I. General Coding
Claims for reimbursement must be reported with valid industry standard CPT, CDT, HCPCS procedure codes and ICD-10 diagnosis codes and appropriate modifiers.
The following payment applies to the category of codes outlined below.
Category II CPT Codes
This code set is a set of supplemental tracking codes that can be used for performance measurement and are intended to facilitate data collection. Using these codes is optional for correct coding and may not be used as a substitute for Category I codes. These services are included in the E&M services billed and are not separately reimbursable. Arkansas BCBS does not require physicians to report the data represented by CPT code. The member is not responsible for charges related to the reporting of the CPT code.
Category III CPT Codes
Category III codes are temporary codes created to identify emerging technology services and procedures. Unlike unlisted or deleted codes, the Category III codes allow data collection for specific emerging technology services. If a Category III code is available, providers must use that code instead of an unlisted or deleted Category I code. The services or procedures represented by Category III codes may not have FDA approval, may not be performed by many health care professionals across the country, and the service or procedure may not have proven clinical efficacy. Claims filed for services using Category III codes will be denied unless the code is addressed as a covered service in an Arkansas Blue Cross and Blue Shield Medical Coverage Policy.
HCPCS "C" Codes
HCPCS "C" codes are temporary codes established by CMS for use under the Hospital Outpatient Prospective Payment System (OPPS). Claims filed for services using HCPCS C codes will be denied unless the code is required to report a covered service in an Arkansas Blue Cross and Blue Shield Medical Coverage Policy.
HCPCS "G" Codes
In general, HCPCS “G” codes are temporary national codes assigned by CMS to identify professional healthcare procedures and services that may not have assigned CPT codes or are under review before being included in the CPT coding system. In general, ABCBS considers G codes as a fragmentation of any other service provided and are generally not reimbursable. Arkansas Blue Cross and Blue Shield would expect that the CPT code that best describes the service(s) would be billed. Some exceptions may apply when there is not a specific equivalent CPT code that exists.
HCPCS "H" Codes
The HCPCS "H" codes are used by those state Medicaid agencies that are mandated by state laws to establish separate codes for identifying mental health services that include alcohol and drug treatment services. Claims filed for services using HCPCS H Codes will be denied. Arkansas Blue Cross and Blue Shield would expect that the CPT code that best describes the service(s) would be billed. Some exceptions may apply when there is not a specific equivalent CPT code that exists.
HCPCS "T" Codes
HCPCS "T" codes are designed exclusively for use by Medicaid state agencies to establish codes for items for which there are no permanent national codes but for which codes are necessary to administer the Medicaid program. Claims filed for services using HCPCS “T” Codes will be denied. Arkansas Blue Cross and Blue Shield would expect that the CPT code that best describes the service(s) would be billed.
Revenue Codes
Revenue codes are four-digit numeric codes used by institutional providers. HCPCS or CPT codes may be required in addition to specific revenue codes, to describe the services rendered.
EFFECTIVE 8/1/2025: The following applies to outpatient institutional claims (bill types 13X, 14X and 85X)
- Claims submitted with the following revenue codes require the appropriate associated CPT or HCPCS codes to be submitted for reimbursement:
- 0270 Medical/Surgical Supplies and Devices - General
- 0271 Medical/Surgical Supplies and Devices - Nonsterile
- 0272 Medical/Surgical Supplies and Devices - Sterile
- 0273 Medical/Surgical Supplies and Devices - Take-home supplies
- 0274 Medical/Surgical Supplies and Devices - Prosthetic/orthotic devices
- 0276 Medical/Surgical Supplies and Devices - Intraocular lens
- 0277 Medical/Surgical Supplies and Devices - Take-home oxygen
- 0279 Medical/Surgical Supplies and Devices - Other supplies/devices
- 0290 DME - General
- 0291 DME - Rental
- 0292 DME - Purchase of new DME
- 0293 DME - Purchase of used DME
- 0294 DME - Supplies/Drugs for DMEC
- 0299 DME - Other equipment
- 0940 Other therapeutic services - General
If a claim submitted for one of these revenue codes does not include an associated CPT/HCPCS code, the service will not be reimbursed.
