Claims are reviewed to determine eligibility for payment. Services considered incidental, mutually exclusive, integral to the primary service rendered, or part of a global allowance, are not eligible for separate reimbursement. Definitions for incidental, mutually exclusive, integral, or global procedures or services are as follows:
A. Incidental Procedures
An incidental procedure is carried out at the same time as a more complex primary procedure. These procedures require little additional provider resources and are generally not considered necessary to the performance of the primary procedure. For example, the removal of an asymptomatic appendix is considered an incidental procedure when done during hysterectomy surgery.
An incidental procedure is not reimbursed separately on a claim.
B. Mutually Exclusive Procedures
Mutually exclusive procedures are two or more procedures that are usually not performed on the same patient on the same date of service. Mutually exclusive rules may also include different procedure code descriptions for the same type of procedures for which the provider should be submitting only one of the procedure codes. Only the most clinically intense procedure will be allowed. Generally, an open procedure and a closed procedure in the same anatomic site are not both reimbursed. If both codes accomplish the same result, the clinically more intense procedure supersedes and the comparative code is denied as mutually exclusive.
C. Integral Procedures
Procedures considered integral occur in multiple surgery situations when one or more of the procedures are included in the major or principle procedure. Integral procedures are those commonly carried out as part of a total service and do not meet all the criteria listed under the policy “Multiple Surgical Procedure Guidelines.” Some of the procedures or services listed in the CPT manual that are commonly carried out as an integral component of a total service or procedure have been identified by the term “separate procedure.” These codes should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.
D. Global Allowance
Most medical and surgical procedures include pre-procedure, intra-procedure, and post-procedure work. Reimbursement for these services is based on a global allowance. Claims for services considered to be directly related to pre-procedure, intra-procedure, and post-procedure work are included in the global reimbursement and will not be paid separately.
The pre- and post-operative global days are based on CMS standards. The global period is defined as the period of time during which claims for related services will be denied as an unbundled component of the total surgical package. Major procedures have a global period of 90 days. Minor procedures have a global period of 10 or 0 days.
The global surgical package includes all necessary services normally furnished by the surgeon before, during and after a surgical procedure. The global period also includes Evaluation and Management services that are related to the procedure.
Payment for related medical or surgical services performed the day prior to, the day of, or within 90 days of a major surgical procedure is included in global allowance. Payment for related medical or surgical services performed the same day as a minor surgical procedure, as well as medical or surgical services performed within 10 days of a 10 day procedure, is included in the global allowance.
Bone Marrow or Stem Cell Services/Procedures – Codes 38204, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214 and 38215 are considered incidental to 38240, 38241 and 38242. Separate reimbursement is not allowed for incidental services.
Cardiac Stress Test – A stress test may require the administration of pharmacological agents. An IV injection of a pharmacological agent is considered an integral component of the stress test. It does not warrant separate reimbursement.
Casting Application and Strapping – Separate reimbursement is allowed for an initial Evaluation and Management code when billed with a casting/strapping code. In a situation where a separate, identifiable evaluation and management service is provided in addition to the casting/strapping service, such as treat-ment of an acute/chronic illness, modifier 25 should be used when billing. In these cases, further review of the claim and supporting documentation may be necessary to make the appropriate reimbursement decision.
Separate reimbursement will be allowed for A4590, ‘special casting materials, hexcilite and light cast,’ when submitted with casting and strapping procedures 29000-29799. Due to the significantly greater cost of fiberglass, it is considered over and above what is included in standard casting application.
Casting/strapping services 29000-29799 are considered integral to surgical procedures. Established Evaluate and Management services will be denied when billed with casting/strapping services.
Reapplication and supplies necessary for casting/strapping during the follow-up period are eligible for separate reimbursement. The office visit is considered to be within the global period of the original fracture repair.
Chemotherapy – Evaluation and Management services will generally be denied when submitted on the same date of service as a chemotherapy administration code. If a significant, separately identifiable service is performed, modifier 25 is used. Office notes must document the significant, separately identifiable service.
