Imaging/Radiation Therapy Centers - Reimb. Schedules Effective 8/15/09

Evidence Based Reimbursement 

Performance Management Codes
Effective December 15, 2009, Blue Cross and Blue Shield of Texas (BCBSTX) will begin reimbursing for the following Performance Management CPT codes:

Category II Code
Description
Frequency
0500F
Initial prenatal care visit
As appropriate
0501F
Prenatal flow sheet documented in medical record by first prenatal visit
As appropriate
1034F
Current tobacco smoker (CAD, CAP, COPD, PV) (DM)
Annual
1035F
Current smokeless tobacco user (eg, chew, snuff) (PV)
Annual

These codes facilitate data collection about quality of care. They allow physicians to report services based on nationally established, evidence-based performance guidelines for improving quality of patient care. The codes will provide us with information unavailable from claims data.

  • Codes 1034F and 1035F identify tobacco users.
  • Initial prenatal care visit codes (0500F and 0501F) identify maternity cases.

Use of these codes should allow us to increase referrals to the Lifestyle Management Program and to Special Beginnings®, the BCBSTX maternity program designed to offer support and education from prenatal to postpartum care.

We encourage physicians to report these codes. Reimbursing these codes supports the BCBSTX goal of improving the health of the population and our focus on wellness.

Note: When billing codes 0500F, 0501F 1034F, and 1035F, submit your usual charge. Please do not submit the codes with a $0 charge.

Reimbursement Changes and Updates 

Reimbursement Changes/Updates 

 

BCBSTX Relative Values 

Assistant Surgery allowable is 20% of the Surgery rate.

Physician Assistants, Advance Nurse Practitioners, Registered Nurse First Assistants, Licensed Surgical Assistants, Clinical Nurse Specialists and Nurse Midwives will be reimbursed 85% of the rates posted on the internet except for Drugs, Clinical Lab, Durable Medical Equipment/Prosthetics and Orthotics. Drugs, Clinical Lab, Durable Medical Equipment/ Prosthetics and Orthotics will be reimbursed at 100% of the rates posted on the internet.

Facility Relative Values 

Non-Facility Relative Values 

Clinical Laboratory 

Professional component for procedures listed on the Clinical Lab Schedule will be reimbursed at $5.00 for HMO and $5.50 for PPO.

Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount.

Clinical Lab Schedule 

Durable Medical Equipment/Prosthetics and Orthotics 
Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount.

DME Schedule 

Drugs

Note: The Drug/Injectable Fee Schedule will be updated on the following dates: 6/1/2009, 9/1/2009, 12/1/2009, 3/1/2010 and 6/1/2010.

Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount.

Drug Schedule 

Other Codes 

Assistant Surgery allowable is 20% of the Surgery rate.

Physician Assistants, Advance Nurse Practitioners, Registered Nurse First Assistants, Licensed Surgical Assistants, Clinical Nurse Specialists and Nurse Midwives will be reimbursed 85% of the rates posted on the internet except for Drugs, Clinical Lab, Durable Medical Equipment/Prosthetics and Orthotics. Drugs, Clinical Lab, Durable Medical Equipment/ Prosthetics and Orthotics will be reimbursed at 100% of the rates posted on the internet.

Codes not listed may require individual consideration (IC) to determine the BCBSTX compensation allowable amount.

Other Codes Schedule 

Multiple Imaging Procedure Reduction – Technical Component  

Multiple Procedure Reduction of the Technical Component (TC) of Certain Diagnostic Imaging Procedures