CurrentBlue Cross Blue Shield - TexasPolicy CPCP018

Revenue Codes Requiring Supporting CPT, HCPCS and/or NDC Codes - Outpatient Facility Claims

Governs outpatient facility claim submissions to Blue Cross and Blue Shield of Texas, requiring appropriate HCPCS/CPT or NDC codes paired with revenue codes; does not apply to inpatient claims and affects outpatient facility providers submitting electronic or paper claims.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyRevenue Codes Requiring Supporting CPT, HCPCS and/or NDC Codes - Outpatient Facility Claims

Policy CodePolicy CPCP018

Change TypeMinor/administrative

Effective DateApr 14, 2025

Next Review DateN/A

Key ActionInclude supporting HCPCS, CPT, or NDC codes on the same line with the revenue code for outpatient facility claims; if multiple procedure codes apply, place revenue code on separate lines to match each procedure code.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Outpatientsetting

12x,13x,14x,74x,75x,76x,83x,84x,85x,89xat-risk bill types

1.0version

2025-04-14effective

Voluntary

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Revenue Code Reporting Requirements for Outpatient Facility Claims

Outpatient facility revenue code reporting requirements

Outpatient facility claims must include supporting procedure or drug codes with revenue codes; NDC reporting is voluntary unless contractually required.

ALL of the following

Codes submitted must reflect the services provided on the date of service and be submitted on the same line as the revenue code for accurate claims processing.
If more than one HCPCS, CPT or NDC code applies to a revenue code, submit the revenue code on separate line(s) to match each procedure code.

Denial risk for missing procedure codes

Plan may deny an outpatient facility claim when a revenue code is submitted without the appropriate procedure code(s) for the following bill types: 12x, 13x, 14x, 74x, 75x, 76x, 83x, 84x, 85x, 89x.

NDC reporting

Follow the specified electronic (ANSI 837I) and paper (CMS-1500, UB-04) formats for NDC reporting as applicable.

Procedure and NDC Reporting Format

NDC reporting formatNDC

N4 qualifier + 11-digit NDC (billing format)

NDC reporting format for electronic and paper claims as specified (enter N4 in Product ID Qualifier field and 11-digit NDC in billing format; include unit of measure qualifier UN, ML, GR, or F2 and quantity).

inv-03: Required procedure code presence

RequirementRevenue codes on outpatient facility claims must be accompanied by compatible HCPCS/CPT or NDC procedure codes.

Denial risk bill typesPlan may deny claims lacking appropriate procedure codes for bill types: 12x, 13x, 14x, 74x, 75x, 76x, 83x, 84x, 85x, 89x.

Compatibility guidanceRevenue code(s) and corresponding procedure code(s) must be compatible; refer to CMS OPPS/I/OCE for up-to-date HCPCS requirements.

What Providers Must Do

Documentation Required

Documentation expectation

Claims are subject to review for coding, billing and coverage compliance. Providers must submit accurate documentation and be prepared to provide supporting records upon request. Failure to adhere to coding and billing policies may delay or impact claims processing and reimbursement.

Providers are responsible for submission of accurate documentation of services performed and must code claims using valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, etc.).
Upon request, providers should submit additional documentation to support medical necessity, coding and billing.
Claim submissions are subject to plan benefit terms, provider contract language, clinical payment and coding policies, and code edit protocols including CMS/NCCI rules.

Denial Risk

Claim submission and denial risk

Outpatient facility claims must include compatible revenue and procedure codes on the same line; otherwise claims may be denied. If multiple procedure codes are required for a single revenue code, submit the revenue code on separate lines with each procedure code.

Key Definitions and Reporting Details

inv-06: Definition of outpatient facility claims and scope exclusion for inpatient claims

DefinitionOutpatient facility claims are claim submissions by facility providers for services rendered in an outpatient setting; this policy does not apply to inpatient claims.

Scope exclusionThis policy does not apply to Inpatient claims.

Provider responsibilityOutpatient facility providers must indicate the most appropriate HCPCS/CPT and NDC in addition to the revenue code on electronic outpatient facility claims.

inv-07: NDC reporting specifics

ANSI 837I electronic formatEnter Product ID Qualifier N4 in Loop 2410 and the 11-digit NDC in the National Drug Code field; include National Drug Unit Count (quantity) in CTP04 and Unit or Basis for Measurement (UN, ML, GR, or F2) in CTP05.

CMS-1500 paper form