CurrentBlue KCPolicy POL-PP- 231

Physician Fee Schedule Status Indicator

Defines Medicare Physician Fee Schedule (PFS) status indicators and Blue KC's payment integrity application for professional claims; affects professional providers submitting claims to Blue KC across commercial and Medicare Advantage lines.

Policy Summary

PayerBlue KC

PolicyPhysician Fee Schedule Status Indicator

Policy CodePolicy POL-PP- 231

Change TypeNo material change

Effective DateJul 1, 2022

Next Review DateJul 1, 202618d

Key ActionUse PFS status indicators to determine payment eligibility and bundling; consult CMS PFS files for code-specific determination.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

A, B, C, E, I, M, NMedicare PFS status indicator categories described

P, R, T, XBlue KC payment-integrity status indicators described

ProfessionalProvider types explicitly affected

7/1/2022Original effective date

7/1/2026Next scheduled review

Coverage stance and payment eligibility

Coverage stance

Status indicators determine whether a CPT/HCPCS code is eligible for separate payment, bundled with another service, or excluded from payment under the Physician Fee Schedule. Blue KC follows CMS PFS classifications and applies additional payment‑integrity indicators (P, R, T, X) for claims adjudication.

Determine payment action by the code's PFS status indicator (as assigned in the CMS PFS files).

Payment actions mapped from status indicators

P — Bundled/Excluded (Blue KC): No RVUs and no separate payment amounts; paid only when incident to a physician service (bundled into the physician payment) or excluded from the PFS and paid under other payment provisions as applicable.
R — Restricted coverage (Blue KC): Special coverage instructions apply; coverage and payment are subject to the specific restrictions documented for the code.

Policy Summary

PayerBlue KC

PolicyPhysician Fee Schedule Status Indicator

Policy CodePolicy POL-PP- 231

Change TypeNo material change

Effective DateJul 1, 2022

Next Review DateJul 1, 202618d

Key ActionUse PFS status indicators to determine payment eligibility and bundling; consult CMS PFS files for code-specific determination.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Physician Fee Schedule (PFS) status indicators

Medicare PFS status indicatorsCPT

A	Active code — separately paid under physician fee schedule if covered
B	Bundled code — payment always bundled into other services; no RVUs or separate payment
C	Carriers/MACs priced code — carriers/MACs establish RVUs and payment amounts
E	Excluded from fee schedule by regulation — no RVUs or payment amounts shown; not payable under fee schedule
I	Not valid for Medicare purposes — Medicare uses another code for reporting/payment
M	Measurement codes — used for reporting purposes only
N	Non-covered service

Blue KC payment-integrity status indicatorsCPT

P	Bundled/excluded codes — no RVUs and no payment amounts; no separate payment under fee schedule
R	Restricted coverage — special coverage instructions apply
T	Paid as only service — paid only if no other PFS services billed same date by same provider; otherwise bundled
X	Statutory exclusion — not in statutory definition of physician services; no RVUs or payment amounts; not payable under fee schedule

Billing, determination, and provider guidance

Billing Rule

Use PFS status indicators and CMS files to determine payment and bundling

Determine payment eligibility and bundling by checking the CMS Physician Fee Schedule (PFS) status indicator assigned to each CPT/HCPCS code; Blue KC applies these status indicators (and its payment-integrity indicators P, R, T, X) when adjudicating professional claims. Consult the current CMS PFS files for the specific status indicator for each code to know whether a code is separately payable, bundled, restricted, paid only as a sole service, or statutorily excluded, and apply Blue KC's corresponding payment treatment.

Verify the code's CMS PFS status indicator before billing to determine separate payment vs. bundling.
Apply Blue KC payment-integrity indicators (P, R, T, X) as described in the policy when adjudicating claims.
Refer to the CMS PFS files for code-specific determinations (status indicator assignments and payment treatment).

Key terms and Blue KC status indicators

Status indicator (SI)

DefinitionStatus indicator (SI): a payment indicator assigned to each CPT/HCPCS code that identifies whether a service is payable under the physician fee schedule or another payment system and how it is paid (separately paid, bundled, excluded, etc.). Only one status indicator is assigned to each CPT/HCPCS code.

ScopeApplies to CPT and HCPCS codes used to determine payment treatment under the Medicare Physician Fee Schedule and Blue KC adjudication.

PurposeUsed to determine whether a code receives separate payment, is bundled into another service, or is excluded from fee-schedule payment.

Source guidanceBlue KC follows CMS PFS classifications and consults CMS PFS files for code-specific determinations.

P — Bundled/excluded (Blue KC)

Blue KC indicatorP — Bundled/excluded codes with no RVUs or payment amounts; no separate payment made under the fee schedule.

Bundling when incident to physician serviceIf covered as incident to a physician service and provided same day, payment is bundled into the physician service payment.

If not incident to physician serviceIf covered other than incident to a physician service, the item/service is excluded from the fee schedule and paid under other payment provisions.

R — Restricted coverage (Blue KC)

Blue KC indicatorR — Restricted coverage; special coverage instructions apply.

Action requiredConsult the specific coverage instructions associated with the code to determine payment eligibility and any documentation requirements.

Relation to PFSRepresents Blue KC’s application of CMS PFS status indicators where additional coverage restrictions are imposed.

T — Paid only as sole service (Blue KC)

Blue KC indicatorT — Paid only as sole service: these codes are paid only if no other services payable under the physician fee schedule are billed on the same date by the same provider.

Bundling ruleIf any other payable PFS services are billed on the same date by the same provider, the T-coded service is bundled into the payable physician services.

Claim evaluationAdjudicate claims to verify no other same-day PFS services from the same provider before allowing separate payment for T-coded services.

X — Statutory exclusion (Blue KC)

Blue KC indicatorX — Statutory exclusion; these codes represent items or services not within the statutory definition of ‘physician services’ and are not payable under the physician fee schedule.

Payment impactNo RVUs or payment amounts are shown and no payment may be made under the physician fee schedule for X-coded services.

ExamplesExamples include ambulance services and clinical diagnostic laboratory services (statutorily excluded items).