- Claims submitted with the following revenue codes require the appropriate associated HCPCS codes to be submitted for reimbursement (EFFECTIVE 02/01/2026):
- 0250 Pharmacy - General
- 0251 Pharmacy - Generic drugs
- 0252 Pharmacy - Non-generic drugs
- 0253 Pharmacy - Take-home drugs
- 0254 Pharmacy - Drugs incident to other diagnostic services
- 0255 Pharmacy - Drugs incident to radiology
- 0256 Pharmacy - Experimental drugs
- 0257 Pharmacy - Nonprescription
- 0258 Pharmacy - IV Solutions
- 0259 Pharmacy - Other
- 0631 Pharmacy - Extension of 025X - Single source drug
- 0632 Pharmacy - Extension of 025X - Multiple source drug
- 0633 Pharmacy - Extension of 025X - Restrictive prescription
- 0634 Pharmacy - Extension of 025X - Erythropoietin (EPO) less than 10,000 units
- 0635 Pharmacy - Extension of 025X - Erythropoietin (EPO) 10,000 or more units
- 0636 Pharmacy - Extension of 025X - Drugs requiring detailed coding
- 0637 Pharmacy - Extension of 025X - Self-administered drugs
If a claim submitted for one of these revenue codes does not include an associated HCPCS code, the service will not be reimbursed.
- Claims filed with Revenue code 0450 (Emergency Room - General) are required to include one of the following CPT codes 99281-99285 and 99291 or HCPCS codes G0380-G0384. Claims filed with Revenue code 0450 without one of these CPT/HCPCS codes will be rejected.
- The following Revenue Codes are not reimbursable (EFFECTIVE 8/1/2025)
| 0275 |
0518 |
0528 |
0963 |
0973 |
0983 |
| 0278 |
0519 |
0529 |
0964 |
0974 |
0984 |
| 0510 |
0520 |
0681 |
0965 |
0975 |
0985 |
| 0511 |
0521 |
0682 |
0966 |
0976 |
0986 |
| 0512 |
0522 |
0683 |
0967 |
0977 |
0987 |
| 0513 |
0523 |
0684 |
0968 |
0978 |
0988 |
| 0514 |
0524 |
0689 |
0969 |
0979 |
0989 |
| 0515 |
0525 |
0960 |
0970 |
0980 |
|
| 0516 |
0526 |
0961 |
0971 |
0981 |
|
| 0517 |
0527 |
0962 |
0972 |
0982 |
|
- Outpatient institutional claims containing revenue codes 0905, 0906, 0912, 0913 and 0915 will require CPT/HCPCS codes in conjunction with these revenue codes. When submitting outpatient claims with these revenue codes (both electronic and paper), facilities must also use the appropriate corresponding CPT codes as follows:
- Revenue Code 0905 (Intensive outpatient services - psychiatric) and 906 (Intensive outpatient services-Chemical Dependency) claim must include HCPCS S9480
- Revenue Code 0912 (Partial hospitalization-less intensive) and 0913 (Partial hospitalization-intensive) claim must include HCPCS S0201
- Revenue Code 0915 (Group Therapy) claim must include one of the following CPT/HCPCS 90801-90880, 90901, 96101-96120, G0176, G0177, G0396, G0397, G0410, G0411
If billed without the appropriate corresponding CPT/HCPCS code, the claim will reject.
Unlisted or Miscellaneous Codes
Unlisted or miscellaneous codes should only be used when an established code does not exist to describe the diagnosis, service, procedure, or item rendered.
Reimbursement is based on review of the unlisted or miscellaneous codes on an individual claim basis. Claims submitted with unlisted or miscellaneous codes must contain the applicable information and/or documentation below for consideration during review:
- A written description, office notes, or operative report describing the procedure or service performed
- An invoice with written description of items and supplies
- The corresponding National Drug Code number for an unlisted drug code
If the description of the service provided is not present on the claim form and/or electronic record, the information will be requested through a Medical Record Request.
II. Code Editing Software
The Health Plan uses software products that ensure compliance with standard code edits and rules. These products increase consistency of payment for providers by ensuring correct coding and billing practices and may automatically apply edits using the software’s editing logic.
The automated editing includes but is not limited to, code editing software, CMS National Correct Coding Initiative (NCCI) edits and plan specific policy edits. Code editing software is updated regularly to conform to changes in coding standards, CMS published updates and plan specific policy.
The following code edits apply:
- PTP (Procedure to Procedure)
- These edits prevent inappropriate payment of services that should not be reported together. Each edit has a Column One and Column Two HCPCS/CPT code. If a provider reports the two codes of an edit pair for the same member on the same date of service, the Column One code is eligible for payment, but the Column Two code is denied. In mutually exclusive relationships, the higher valued code will be denied. If a clinically appropriate NCCI PTP-associated modifier is allowed as indicated on the PTP file and reported, both services may be allowed.