Intravenous infusion codes are not allowed in addition to intravenous chemotherapy administration services unless the intravenous infusion represents a treatment apart from chemotherapy administration. The reason for a separate intravenous infusion should be noted in the medical record, and the service code modifier for a distinct procedure appended to the procedure code for intravenous infusion.
Clinical photography – for documentation/record-keeping purposes is considered to be an integral part of an evaluation and management (E&M) service or procedure and not eligible for separate reimbursement consideration.
Critical Care Services – Codes 36000, 36410, 36415, 36591, 36600, 43752, 43753, 71010, 71015, 71020, 92953, 93561, 93562, 94002, 94003, 94004, 94660, 94662, 94760, 94761, 94762, and 99090 are considered incidental to 99291 and 99292(Critical Care Services). Critical care service procedures will be denied as incidental when submitted with Neonatal and Pediatric Critical Care services (99466, 99467, 99468, 99469, 99471, 99472, 99475, 99476). The critical care service procedures are included in the pediatric and neonatal critical care codes. Separate reimbursement is not allowed for incidental services.
Electrical Stimulation Electrodes – The supply of electrodes is considered incidental to electrical stimulation. Separate reimbursement is not allowed for incidental supplies.
Electrocardiogram – Electrocardiograms are considered incidental to a stress test, a cardiac test which includes an ECG as part of the test, and as part of initial hospital care. A 3 lead ECG is considered incidental to a 12 lead ECG. Separate reimbursement is not provided for ECGs which are considered incidental.
An ECG is considered mutually exclusive to provider services for cardiac rehabilitation (93797). Separate reimbursement is not provided for ECGs which are considered mutually exclusive. See also policy titled, “ECG Reimbursement.”
Intra-operative use of kinetic balance sensor for implant stability during knee replacement arthroplasty (0396T) is considered incidental to the primary procedure being performed and is not eligible for separate reimbursement.
Lab Tests – Lab codes 80047 – 80076 are lab panels that were developed for coding purposes. When the lab tests performed on a particular patient constitute one of the listed panels, the panel should be reported. The individual lab tests are rebundled into the lab panel code for reimbursement. Individual lab codes which constitute a panel are considered mutually exclusive to the lab panel.
Lesion Biopsy – Lesion biopsy of separate anatomical sites will be allowed in addition to surgical procedures such as removal of skin tags/ lesions and closure.
Lesion Excision and Closure – Separate reimbursement is allowed for the excision of lesion procedures when submitted with intermediate, complex, or reconstructive closures; 12031-12057, 13100-13160, 14000-14350, 15002 – 15261, and 15570-15770. Simple wound repair procedures, 12001 through 12021, will be found incidental to excision of lesions, unless the excision is a Mohs’ procedure.
Lumbar Laminectomy, Facetectomy or Foraminotomy reported with a Lumbar Spinal Fusion – When a lumbar laminectomy, facetectomy or foraminotomy is performed in conjunction with a posterior approach for a lumbar spinal fusion procedure, the laminectomy, facetectomy or foraminotomy is generally incidental, and should be bundled with the fusion. Modifier 59 will not allow additional payment when appended to CPT4 codes 63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047 and 63048 and when performed in conjunction with 22630, 22632, 22633, and/or 22634. Based on the most common clinical scenario, it is expected that when a lumbar laminectomy, facetectomy, and/or foraminotomy is billed with a lumbar arthrodesis, posterior interbody technique, the procedures are being performed on the same level. In the unusual clinical circumstance when the procedures are performed at different vertebral levels, clinical information will be required to be submitted on appeal.
Myocardial strain imaging (0399T) – the quantitative assessment of myocardial mechanics using image-based analysis of local myocardial dynamics for the detection of myocardial malformation is considered incidental to the primary procedure being performed and is not eligible for separate reimbursement.
Pediatric and Neonatal Critical Care – Codes 36000, 36140, 36620, 36510, 36555, 36400, 36405, 36406, 36420, 36600, 31500, 94002, 94003, 94004, 94375, 94610, 94660, 94760, 94761, 94762, 36430, 36440, 43752, 51100, 51701, 51702 and 62270 are considered incidental to 99468, 99471 and 99475(Inpatient Neonatal and Pediatric Critical Care). The critical care procedure codes listed as a part of 99291 and 99292 are included in the Pediatric Neonatal Critical care and are considered incidental. Separate reimbursement is not allowed for incidental services.
