CurrentHighmark DelawarePolicy N/A

Procedure Terminology-Based Combinations

Defines how Highmark Delaware's claim processing system treats procedure codes that are combinations of component procedure codes and provides a listing of combination codes and their component codes; applies to claim adjudication for Highmark Delaware members and providers submitting claims.

Policy Summary

PayerHighmark Delaware

PolicyProcedure Terminology-Based Combinations

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionReport component procedure codes when applicable; the system may combine reported components into a combination/total procedure code during claim adjudication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

hundredsprocedure codes listed

20+document chunks

manyprocedure-to-component mappings

Adjudication and Combination Code Rules

Adjudication rule

Policy governs adjudication edits where component procedure codes reported separately may be combined into a combination/total procedure code according to governing terminology and/or entity guidelines.

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Highmark's claim processing system applies edits that may combine reported component procedure codes into a combination or 'total' procedure code when codes represent a combination based on procedure terminology or applicable governing entity guidelines (e.g., AMA, CMS, or Blue Cross Blue Shield Association).

When component codes are reported separately on a claim, the adjudication system may automatically combine them into the designated combination/total procedure code per the mappings maintained in this policy.

Providers should continue to report component procedure codes where applicable; claim adjudication may result in replacement with the combination code for payment and processing purposes.

Code combination listings

This section enumerates procedure codes and their applicable component procedure codes used for combination/bundling adjudication.

The following are sample mappings of combination procedure codes to component procedure codes (representative excerpt). See the full list for additional mappings.

ALL of the following

Example: Pelvic/Genitourinary procedures
- 50606 -> 75989, 76000, 77001, 77002, 77003
- 50693 -> 75989, 76000, 77001, 77002, 77003
- 50694 -> 75989, 76000, 77001, 77002, 77003
- 50695 -> 75989, 76000, 77001, 77002, 77003
- 50705 -> 75989, 76000, 77001, 77002, 77003
- 50706 -> 75989, 76000, 77001, 77002, 77003
Example: Procedures combining surgical and imaging components
- 52327 -> 52005
- 52315 -> 52310
- 52240 -> 52234, 52235, 52281
Example: Procedures with multiple component mappings
- 53660 -> 53661, 53665
- 52285 -> 53660, 53661, 53665
- 52630 -> 53600, 53601, 53605, 53620, 53621, 53660, 53661, 53665
Example: Additional mappings (excerpt)
- 54130 -> 38760, 54125
- 54135 -> 38770, 54125
- 54162 -> 54001, 54150, 54160, 54161
- 55706 -> 75989, 76000, 77001, 77002, 77003
- 55875 -> 52005, 52007, 52204

This listing is not exhaustive in this excerpt; the policy contains an extended list of procedures and their component codes used by the adjudication system to determine when to apply a combination/total procedure code.

Billing Guidance and Claim Processing Behavior

Billing Rule

Procedure code combinations — provider billing behavior

Highmark's claim processing system may combine individual component procedure codes into a single combination or 'total' procedure code during adjudication. Providers should report component codes when applicable; however, the system may consolidate those components into the combination code. Use this guidance when preparing claims to avoid unexpected adjudication adjustments.

Procedure codes listed below have component relationships and may be combined by the adjudication system.
When component codes are submitted separately, the system may reimburse the combination/total procedure code instead of individual components.
No separate prior authorization rules are implied by these combinations; this block documents billing relationships and claim-processing behavior.

Note

Billing relationships list (component → combination)

The following is the billing relationships list indicating procedure codes and their component procedure codes. Providers should be aware that codes listed as components (including the Q99xx codes and others) may be combined into the listed procedure code during claim adjudication.

77003: 75803, 75801, 75989, 76000, 77001, 77002, 77003
75805: 75989, 76000, 77001, 77002, 77003
75807: 75805, 75989, 76000, 77001, 77002, 77003
75809: 75989, 76000, 77001, 77002, 77003
75810: 75989, 76000, 77001, 77002, 77003
75820: 75989, 76000, 77001, 77002, 77003
75831: 75989, 76000, 77001, 77002, 77003
75840: 75989, 76000, 77001, 77002, 77003
75959: 75989, 76000, 77001, 77002, 77003
76511: 76512, 76516
76705: 76775
59025: 93922, 93923, 93924, 93925, 93926, 93930, 93931, 93970, 93971
Q9958, Q9959, Q9960, Q9961, Q9962, Q9963, Q9964: may appear as component codes alongside 75989, 76000, 77001, 77002, 77003
77402: 77407
78012: 78013
78451: 78453

Key Terms

Combination procedure code

TermCombination procedure code

DefinitionA procedure code that represents a combination or 'total' procedure made up of two or more component procedures; when component codes are reported separately they may be combined into this code during claim adjudication.

Governing sourcesMay be governed by AMA, CMS, or the Blue Cross Blue Shield Association.

Component procedure code

TermComponent procedure code

DefinitionAn individual procedure code that represents one part (component) of a larger combined procedure; when reported separately the system may map or combine it into the combination/total procedure code during adjudication.

Claim handlingProviders should report component codes when applicable; the claim processing system may combine them into the combination code based on terminology or governing guidelines.

component procedure code — examples

Example (imaging)72130 may have components Q9958, Q9959, Q9960, Q9961, Q9962, Q9963, Q9964 and related codes 72128, 72129.

Example (group mapping)72240 lists components 75989, 76000, 77001, 77002, 77003.

Example (radiology supervision/interpretation)73030 is associated with DISC OGRAPHY, LUMBAR, RADIOLOGICAL SUPERVISION AND INTERPRETATION and 73020 as related component entries.