procedure code to avoid the edit.

If the device‑intensive procedure is billed without the associated device procedure code on the same claim/date/provider, the device line may be denied.
An applicable modifier indicating reduced, discontinued, or terminated procedure may affect the edit outcome.

Definitions

Device Intensive Procedure

DefinitionA procedure designated as device intensive under applicable reimbursement methodologies in which the cost of an implantable or medical device represents a significant portion of the total procedure cost.

Reimbursement basisDesignation is based on industry-standard reimbursement methodologies such as CMS OPPS guidance.

Impact on claimsDevice-intensive designation triggers requirement for associated device procedure coding for outpatient facility billing.

Device Procedure Code

DefinitionA HCPCS or CPT code that identifies the insertion, implantation, replacement, supply, or use of a qualifying medical device associated with a device intensive procedure.

Usage requirementWhen required, the device procedure code must be billed on the same claim, same date of service, and by the same provider as the device intensive procedure code.

Code list maintenanceApplicable device procedure codes are identified per current reimbursement methodologies (e.g., CMS device intensive procedure list) and may be updated periodically.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyDevice intensive procedure edit for outpatient facility claims

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 15, 2026

Next Review DateN/A

Key ActionEnsure the device procedure HCPCS/CPT code is billed on the same claim, same date of service, and by the same provider to avoid denial of the device-intensive procedure line.

SourceLink

On This Page

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Device intensive procedure edit for outpatient facility claims

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Sign up for all Blue Cross Blue Shield - Rhode Island policy alerts

Know when Blue Cross Blue Shield - Rhode Island releases new policies or updates existing guidance.

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Coverage Criteria

Device intensive procedure billing and denial criteria

Conditions under which the device‑intensive procedure line may be denied or considered for payment:

Applies to facility outpatient institutional claims submitted on UB‑04 (or electronic equivalent) with bill types 13X (Hospital Outpatient) and 76X.

Does not apply to professional (physician) claims, physician office claims, inpatient facility claims, or claims outside the identified bill types.

Coding and Claim Requirements

Device procedure codes (HCPCS/CPT)mixedCovered

Device procedure HCPCS or CPT codes corresponding to insertion/implantation/replacement/supply/use of device; see CMS device intensive procedure list for specific codes.

Claim requirements

Same claim and dateDevice intensive procedure code and associated device procedure code must be on the same claim and same date of service.

Same provider requirementBoth codes must be billed by the same provider on the claim.

Applicable bill typesApplies to outpatient facility claims submitted with bill types 13X (Hospital Outpatient) and 76X (Community Mental Health Center when applicable).

Provider Actions and Billing Rules

Denial Risk

Device Intensive Procedure Edit — denial condition

Applies to outpatient facility claims only (UB‑04 or electronic equivalent) billed on bill types 13X or 76X.
Does not apply to professional, physician office, or inpatient facility claims.

Billing Rule

Required provider billing action

If the device‑intensive procedure is billed without the associated device procedure code on the same claim/date/provider, the device line may be denied.
An applicable modifier indicating reduced, discontinued, or terminated procedure may affect the edit outcome.

Definitions

Device Intensive Procedure

Reimbursement basisDesignation is based on industry-standard reimbursement methodologies such as CMS OPPS guidance.

Impact on claimsDevice-intensive designation triggers requirement for associated device procedure coding for outpatient facility billing.

Device Procedure Code

DefinitionA HCPCS or CPT code that identifies the insertion, implantation, replacement, supply, or use of a qualifying medical device associated with a device intensive procedure.

Usage requirementWhen required, the device procedure code must be billed on the same claim, same date of service, and by the same provider as the device intensive procedure code.

Code list maintenanceApplicable device procedure codes are identified per current reimbursement methodologies (e.g., CMS device intensive procedure list) and may be updated periodically.