Clinical Payment and Coding Policies

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Clinical payment and coding policies (CPCPs) are based on criteria developed using healthcare professionals and industry standard guidelines.

  • CPCPs are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.
  • CPCPs are neither intended to address every aspect of a reimbursement situation nor cover all issues related to reimbursement for services rendered to Blue Cross and Blue Shield of Texas enrollees. BCBSTX reserves the right to modify a CPCP at any time by publishing a new version.
  • Certain CPCPs may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If a conflict arises between a CPCP and any plan document under which a member is entitled to Covered Services, the plan document will govern.
  • If a conflict arises between a CPCP and any provider contract pursuant to which a provider participates in and/or provides Covered Services to eligible member(s) and/or plans, the provider contract will govern.
  • “Plan documents” include, but are not limited to, Certificates of Health Care Benefits, Benefit Booklets, Summary Plan Descriptions, and other enrollee benefit Coverage Documents. Blue Cross and Blue Shield of Texas (BCBSTX) (the Plan) may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case. BCBSTX has full and final discretionary authority for their interpretation and application to the extent provided under any applicable plan documents.
  • Claims should be coded appropriately according to industry-standard coding guidelines. For Current Procedural Terminology (CPT®) and/or Healthcare Common Procedure Coding System (HCPCS) codes that have been replaced by a new code(s), or the criteria for the codes has materially changed, Providers must submit the new code(s) which accurately reflects the services provided.
  • For CPCP effective dates for in-network BCBSTX providers, please refer to the effective date listed on the CPCP. For out-of-network providers in Texas, the CPCP is effective as of the date the policy is posted to the BCBSTX provider website.

View the current policies below:

For Clinical Payment and Coding policy effective dates for in-network providers, please refer to the effective date listed on the policy. Disclosure notices subject to Title 28 of the Texas Administrative Code are posted at least 90 days in advance of the effective date of the change. All other disclosures will be provided with as much notice as is practicable and in compliance with applicable law. For out-of-network providers, the policy will be effective on the date the policy is posted to the provider website.

CPT copyright 2020 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Policy Name Policy NumberPostedEffective DateArchived Documents
Anesthesia Clinical Payment and Coding Information PDF Document CPCP010 04/20/2020 07/20/2020 View Archive
Applied Behavior Analysis PDF Document CPCP011 12/02/2020 03/03/2021 View Archive
Chiropractic Services PDF Document CPCP016 10/07/2020 10/15/2020 View Archive
Co-Surgeon/Team Surgeon Modifiers PDF Document CPCP009 10/07/2020 10/15/2020 View Archive
Coordinated Home Care /Private Duty Nursing Policy Guideline PDF Document CPCP005 10/07/2020 10/15/2020 View Archive
Corrected Claim Submission PDF Document CPCP025 05/09/2020 08/15/2020 View Archive
Drug Testing Clinical Payment and Coding Policy PDF Document CPCP020 09/18/2020 12/28/2020 View Archive
Emergency Department Services Evaluation and Management (E/M) Services Coding – Facility Services CPCP003 11/19/2020 02/25/2021 View Archive
Evaluation and Management (E/M) Coding – Professional Provider PDF Document CPCP024 10/01/2020 01/01/2021 View Archive
Global Surgical Package PDF Document CPCP014 05/09/2020 08/15/2020 View Archive
Hernia Repair PDF Document CPCP012 06/08/2020 09/15/2020 View Archive
Home Infusion PDF Document CPCP019 07/09/2020 10/10/2020 View Archive
Implant Payment and Coding Policy PDF Document CPCP007 07/09/2020 10/10/2020 View Archive
Increased Procedural Services (Modifier 22) PDF Document Effective 08/12/2021 CPCP013 05/11/2021 08/12/2021 View Archive
Increased Procedural Services (Modifier 22) PDF Document Effective through 08/11/2021 CPCP013 04/20/2020 07/20/2020 View Archive
Inpatient Readmissions PDF Document CPCP027 03/18/2020 06/20/2020 N/A
Inpatient/Outpatient Unbundling Policy CPCP002 12/14/2020 03/18/2021 View Archive
Laboratory Panel Billing Guideline CPCP021 05/29/2020 09/01/2020 View Archive
Medical Record Documentation Guideline Effective 07/12/2021 CPCP029 04/08/2021 07/12/2021 View Archive
Medical Record Documentation Guideline Effective through 07/11/2021 CPCP0029 03/10/2020 03/10/2020 View Archive
Modifier Reference Guideline Effective 07/15/2021 CPCP023 04/10/2021 07/15/2021 View Archive
Modifier Reference Guideline Effective through 07/14/2021 CPCP023 04/07/2020 07/10/2020 View Archive
Multiple Surgical Procedures - Professional Provider Services CPCP015 08/07/2020 11/10/2020 View Archive
Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy PDF Document (Note: on 2/15/2021, the 90-day effective date was corrected from 5/5/2021 to 4/5/2021) CPCP004 12/29/2020 04/05/2021 View Archive
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) PDF Document Effective 08/15/2021 CPCP028 05/14/2021 08/15/2021 View Archive
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) PDF Document Effective 05/15/2021 - 08/14/2021 - Updated 03/26/2021 for code C9771 CPCP028 02/09/2021

Updated 03/26/2021
05/15/2021 View Archive
Observation Services Tool for Applying MCG Care Guidelines CPCP001 06/08/2020 06/15/2020 View Archive
Outpatient Facility and Hospital Claims: Revenue Codes Requiring CPT or HCPCS Codes CPCP018 11/05/2020 02/10/2021 View Archive
Point-of-Care Ultrasound Examination Guideline PDF Document CPCP030 06/08/2020 09/15/2020 N/A
Pneumatic Compression Devices – Outpatient Use PDF Document CPCP022 09/18/2020 10/01/2020 View Archive
Preventive Services Policy PDF Document CPCP006 03/30/2021 04/01/2021 View Archive
Psychological and Neuropsychological Testing PDF Document Effective 07/12/2021 CPCP008 04/08/2021 07/12/2021 View Archive
Psychological and Neuropsychological Testing PDF Document Effective through 07/11/2021 CPCP008 04/07/2020 07/10/2020 View Archive
Surgical and Non-Surgical Services Guide PDF Document TXCPCP03 04/08/2021 07/12/2021 N/A
Telemedicine and Telehealth Services PDF Document CPCP033 03/26/2021 03/25/2021 View Archive
Trauma Activation CPCP031 05/29/2020 09/01/2020 View Archive
Wasted/Discarded Drugs and Biologicals Guideline CPCP017 10/07/2020 01/10/2021 View Archive