Clinical Payment and Coding Policies

  • 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 For Current Procedural Terminology (CPT®) and/or Healthcare Common Procedure Coding System (HCPCS) codes that have been replaced by a new code(s), or the criteria for the codes has materially changed, Providers must submit the new code(s) which accurately reflects the services provided.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.

Previous policies can be located on the Archive page.

 

Policy Name Policy Number Posted Effective Date Archived Documents
Anesthesia Information CPCP010 03/24/2023 06/26/2023 View Archive
Applied Behavior Analysis CPCP011 06/01/2023 09/01/2023 View Archive
Chiropractic Services CPCP016 01/25/2024 01/26/2024 View Archive
Co-Surgeon/Team Surgeon Modifiers CPCP009 01/18/2024 01/19/2024 View Archive
Coordinated Home Care /Private Duty Nursing Policy CPCP005 12/12/2022 12/13/2022 View Archive
Corrected Claim Submission CPCP025 05/09/2020 08/15/2020 View Archive
Drug Testing Clinical Payment and Coding Policy Effective 03/07/2024 CPCP020 12/06/2023 03/07/2024 View Archive
Drug Testing Clinical Payment and Coding Policy Effective through 03/06/2024 CPCP020 03/24/2023 03/27/2023 View Archive
Emergency Department Evaluation and Management (E/M) Services Coding — Facility Services CPCP003 07/24/2023 10/25/2023 View Archive
Emergency Department Evaluation and Management (E/M) Services Coding — Professional Services CPCP042 07/24/2023 10/25/2023 N/A
Evaluation and Management (E/M) Coding — Professional Provider CPCP024 12/07/2023 12/08/2023 View Archive
Global Surgical Package - Professional Providers - Effective 01/22/2024 CPCP014  01/19/2024 01/22/2024 View Archive
Hernia Repair CPCP012 05/17/2023 08/18/2023 View Archive
Home Infusion CPCP019 01/04/2023 01/05/2023 View Archive
Increased Procedural Services (Modifier 22) CPCP013 01/18/2024 01/19/2024 View Archive
Inpatient Readmissions CPCP027
10/24/2023 10/24/2023 View Archive
Inpatient/Outpatient Unbundling Policy CPCP002 01/14/2022 01/14/2022 View Archive
Intraoperative Neurophysiology Monitoring (IONM) Coding and Reimbursement Policy CPCP032 05/02/2022 05/03/2022 View Archive
Laboratory Panel Billing CPCP021 06/27/2023 09/28/2023 View Archive
Medical Record Documentation CPCP029 09/23/2022 12/26/2022 View Archive
Modifier Reference Policy - Effective 04/19/2024 CPCP023 01/18/2024 04/19/2024 View Archive
Modifier Reference Policy - Effective through 04/18/2024 CPCP023 3/24/2023 06/26/2023 View Archive
Multiple Surgical Procedures — Professional Provider Services CPCP015 01/23/2024 01/24/2024 View Archive
Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy Effective 03/06/2024 CPCP004 12/05/2023 03/06/2024 View Archive
Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy Effective through 03/05/2024 CPCP004 01/14/2022 01/14/2022 View Archive
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)  Effective 05/15/2024  NOTE: This policy applies ONLY to BCBSTX ERISA Administrative Services only (ASO) plans. CPCP028 02/14/2024 05/15/2024 View Archive
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) Effective 01/15/2024 through 05/14/2024  NOTE: This policy applies ONLY to BCBSTX ERISA Administrative Services only (ASO) plans. CPCP028 10/16/2023 01/15/2024 View Archive
Observation Services Policy CPCP001 05/31/2023 09/01/2023 View Archive
Outpatient Facility and Hospital Claims: Revenue Codes Requiring Supporting CPT, HCPCS and/or NDC Codes CPCP018 10/31/2022 02/01/2023 View Archive
Outpatient Facility Service(s) Overlapping During an Inpatient Stay CPCP039 05/22/2023 09/01/2023 N/A
Outpatient Services Prior to Inpatient Admission CPCP038 02/21/2024 02/22/2024 View Archive
Paravertebral Facet Injection Procedure Coding & Billing Policy CPCP036 01/05/2023 01/06/2023 View Archive
Physical Medicine and Rehabilitation Services   CPCP040 01/19/2024 01/22/2024 View Archive
Point-of-Care Ultrasound Examination Policy - Effective 03/06/2024 CPCP030 12/05/2023 03/06/2024 View Archive
Point-of-Care Ultrasound Examination Policy -Effective through 03/05/20024 CPCP030 03/04/2022 03/07/2022 View Archive
Pneumatic Compression Devices — Outpatient Use CPCP022 02/23/2024 02/26/2024 View Archive
Preventive Services Policy CPCP006 12/22/2023 01/01/2024 View Archive
Psychological and Neuropsychological Testing CPCP008 12/06/2023 12/07/2023 View Archive
Sepsis Policy CPCP041 06/06/2023 09/06/2023 N/A
Surgical and Non-Surgical Services TXCPCP03 03/08/2023 03/09/2023 View Archive
Telemedicine and Telehealth/Virtual Health Care Services Policy Effective 03/08/2024 CPCP033 03/07/2023 03/08/2024 View Archive
Telemedicine and Telehealth Services Efffective through 03/07/2024 CPCP033 04/29/2022 03/28/2022 View Archive
Therapeutic, Prophylactic and Diagnostic Injection and Infusion Coding CPCP026 05/17/2023 05/17/2023 View Archive
Trauma Activation - Facility Services CPCP031 07/17/2023 10/18/2023 View Archive
Unbundling Policy — Professional Providers CPCP034 05/15/2023 08/15/2023 View Archive
Unlisted/Not Otherwise Classified (NOC) Coding Policy CPCP035 09/19/2022 09/20/2022 View Archive
Wasted/Discarded Drugs and Biologicals Policy CPCP017 02/15/2023 05/16/2023 View Archive

 

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