Facility Guidelines for Claims Related to Professional Services
Defines billing and reimbursement rules for professional services billed on facility (UB-04) versus professional (CMS-1500) claim forms for Empire BlueCross commercial members; affects professional providers and facilities submitting claims.
No material clinical or coverage changes in this revision.
Billing and Reimbursement Criteria
Billing and reimbursement criteria for professional services
Covered when ALL of the following are met:
ONE of
- Evaluation and Management services rendered in an office, professional building, medical office building, clinic, or a space owned by or rented from a hospital or institutional provider that is outside the primary hospital/institutional structure must be billed on a CMS-1500 (not a UB-04).
- Preventive counseling services rendered in an outpatient setting of a facility must be billed on a CMS-1500 claim form.
- Evaluation and Management services rendered within the primary structure of a facility must be billed on a CMS-1500 claim form.
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