Description
This policy is being archived effective December 1, 2024. This policy provides direction on services identified as bundled into an evaluation and management (E/M) service.
Policy Application
All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date.
Policy
Blue Cross Blue Shield of North Dakota (BCBSND) considers services discussed in this policy inherent components of an E/M service. Routine medical care may include itemized billing. Some services cannot be separately billed when an E/M is billed on the same day.
The Current Procedural Terminology (CPT) Guidelines must be followed when separately reporting services that are components of an E/M service. When any of the below services are reported on the same day as an E/M service, payment for the below services will be included in the allowance for the E/M service.
- 96127 - Brief emotional/behavioral assessment may not be billed on the same day as an E/M service.
- 99172 and 99173 - Visual function screening, automated or semi-automated may not be billed on the same day as an ophthalmological service or a non-preventive E/M service.
The above list is not an all-inclusive list of services not separately billable with an E/M service. Providers must refer to the National Correct Coding Initiative (NCCI) and the CPT & HCPCS Coding Guidelines.
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
History
Date
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Updates
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9/20/2021
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Updated format and added cross references
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8/18/2022
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Policy reviewed and updated cross-referenced title Correct Coding Guidelines – Commercial and updated hyperlink for National Correct Coding Initiative Edits.
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8/24/2023
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Policy Reviewed and updated cross-referenced title Correct Coding Guidelines-Medicaid and included payment integrity under Limitation & Exclusions.
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7/22/2024
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Policy application was added to the policy. Policy was updated to remove statement of “within the designated timeframe” as the policy rules are applied to services rendered on the same day as an E/M. Revised date remains the same as no policy application has changed and language update is to add clarity on how BCBSND applies policy application.
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09/24/2024
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Archiving policy as this is now included in NDRP-GC-034 Evaluation and Management Policy.
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