CurrentBlue Cross Blue Shield - WisconsinPolicy C-20005

Treatment Rooms with Office Evaluation and Management Services - Facility

This commercial reimbursement policy governs reporting and reimbursement when treatment room revenue codes are billed in an outpatient facility setting and the interaction with office evaluation and management (E/M) services for Blue Cross Blue Shield - Wisconsin members and affected providers.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyTreatment Rooms with Office Evaluation and Management Services - Facility

Policy CodePolicy C-20005

Change TypeNo material change

Effective Date07/17/2024

Next Review Date

Key ActionReport CPT or HCPCS codes when billing treatment room revenue codes on an outpatient facility UB-04; deny facility claim lines with revenue codes 760, 761, or 769 if an accompanying CPT/HCPCS code is not reported.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

760,761,769revenue codes referenced

noexemptions

07/17/2024effective

3related policies

Coverage and Billing Rules

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Coverage and billing rules

Covered when ALL of the following billing and reporting requirements are met:

ALL of the following

The Health Plan requires reporting of CPT® or HCPCS codes for treatment room revenue codes in an outpatient facility setting unless provider, state, federal contracts and/or mandate indicate otherwise.
The Health Plan does not allow reimbursement for office evaluation and management services when reported along with revenue codes 760, 761 or 769.
There are no exemptions from this policy.
Deny a facility claim line if revenue codes 760, 761 or 769 is not billed with an accompanying CPT® or HCPCS code on a UB-04.

Report CPT® or HCPCS codes on the outpatient facility (UB-04) claim line when billing treatment room revenue codes; failure to report an accompanying CPT/HCPCS may result in denial of the facility line.

Related Coding and Reporting

Related coding referenced in historyHCPCS

G0463

Hospital outpatient clinic visit for assessment and management of a patient

Required reporting — treatment room revenue codes (inv-03)

RequirementCPT® or HCPCS codes must be reported for treatment room revenue codes on outpatient facility claims (UB-04).

Enforcement actionDeny a facility claim line if revenue codes 760, 761, or 769 is not billed with an accompanying CPT® or HCPCS code on a UB-04.

ScopeApplies in an outpatient facility setting unless provider, state, federal contracts and/or mandate indicate otherwise.

Policy history notePolicy history documents additions and expansions, including the addition of HCPCS G0463 and expansion to revenue codes 760 and 769; effective 07/17/2024.

Billing Requirements and Denial Risk

Denial Risk

Billing requirement and denial risk

The Health Plan requires providers to report a valid CPT® or HCPCS code on outpatient facility UB-04 claim lines when billing treatment room revenue codes (e.g., revenue codes 760, 761, 769) unless superseded by provider, state, or federal contracts or mandates. A facility claim line with revenue code 760, 761 or 769 that is not accompanied by a CPT or HCPCS code may be denied. The Health Plan does not allow reimbursement for office evaluation and management (E/M) services when billed along with revenue codes 760, 761 or 769 on the same facility claim line.

Report a CPT® or HCPCS code when billing treatment room revenue codes on an outpatient facility UB-04 (examples: revenue codes 760, 761, 769).
A facility claim line with revenue code 760, 761 or 769 lacking an accompanying CPT or HCPCS code on the UB-04 may be denied.
Do not bill office E/M or office consultation codes for reimbursement on the same facility claim line with revenue codes 760, 761 or 769.

Reimbursement and Coding Requirements

Reimbursement and coding requirements (inv-05)

Use of standardized codesClaims must use industry-standard CPT, HCPCS, and revenue codes to denote services and procedures; these codes must be supported in the medical record or office notes.

Reimbursement limitationThe Health Plan does not allow reimbursement for office evaluation and management services when reported along with revenue codes 760, 761, or 769.

Documentation requirementServices must meet authorization and medical necessity guidelines and be fully supported by medical records; improper coding/billing may result in claim rejection, denial, or recoupment.

Contract and mandate precedenceReimbursement policies may be superseded by provider, state, federal, or CMS contracts and requirements.