BCBSTX Implementing Two ClaimsXtenTM Updates to Add-On Without Base Rule

July 23, 2018

Blue Cross and Blue Shield of Texas (BCBSTX) is updating and removing two items within the “Add-on without Base Rule” implemented 9/18/17, regarding add-on codes 01968, 01969, and 99292 denying when not billed with the parent code. This update will better address special circumstances which often present at the time the services are rendered, which currently doesn’t allow the base and add-on code(s) to be billed separately or by the different physician as per Current Procedural Terminology (CPT®) and Centers for Medicare and Medicaid Services (CMS) guidelines.

BCBSTX recognizes, although CPT defines an add-on code(s) as one that is not considered a “stand-alone” code, certain unique circumstances may require special consideration:

Obstetric Anesthesia Services

Obstetric Anesthesia often involves extensive hours and/or the transfer of anesthesia management to a second physician, or if/when the patient labors past midnight; therefore, special consideration will be given by BCBSTX:

  • When a cesarean delivery or an emergency cesarean hysterectomy is performed after a lengthy vaginal labor, the vaginal neuraxial analgesia/anesthesia (01967) and the cesarean anesthesia (01968, 01969) may be performed and billed by two separate anesthesia providers.
  • When the neuraxial labor analgesia/anesthesia is initiated prior to midnight, and the cesarean delivery or cesarean hysterectomy is performed after midnight, the total anesthesia service is provided as a continuous service but the two portions occur on different, sequential dates.

Critical Care Evaluation and Management Services

Research of industry resources conclude that CPT guidelines and CMS guidelines conflict with each other and BCBSTX finds it is not unusual for ‘partners’ within the same practice to assist and/or cover each other for the same patient; therefore, special consideration will be given:

  • When critical care Evaluation and Management (E/M) add-on code 99292 is submitted as a standalone code on a claim.
  • When submitted by a different rendering National Provider Identifier (NPI).

These changes will be implemented within an upcoming release; however, interim processes have already been established, effective immediately to accommodate and remediate previously impacted claims which meet the above criteria. BCBSTX is reviewing previously processed claims back to 9/18/17 and they will be adjusted as appropriate for payment.

If you have any questions, please contact your Network Management Representative.

CPT, copyright 2018, by the American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. Healthcare Common Procedure Coding System (HCPCS) Level II codes are maintained by the Centers for Medicare and Medicaid Services.