- MUE (Medically Unlikely Edits)
- The National Correct Coding Initiative (NCCI) includes a set of edits known as Medically Unlikely Edits (MUE’s). An MUE represents a maximum number of units-of-service that would be expected to be included in any specific CPT or HCPCS code, and therefore could be medically necessary. If more services are submitted than allowed for one date of service for a specific CPT or HCPCS code, the units exceeding the MUE limit will be denied.
- Add-On Codes
- Add-on codes describe procedures or services that are always provided “in addition to” other, related services or procedures. Add-on codes cannot stand alone as separately reportable services. Any add on code submitted without an appropriate primary code will be denied.
- Deleted Codes
- Claim lines containing deleted procedure codes when submitted with a date of service after the deletion date of the procedure code will be denied.
- Gender and Age Specific Codes
- Gender and age specific editing is utilized to identify incorrect coding or fraud. Claim lines containing procedure codes that are inconsistent with the member’s gender or age as indicated in the code descriptor may be denied. If inappropriately applied, claims may be considered on re-review.
- Procedure Code Unbundling/Rebundling
- Procedure code unbundling is the submission of multiple procedure codes for a group of specific procedures that are components of a single comprehensive code. Procedure unbundling may occur in one of two ways:
- A professional claim could be submitted that has procedure codes for both the individual components and the comprehensive procedure. Arkansas Blue Cross and Blue Shield would rebundle the individual component codes into the comprehensive procedure.
- Procedure unbundling could also occur when a professional claim is submitted with only the individual components of the comprehensive code. In this situation, the system will recognize the relationship between the comprehensive code and its individual components. Then, it will automatically add the comprehensive code to the claim and rebundle the individual components into that comprehensive code.
- Mutually Exclusive Procedures
- Mutually exclusive procedures exist when a claim is submitted for two or more procedures that are not usually performed on the same patient on the same date of service. In mutually exclusive relationships, the most clinically intense code is denied. Clinical intensity is generally based on the total RVU for the procedures submitted. This edit would result in the line-item denial of the least clinically intense code as provider liability.
- Incidental Procedures
- Incidental is defined as a procedure carried out at the same time as a primary procedure but is clinically integral to the performance of the primary procedure, and therefore, should not be separately reimbursed. This edit would result in the line item denial of the incidental code as provider liability.
- Medical and Surgical Supplies
- Medical and surgical supplies during an outpatient or physician office visit are included as incidental to the E/M service or procedure performed and will not be separately reimbursed.
- National Drug Code (NDC) Numbers
- A valid 11-digit NDC number, NDC unit of measurement, and NDC units dispensed is required on professional (837P) and outpatient institutional (837I) electronic claim transactions for reimbursement of physician-administered drugs. The NDC must match the valid HCPCS code submitted for the medical drug.
- NDC's must be reported using the (5-4-2 format). If a drug’s NDC does not follow this format, then a zero must be inserted at the beginning of the appropriate section of the number, to create the 5-4-2 format.
- The NDC should not be added to the line item on the claim for an office visit, administration code, lab or x-ray code.
- The appropriate HCPCS/NDC combination should be billed when available instead of a not otherwise specified code (i.e., J3490, J3590, J7999, J8499, J9999, A4641, A9699, and C9399).
- Effective February 2025 If the claim does not include the appropriate HCPCS/NDC combination, the entire claim will reject.
- Expired NDC or expired HCPCS code should not be billed. This will result in the rejection of the claim.
- NDC, procedure code and effective date combination will be validated. If the combination is not valid, the claim will reject.
- If the line on the claim containing the NDC cannot be validated, the entire claim will reject.
- Modifier Procedure Validation
- Modifiers are subject to compatibility edits with the procedure to which they are appended. For example, an Evaluation and Management (E/M) service appended with a -59 modifier will be denied.
- Ancillary Services
- Certain procedures are deemed to be non-covered based on medical coverage policy or a specific benefit exclusion in the member benefit certificate of coverage. When procedures related to those non-covered services are submitted, reimbursement for these ancillary services will be denied. If no other payable major surgical service was performed on the same date of service, the ancillary services (i.e., anesthesia, assistant surgeon, pre-op testing, pathology or radiology) will also be denied.
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