Professional Reimbursement Schedules Effective 9/1/11

Reimbursement Changes and Updates

Reimbursement Changes/Updates 

Note: You received a letter in May 2011 regarding a change in the maximum allowable fee schedule used for BlueChoice®, HMO Blue® Texas, and ParPlan effective September 1, 2011. In the conversion factor table included in the letter, CPT codes 98925-98929 were listed with the incorrect set of Medicine codes. Please click on the link below to view the REVISED table that lists CPT codes 98925-98929 with the correct set of Medicine codes.

Maximum Allowable Fee Schedule Revision of Medicine Codes 

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, Other Lab, Durable Medical Equipment/Prosthetics and Orthotics. Drugs, Clinical Lab, Other 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 

Lab 

Professional component for procedures listed on the Lab Schedules 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 

Other Lab Codes 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: 9/1/2011, 12/1/2011, 3/1/2012 and 6/1/2012.

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

NDC pricing listed is based on NDC units and should be billed appropriately.

  1. Effective March 1, 2012, BCBSTX will temporarily discontinue reimbursing claims submitted with an NDC in accordance with the NDC schedule posted on the website under "Drugs" with the exception of immunizations. Immunizations submitted with an NDC will continue to be reimbursed in accordance with the NDC schedule posted on the website under "Drugs" until July 14, 2012. Drugs other than immunizations submitted with an NDC will be reimbursed in accordance with the schedule posted on the website under "Drugs" based on the applicable Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT®) code(s) included on the claim. BCBSTX will continue to accept NDC for billing of all physician-administered and physician-supplied drugs.
  2. Effective July 15, 2012, immunizations submitted with an NDC will be reimbursed in accordance with the schedule posted on the website under "Drugs" based on the applicable Current Procedural Terminology (CPT®) code(s) included on the claim. BCBSTX will continue to accept NDC for billing of all physician-administered and physician-supplied drugs, including immunizations.

CPT/HCPCS/NDC Drug Schedule 

NDC / CPT / HCPCS Billable Units 

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, Other Lab, Durable Medical Equipment/Prosthetics and Orthotics. Drugs, Clinical Lab, Other 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