Treatment Rooms - Facility
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Defines billing and reimbursement rules for treatment room revenue codes in outpatient facility settings for Empire Bluecross commercial plans; applies to facility claim submissions unless overridden by provider, state, or federal mandates.
Updated title and added language to prohibit reimbursement for new or established patient and consultation E/M services reported with revenue codes 0760, 0761 or 0769.
Added explicit prohibition on reimbursement for revenue codes 0760, 0761, and 0769 when billed with specific room revenue codes (Emergency Room 045X; Outpatient Surgery 036X; Recovery Room 071X; Observation 0762; Clinic 051X/Freestanding Clinic 052X).
Clarified that a facility must report CPT or HCPCS codes with treatment room revenue codes on outpatient facility claims unless contracts or mandates indicate otherwise.
Coverage criteria for treatment room revenue codes
Coverage criteria for treatment room revenue codes
Covered when ALL of the following are met:
ALL of the following
- Do not reimburse new or established patient office evaluation and management (E/M) or consultation CPT/HCPCS codes when reported with treatment room revenue codes 0760, 0761, or 0769.
- Do not reimburse revenue codes 0760, 0761, or 0769 when billed on the same claim with any of the following room revenue codes: Emergency Room (045X); Outpatient Surgery (036X); Recovery Room (071X); Observation (0762); Clinic (051X); or Freestanding Clinic (052X).
- A CPT or HCPCS code must be reported on outpatient facility claims for treatment room revenue codes unless overridden by provider, state, or federal contract or mandate; absence may result in denial, rejection, or recoupment per payer guidelines.
Revenue codes referenced
- 0760 - Treatment room revenue code
- 0761 - Treatment room revenue code
- 0769 - Other treatment room revenue code
- 045X - Emergency Room revenue code
- 036X - Outpatient Surgery revenue code
- 071X - Recovery Room revenue code
- 0762 - Observation revenue code
- 051X - Clinic revenue code
- 052X - Freestanding Clinic revenue code
Revenue codes, CPT/HCPCS reporting expectations
| 0760 | Treatment room revenue code |
| 0761 | Treatment room revenue code |
| 0769 | Other treatment room revenue code |
| 045X | Emergency Room revenue code |
| 036X | Outpatient Surgery revenue code |
| 071X | Recovery Room revenue code |
| 0762 | Observation revenue code |
| 051X | Clinic revenue code |
| 052X | Freestanding Clinic revenue code |
Billing and submission requirements and provider actions
Report CPT/HCPCS with treatment room revenue codes or face denial/recoupment
When billing outpatient facility claims that include treatment room revenue codes (0760, 0761, 0769), report an accompanying CPT® or HCPCS code on the UB-04; failure to follow coding/billing guidelines may result in claim rejection, denial, or recoupment.
- Treatment room revenue codes 0760, 0761, 0769 require a CPT or HCPCS code on outpatient facility claims unless overridden by provider, state, or federal contracts/mandates.
- If appropriate coding/billing guidelines or current reimbursement policies are not followed, the plan may reject or deny the claim and may recover and/or recoup payment.
Policy definitions
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