CurrentFlorida BluePolicy 23-080

Outpatient Facility Alternate Procedure Code Reimbursement

Governs outpatient hospital/facility billing when revenue codes require an alternate HCPCS/CPT procedure code for Florida Blue Commercial business; affects short-term acute care, critical access, and long-term care hospitals submitting outpatient UB-04 claims.

Policy Summary

PayerFlorida Blue

PolicyOutpatient Facility Alternate Procedure Code Reimbursement

Policy CodePolicy 23-080

Change TypeEditorial updatesclarifying scope added

Effective DateDec 1, 2023

Next Review DateAug 14, 2025

Key ActionSubmit both a revenue code and a corresponding CPT/HCPCS code on outpatient UB-04 claims to avoid payment impact or claim denial.

SourceLink

POLICY UPDATE CHANGES

08/14/2025 annual review - Minor editorial changes implemented.

Policy explicitly states it applies to outpatient claims for acute care hospitals (including children's and cancer hospitals), critical access hospitals, and long term care hospitals.

1attachments listing revenue codes requiring HCPCS/CPT

3hospital/facility types called out

3reference sources listed

2annual review entries

Outpatient Revenue Code Billing Criteria

Outpatient revenue code billing criteria

Required billing practice for outpatient facility claims

Outpatient UB-04 claims must be billed with both a revenue code and a corresponding CPT or HCPCS code for the listed revenue codes.

Absence of a CPT/HCPCS code for any listed revenue code may affect claim payment or result in a claim denial.

Applies to Florida Blue Commercial outpatient claims for acute care hospitals (including Children's and Cancer Hospitals, bill types 13X, 14X), Critical Access Hospitals (85X), and Long Term Care Hospitals (13X).

If multiple CPT or HCPCS codes are necessary to reflect multiple, distinct, or independent visits with the same revenue code, repeat the revenue code and include the applicable date of service.

Policy Summary

PayerFlorida Blue

PolicyOutpatient Facility Alternate Procedure Code Reimbursement

Policy CodePolicy 23-080

Change TypeEditorial updatesclarifying scope added

Effective DateDec 1, 2023

Next Review DateAug 14, 2025

Key ActionSubmit both a revenue code and a corresponding CPT/HCPCS code on outpatient UB-04 claims to avoid payment impact or claim denial.

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.

Revenue Codes and Coding Requirements

Revenue codes requiring HCPCS/CPTmixedCovered

Attachment contains specific revenue codes that require an alternate HCPCS/CPT procedure code

Requirement threshold — Outpatient revenue codes and procedure codes

RequirementAll listed revenue codes on outpatient claims must be billed with a corresponding HCPCS or CPT code or risk denial/payment impact.

Denial riskOutpatient facility claims may be denied when received without the corresponding appropriate HCPCS/CPT codes.

Multiple visitsIf multiple CPT or HCPCS codes are necessary to reflect multiple, distinct, or independent visits with the same revenue code, repeat the revenue code and include the applicable date of service.

ScopeApplies to revenue codes that impact commercial reimbursement programs (see attachments for the specific list).

Billing Requirements and Provider Instructions

Billing Rule

UB-04 outpatient billing: include revenue code plus CPT/HCPCS

Submit both a revenue code and a corresponding CPT or HCPCS code on outpatient UB-04 claims; absence of the procedure code for any revenue code listed on this policy may affect claim payment or result in denial. If multiple CPT/HCPCS codes are necessary to reflect multiple, distinct, or independent visits with the same revenue code, repeat the revenue code and include the applicable date of service.

Applies to outpatient claims for Acute Care Hospitals (including Children's and Cancer Hospitals — bill types 13X, 14X), Critical Access Hospitals (85X), and Long Term Care Hospitals (13X).
Revenue codes that require HCPCS/CPT codes are listed in the Attachments section of the policy.
Claims received without the corresponding appropriate HCPCS/CPT codes may be denied or have payment affected.

OpenPayer

Outpatient Facility Alternate Procedure Code Reimbursement

Outpatient Revenue Code Billing Criteria

Revenue Codes and Coding Requirements

Billing Requirements and Provider Instructions

Applicable Facility Types and Claim Forms