CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy: Hospital-Based Clinics and Facility-Based Outpatient Psychotherapy

Defines claim and reimbursement guidelines for services provided in hospital-based clinics and facility-based outpatient psychotherapy services for Medicare Advantage and Commercial products, including billing requirements for primary care/dual providers and non-primary care providers.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy: Hospital-Based Clinics and Facility-Based Outpatient Psychotherapy

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2023

Next Review DateN/A

Key ActionPrimary Care or Dual Providers must bill on CMS-1500 with their Type 1 NPI using appropriate E/M or AWV codes; non-primary care providers must file on UB-04 and are paid via a facility global fee.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CMS-1500Billing form for PCP/Dual

UB-04Billing form for non-PCP

POS 11POS allowed

051X/090X/091XRevenue codes

Global feeNon-PCP reimbursement

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Coverage and Billing Criteria

Coverage and billing criteria

Billing and reimbursement rules depending on provider credentialing:

Primary Care Physicians or Dual Providers must bill on a CMS-1500 using their Type 1 NPI and appropriate Evaluation and Management codes (99000s) or Medicare annual wellness visit codes (G0438, G0439). Place of Service 11 (Office) is allowed for CMS-1500 billing.

Non-Primary Care Physicians or Non-Dual Providers delivering services in hospital-based clinics or facility-based outpatient psychotherapy are reimbursed via a facility global fee that includes Evaluation and Management services, drugs, administration, and supplies; laboratory and radiology services obtained at the visit are excluded from the global rate and are reimbursed separately.

Non-Primary Care Physicians or Non-Dual Providers should file claims on a UB-04 using the appropriate facility revenue code plus the applicable CPT/HCPCS code: hospital-based clinic revenue code 051X (with appropriate fourth digit) for clinic services, and behavioral health revenue codes 090X or 091X (with appropriate fourth digit) for facility-based outpatient psychotherapy.

BCBSRI will not separately reimburse a non-Primary Care Physician or non-Dual Provider for the hospital-based clinic visit or facility-based outpatient psychotherapy; reimbursement for those services is made to the facility as part of the global rate.

For all providers, add-on codes must be filed on the same claim form as the primary code to ensure correct claims processing.

This policy applies to all Medicare Advantage Plans and Commercial Products; benefits may vary by group/contract—refer to the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for benefit details.

Referenced Billing and Revenue Codes

Referenced billing codes and revenue codesmixed

051X	Clinic revenue code (hospital-based clinic) with appropriate fourth digit
090X	Behavioral health treatment/services revenue code with appropriate fourth digit
091X	Behavioral health treatment/services revenue code with appropriate fourth digit
99000s	Evaluation and Management series codes referenced for PCP/Dual providers
G0438	Annual wellness visit (Medicare Advantage)
G0439	Annual wellness visit (Medicare Advantage)

Add-on claim filing

RequirementAdd-on codes must be filed on the same claim form as the primary code to ensure correct claims processing.

ScopeApplies to all providers in the hospital-based clinic setting (Primary Care, Dual, Non-Primary Care, Non-Dual).

PurposeEnsures correct claims processing and proper linkage of add-on services to the primary service.

Claiming implicationIf add-on codes are submitted separately from the primary code, claims processing may be incorrect and reimbursement may be impacted.

Provider Actions and Requirements

Prior Authorization

Prior Authorization — Not applicable.

Prior authorization is not applicable for this policy.

Definitions

Hospital-based clinic (CMS definition)

Definition (CMS)An outpatient service that includes preventive, diagnostic, therapeutic, rehabilitative, or palliative services.

ExclusionDoes not include clinics exclusively designed for and providing laboratory, X-ray testing, or therapy.

RelevanceUsed to determine when hospital-based clinic billing and revenue code rules apply.

Coding noteBCBSRI utilizes revenue codes in combination with CPT/HCPCS codes in the hospital-based clinic setting; CPT/HCPCS primarily determines reimbursement while revenue codes determine the appropriate benefit.