Clinical Payment and Coding Policies

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Refer to Telemedicine and Telehealth Services for additional information related to telehealth coverage effective Jan. 1, 2021.

  • 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 For Current Procedural Terminology (CPT®) and/or Healthcare Common Procedure Coding System (HCPCS) codes that have been replaced by a new code(s), or the criteria for the codes has materially changed, Providers must submit the new code(s) which accurately reflects the services provided.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 2021 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Policy Name Policy Number Posted Effective Date Archived Documents
Anesthesia Clinical Payment and Coding Information CPCP010 09/27/2021 12/29/2021 View Archive
Applied Behavior Analysis CPCP011 11/22/2021 03/01/2022 View Archive
Chiropractic Services CPCP016 01/14/2022 01/14/2022 View Archive
Co-Surgeon/Team Surgeon Modifiers CPCP009 10/27/2021 11/01/2021 View Archive
Coordinated Home Care /Private Duty Nursing Policy Guideline CPCP005 11/24/2021 12/01/2021 View Archive
Corrected Claim Submission CPCP025 05/09/2020 08/15/2020 View Archive
Drug Testing Clinical Payment and Coding Policy CPCP020 11/06/2021 09/01/2021 View Archive
Emergency Department Services Evaluation and Management (E/M) Services Coding — Facility Services CPCP003 12/17/2021 03/20/2022 View Archive
Evaluation and Management (E/M) Coding — Professional Provider CPCP024 02/02/2022 05/01/2022 View Archive
Global Surgical Package   CPCP014 03/11/2022 06/13/2022 View Archive
Hernia Repair Effective 08/04/2022 CPCP012 05/02/2022 08/04/2022 View Archive
Hernia Repair Effective through 08/03/2022 CPCP012 06/29/2021 10/01/2021 View Archive
Home Infusion CPCP019 09/17/2021 12/20/2021 View Archive
Implant Payment and Coding Policy CPCP007 07/09/2020 10/10/2020 View Archive
Increased Procedural Services (Modifier 22) CPCP013 03/04/2022 03/07/2022 View Archive
Inpatient Readmissions CPCP027 12/27/2021 01/01/2022 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 Benefit Management Program - POSTPONED - see link for notice CPCPLAB     N/A
Laboratory Panel Billing CPCP021 04/13/2022 04/14/2022 View Archive
Medical Record Documentation Guideline CPCP029 10/06/2021 12/01/2021 View Archive
Modifer Reference Policy Effective 07/15/2022 CPCP023 04/14/2022

07/15/2022 View Archive
Modifer Reference Guideline Effective through 07/14/2022 CPCP023 04/10/2021
Updated – 05/21/2021
07/15/2021 View Archive
Multiple Surgical Procedures — Professional Provider Services CPCP015 06/29/2022 07/01/2022 View Archive
Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy CPCP004 01/14/2022 01/14/2022 View Archive

Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) NOTE: This policy applies ONLY to BCBSTX ERISA Administrative Services only (ASO) plans.

CPCP028 04/27/2022

08/01/2022 View Archive
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) NOTE: Effective May 1, 2022, this policy applies ONLY to BCBSTX ERISA ASO plans.

CPCP028 01/14/2022
(Updated 01/31/2022)
04/15/2022 View Archive
Observation Services Policy CPCP001 08/02/2021 11/04/2021 View Archive
Outpatient Facility and Hospital Claims: Revenue Codes Requiring CPT or HCPCS Codes CPCP018 12/22/2021 03/22/2022 View Archive
Paravertebral Facet Injection Procedure Coding & Billing Policy CPCP036 11/22/2021 02/24/2022 N/A
Point-of-Care Ultrasound Examination Policy CPCP030 03/04/2022 03/07/2022 View Archive
Pneumatic Compression Devices — Outpatient Use CPCP022 01/10/2022 04/12/2022 View Archive
Preventive Services Policy CPCP006 06/24/2022 07/01/2022 View Archive
Psychological and Neuropsychological Testing CPCP008 04/08/2021 07/12/2021 View Archive
Surgical and Non-Surgical Services TXCPCP03 03/10/2022 03/10/2022 View Archive
Telemedicine and Telehealth Services CPCP033 04/29/2022 03/28/2022 View Archive
Therapeutic, Prophylactic and Diagnostic Injection and Infusion Coding CPCP026 09/17/2021 12/20/2021 N/A
Trauma Activation CPCP031 03/04/2022 03/07/2022 View Archive
Unbundling Policy — Professional Providers CPCP034 04/08/2022 04/11/2022 View Archive
Unlisted/Not Otherwise Classified (NOC) Coding Policy CPCP035 10/06/2021 01/08/2022 N/A
Wasted/Discarded Drugs and Biologicals Policy CPCP017 01/14/2022 01/14/2022 View Archive