New Visit Frequency code 99201 – 99205 – BCBSNC does not automatically reassign or reduce the code level of Evaluation and Management codes billed for covered services, with the exception of the new visit frequency editing as described here. When a claim is received reporting a new patient evaluation and management service more than once within a 3 year period, the new patient evaluation and management service code will be replaced with the equivalent established patient evaluation and management code if one is available. Otherwise the claim will be denied.
BCBSNC will replace a code billed for a subsequent office or other outpatient consultation within 6 months of the initial office or other outpatient consultation by the same provider for the same member with the appropriate level of established office visit. The crosswalk is as follows:
99241 to 99212
99242 to 99212
99243 to 99213
99244 to 99214
99245 to 99215
Office Visits – Office services provided on an emergency basis (99058) are considered mutually exclusive to the primary services provided.
Office visit (99211) is considered mutually exclusive to 95115-95117(allergen immunotherapy). Separate reimbursement is not allowed for mutually exclusive services.
Pap Smears – Obtaining a pap smear is integral to the office visit. This includes both preventive and routine office visits. Separate reimbursement is not allowed for Q0091.
Pathologists – Claims submitted by pathologists (provider specialty 29) for clinical interpretation of laboratory results will be allowed for codes 83020, 84165, 84166, 84181, 84182, 85060, 85390, 85576, 86255, 86256, 86320, 86325, 86327, 86334, 86335, 87164, and 87207. Pathology interpretation of all other codes in the 80002-87999 range is considered integral to the laboratory test. Separate reimbursement is not allowed for integral services.
Pulse Oximetry – Pulse oximeters are considered incidental to office visits or procedures. Separate reim-bursement is not provided for incidental procedures.
Respiratory Treatments – Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB devise is considered mutually exclusive to an office visit. Separate reimbursement is not provided for mutually exclusive services.
Robotic Surgical Systems – Payment for new technology is based on the outcome of the treatment rather than the “technology” involved in the procedure. Additional reimbursement is not provided for the robotic surgical technique.
STAT or After Hours Laboratory Charges – Additional charges for STAT or after hours laboratory services are considered an integral part of the laboratory charge.
Surgical Supplies – Surgical supplies will be considered incidental to Surgical; Laboratory; Inpatient, Outpatient or Office Medical Evaluation and Management; and Consultation services.
Surgical dressings applied in the provider’s office are considered incidental to the professional services of the health care practitioner and are not separately payable. Surgical dressings billed in the provider’s office (place of service 11) will be denied.
Surgical trays and miscellaneous medical and/or surgical supplies are generally considered incidental to all medical, chemotherapy, surgery, and radiology services, including those performed in the office setting.
Supplies (except those related to splinting and casting) are considered components of the 0, 10, and 90-day global surgical package, and are not separately billable on the same date of service as the 0, 10, or 90-day procedure.
Supplies are not covered when they do not require a prescription and can be purchased by the member over-the-counter or when they are given to the member as take-home supplies. Medical and/or surgical supplies, such as dressings and packings, used during the course of an office visit are generally considered incidental to the office visit.
Compression/pressure garments, elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered.
Transvaginal Ultrasound – Transvaginal ultrasound (76830) is considered mutually exclusive to a hysterosonography with or without color flow Doppler (76831).
Venipuncture – Refer to policy “Code Bundling Rules Not Addressed in Claim Check.”
Vision Services – please refer to CEC’s bundling guidelines related to routine vision services.
X-Rays – When single view and double view chest X-Rays are billed together (71010 and 71020), only the double view X-Ray is allowed. When the entire spine, survey study is billed (72082) with cervical spine films (72040), thoracic spine films (72070) or lumbosacral spine films (72100) only the entire spine, survey study code is allowed. When a single view X-Ray code is billed with a multiple view X-Ray code, only the multiple view X-Ray code is allowed (e.g., 72020 with 72040, 72070, or 72100). Only one professional and one technical component are allowable per X-Ray.