Provider and Facility Reference Manual
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Information in this manual applies only to your Highmark BCBSWNY legacy patients who have NOT moved onto Highmark’s system.
For your patients who have moved onto Highmark’s system, please visit the Highmark Provider Manual.
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Section 13A - Additional Claims and Billing Information
The CPT4 codes for lesion treatments include specific verbiage that needs to be considered in determining whether more than one unit of service or line of service can be billed for a code and if any other codes can be billed with it.
Listed below are the CPT4 codes and the maximum number of units that should be reported on a claim for a date of service.
|Code Verbiage||Maximum Units|
|11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion||01|
|11056 Two to four lesions||01|
|11057 More than four lesions||01|
|17000 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curretement), premalignant lesions (e.g., actinic keratoses); first lesion||01|
|17003 Second through14th lesion, each (list separately in addition to code for first lesion)||13|
|17004 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curretement), premalignant lesions (e.g., actinic keratoses), 15 or more lesions||01|
|17110 Destruction by any method of flat warts, molluscum contagiosum, or milia; up to 14 lesions||01|
|17111 15 or more lesions
Please be sure to use the appropriate CPT codes when billing mammography to differentiate diagnostic from screening.
Diagnostic codes should be used when the procedure is ordered because of a suspicion of breast disease (due to symptoms or clinical findings), patient history of breast cancer or biopsy proven breast disease.
A screening code should be used when the procedure is done as a baseline or on a routine basis.
Multiple, Bilateral, and Multiple Bilateral Procedures
In accordance with Current Procedural Terminology (CPT) guidelines, bilateral procedures should be billed on one line only, utilizing the modifier 50; enter one as 01 in the units field and bill your total bilateral charge.
Bilateral Billing Examples
- Bilateral breast reconstruction – report as code 19357 with modifier 50 on one claim line with 01 in the units field.
- Bilateral lower and upper blepharoplasties – report as:
- 15820 with modifier 50 on the first claim line with 01 units
- 15822 with modifier 50 on the second claim line with 01 units
Note: For bilateral services, do not bill modifier LT/RT or any other site-specific modifier other than 50.
Separate billing is allowed for multiple procedures performed on the same day that add significant time or complexity and are not incidental or an integral part of the primary procedure. The primary procedure is reimbursed at the fee schedule amount; eligible secondary procedures are reimbursed at 50 percent.
Multiple procedures that involve the same service performed more than once (such as CPT code 26100, arthrotomy of each carpometacarpal joint of the left hand), should be billed as five separate lines on the claim form along with the modifier 59 or the HCPCS individual digit modifiers on lines two through five in order to clarify that the additional lines are definitely separate services.
Procedure code descriptions including more than one unit of service provided, (such as code 95117, professional services for allergy immunotherapy, two or more injections, or code 96406, intralesional injections, more than seven lesions), are reported on one line with only one (01) unit.
Final reimbursement is also determined after applying usual edits such as (but not limited to) preauthorization, cosmetic coverage and bundling. In addition, the member’s contract must be active at the time the service is rendered.
Physician/Provider Exceptions (Does not apply to Hospital category reimbursement)
When the CPT code description includes: "each additional" (for example, code 63048, laminectomy, each additional cervical, thoracic, or lumbar segment), report the code on one line with the number of additional segments indicated in the units field.
When the CPT code states: "specify number of tests, doses" (such as code 95024, intradermal tests with allergenic extracts), report the code on one line with the number of tests, doses, etc., indicated in the units field.
Code & Comment
The Code & Comment section on our provider website is an extremely valuable tool that, among other things, can help you determine if a surgical code is bilateral. The Code & Comment tool provides procedure code coverage information including preauthorization requirements and potential medical policies/ protocols that may apply. Code & Comment is available as a "Quick Link" on our secure website. Once selected, a pop-up window will appear. Once you type in a procedure code and select a code type, the coverage information will be returned. A key is also available to explain the abbreviations used in the results. The key also describes some of the fields found in the tool and provides further explanation. The key should be consulted frequently as information can change.
Non-Ionic Low Osmolality Contrast Media
Contrast media will not be considered for separate payment and cannot be billed to the patient. Reimbursement for contrast media is included in the allowance for the radiology service. To maintain accurate records of the use of non-ionic contrast media, use the appropriate CPT/HCPCS code.
Modifier 26 (for the physician component/CMS 1500 or 837P claim) and modifier TC (for the hospital or technical services/UB04 or 837I claim) must be used when a sleep study is performed at a hospital or affiliated clinic.
|Type of Claim||Revenue Codes||Bill Type||CPT Codes||*Roll-Up/ Reimbursement|
|1||Ambulatory Surgery||0360-0361, 0490, 0750 & 0790||131||
CPT Code Required
|Yes / Category and contract may allow for additional reimbursement of eligible implantable prosthetic devices (revenue codes 274 & 278), pacemakers (revenue code 275). Eligible secondary procedures pay at 50 Percent.|
|1a||Cancelled Ambulatory Surgery||0360-0361, 0490, 0750 & 0790||131||
CPT Code Required
|Bill Claim with Occurrence Code 43. Reimbursement based on record review or use modifier 53|
|2||Emergency Room / "Urgent Care" Service within Emergency Department||0450, 0459||13X||
|YES/ Case Rate|
|2a||ER Physician Fee||0981 (For hospital employed MD's only)||13X||YES||NO/ Fee Schedule|
|3||Observation||0762||13X||NO||Per diem/Per Case, pays in addition to ER|
|4||Urgent Care Centers||456||
|YES/ All-inclusive case rate (fee schedule)|
|5||Clinic||Must be billed on a HCFA1500/ANSI837 Professional Form.||N/A||YES||NA / Follows physician reimbursement guidelines.
