Description
This policy provides direction on services identified as bundled into an evaluation and management (E/M) service.
Policy
Blue Cross Blue Shield of North Dakota (BCBSND) considers services discussed in this policy are 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 or within a designated timeframe from the medical visit.
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 (or within the designated timeframe below), 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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09/20/2021
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Updated format and added cross references
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08/18/2022
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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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