CurrentBlue Cross Blue Shield - WisconsinPolicy C-15004

Facility Guidelines for Claims Related to Professional Services - Facility

Defines billing and reimbursement rules for professional (E/M and related) services billed on facility (UB-04) versus professional (CMS-1500) claim forms; affects providers submitting claims to Anthem/BCBSWI commercial plans in jurisdictions where this policy applies.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyFacility Guidelines for Claims Related to Professional Services - Facility

Policy CodePolicy C-15004

Change TypeTitle revision (non-material)

Effective Date12/01/2023

Next Review Date

Key ActionBill evaluation and management and other professional services on a CMS-1500 claim form rather than a UB-04 except where state or contractual exemptions apply.

SourceLink

POLICY UPDATE CHANGES

Title updated from Place of Service Facility to Facility Guidelines for Claims Related to Professional Services Facility.

C-15004policy identifier

12/01/2023effective

06/28/2023last review

99202-99499E/M code range

Coverage Criteria and Billing Rules

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Coverage criteria and billing rules

Billing and reimbursement stance for professional services on facility (UB-04) claims and applicable exemptions.

Professional services are not allowed when billed on a UB-04 claim form unless provider, state, or federal contracts/mandates indicate otherwise.

ALL of the following

ONE OF
- Evaluation and Management services rendered within a primary structure of a facility.
- Evaluation and Management services rendered in an office, professional building, medical office building, clinic, or a space owned by a hospital or institutional provider (other than the primary structure on the campus), or rented by a professional from the hospital or institutional provider.
- Preventive counseling services rendered in an outpatient setting of a facility.

Revenue codes 960-989 (professional fees) are not allowed for reimbursement when submitted on a UB-04; these professional services should be billed with the applicable HCPCS/CPT on a CMS-1500 claim form.

EXEMPTIONS

Wisconsin allows E/M office visit codes to be billed with revenue code 456 and allows professional services billed under revenue codes 984-989 or professional services with revenue code 964 (historical/market-specific) as noted in exemptions.
Facility charges for E/M services provided in an Emergency Room and billed with Emergency Room revenue codes are not subject to the CMS-1500 requirement; however, professional services for the Emergency Room must still be billed on a CMS-1500 claim form.

Services rendered outside of the primary structure on the campus of a hospital or institutional provider shall not be billed or reimbursed on a UB-04 and must be billed on a CMS-1500 by the provider rendering the service.

Notable Codes, Revenue Codes, and Claim Form Requirements

Notable codes and revenue codesmixed

99202-99499	Evaluation and Management (E/M) CPT code range referenced for E/M services
99401, 99404, 99411, 99412	Preventive counseling CPT codes mentioned (context: outpatient setting/nonreimbursable in certain contexts)
Revenue codes 960-989	Professional fees revenue codes not allowed for reimbursement when submitted on a UB-04 (professional services should be billed on CMS-1500)
Revenue code 456	Wisconsin exemption allowing E/M office visit codes to be billed with revenue code 456
Revenue codes 984-989	Noted as nonreimbursable when submitted on a UB-04 (with some exemptions)
Revenue code 964	Allowed professional services with revenue code 964 for Maine exemption (historical)

Claim form requirement

Claim form requirementE/M and other professional services must be billed on a CMS-1500 (professional) claim form; submission on a UB-04 (facility) is not allowed except where state/federal contracts or specific exemptions apply.

Revenue codes restrictionRevenue codes 960-989 (professional fees) are not allowed for reimbursement when submitted on a UB-04; these services should be billed with the applicable HCPCS/CPT on a CMS-1500.

Emergency Department exceptionFacility charges for E/M services provided in an Emergency Room billed with ER revenue codes are exempt from the CMS-1500 requirement for facility charges, but professional services for the ED must be billed on a CMS-1500.

Services outside primary hospital structureServices rendered outside of the primary structure on a hospital or institutional campus must be billed on a CMS-1500 by the provider rendering the service and shall not be billed/reimbursed on a UB-04.

Outpatient and office settingsE/M services rendered in an office, professional building, medical office building, clinic, or space owned or rented by a hospital/institution (other than the primary structure) must be billed on a CMS-1500.

Authorization and Billing Requirements — Actions for Providers

Documentation Required

Authorization, medical necessity, and proper billing required

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis; follow proper billing and submission guidelines and use industry CPT/HCPCS/revenue codes. Failure to follow coding/billing guidelines or current reimbursement policies may result in recoupment, rejection, or denial of the claim.

Use industry Procedure Terminology (CPT), HCPCS and revenue codes to denote services performed.
Adhere to authorization and medical necessity requirements for the procedure and diagnosis.
Noncompliance may lead to recovery/recoupment of payment or claim denial/rejection.

Definitions

Evaluation and Management Services

Definition (E/M)Evaluation and management (E/M) coding is the use of CPT codes from the range 99202-99499 to represent services provided by a physician or other qualified healthcare professional.

Scope of E/M codesThese E/M codes apply to visits and services that involve evaluating and managing patient health and are required to be billed on CMS-1500 when rendered in outpatient or non-primary facility structures.

Related preventive servicesPreventive counseling services rendered in an outpatient setting of a facility are required to be billed on a CMS-1500 claim form.