TC split for Medicare Primary will be accepted on a UB92.
|6||Chemotherapy*||0280-0289, 0331, 0332, 0335||13X||NO||Identified high-cost drugs, labs and diagnostics pay according to your schedule of allowance|
|7||Radiation Therapy||0330, 0333, 0339||13X||YES||NA/Services pay according to your schedule of allowance in addition to identified high-cost drugs, labs and diagnostics.|
|9||Home Infusion Therapy||0640 - 0649||33X 34X||YES||NO / Schedule of allowance|
|8||Transfusion*||0390, 0391||13X||YES -
|NO / Blood Storage & Processing (Rev Code 390 is not payable. Identified high-cost Injectable drugs, diagnostic services and labs pay according to your schedule of allowance|
|9||Cast Room*||0700, 0709||131||NO||Labs, diagnostic services and durable medical equipment pay according to fee schedule.|
|10||Infusion Therapy*||0260-0269||131||NO||Labs and diagnostic services pay per your schedule of allowance. Drugs are paid according to guidelines indicated in "High-Cost Drugs" (category #28).|
|11||Dialysis||0820, 0821, 0830, 0831, 0840, 0841, 0849, 0850, 0851, 0859||13X 72X||YES, per contract||Ancillaries paid in addition if not included in composite reimbursement.|
|12||Epogen||0634-0635||13X 72X||YES||NO/Per Unit. Appropriate HCPCS code should be billed indicating units given in unit field or use value code 68|
|13||Pre-Admission Testing||13X||YES||Refer to Guidelines for Diagnostics. Bill with Occurrence Code 41. Roll-up to ambulatory surgery/IP stay.|
|14||False Labor||0720 - 0729||13X||NO||Per contract, ER per diem/case rate is paid. 59025 present should pay schedule of allowance|
|15||Recovery Room||0710 - 0719||13X||NO||Roll-up to ambulatory surgery, ER or Observation. Will not pay if billed alone.|
|16||Ambulance||0540 - 0549||131||N/A||Charges (Should not roll up if billed with 450 - ER)|
|17||Cardiac Rehab||0943||131||YES||Schedule of Allowance. Follow applicable protocol for guidelines and limitations|
|18||Diagnostic Testing||0300-0309, 0310-0319, 0340-0349, 0350-0359, 0400-0409, 0460-0469, 0470-0479, 0480, 0482, 0489, 0610-0619, 0621-0622, 0720, 0730-0739, 0740-0749, 0920-0929||131||YES||Schedule of Allowance|
Psych / Other
|0900, 0901, 0902, 0919||13X||YES||Schedule of Allowance|
|20||OP/Alcohol/Drug||0905, 0912, 0914, 0915, 0916, 0944, 0945||13X 89X||YES||Schedule of Allowance|
|21||Durable Medical Equipment (DME)||0290 - 0293, 0299, 0946, 0947||13||YES||Schedule of Allowance|
PT, OT, ST
|0420-0429, 0430-0439, 0440-0449, 0530-0539, 0940-0941, 0949||13X||YES||Schedule of Allowance for each per day|
|Schedule of Allowance|
|23||Hospice||065X||81X 82X||N/A||Flat rate per visit; if Medicare eligible and member elects into Hospice Care, Medicare is responsible for all claims|
|24||Home Health Care||055X , 056X, 057X, 042X, 043X 044X||33X 34X||N/A||YES/Pays off revenue code per visit except rev code 572 - HHA which pays per hour.|
|25||Prosthetics and Implantables||0274, 0278, 0275||13X||HCPCS||Category and contract may allow additional payment for eligible implantables. Payment equal to invoice cost, subject to post-payment audit.|
|26||Treatment Room*||0760, 0761||13X||YES||Pays according to your schedule of allowance|
|27||Inhalation Therapy||0410 - 0419||131||YES||Pays according to your schedule of allowance|
|Pays according to your schedule of allowance|
|29||Supplies||0270, 0271, 0272, 0273, 0277 & 0279||131||NO||These revenue codes will not be paid if billed with unbundled service.|
|30||Miscellaneous Pharmaceuticals||0250-0259||131||NO||These revenue codes will not be paid if billed with unbundled service.|
|31||Sleep Studies/ Polysomnography||0740, 0920||131||95805-95811||Payable per fee schedule.|
|32||Lithotripsy||360, 490, 790||131||YES
Valid Category CPT Code Required
|YES / Secondary procedures pay at 50 percent.|
The policies and procedures referenced in this section represent our standard for claims submission, payment, and adjustment. Certain providers may be subject to different guidelines due to contractual limitation or expansions.
*Service could pay up to $50 per day for room charge