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January 2013
Hospital outpatient reimbursement, HCPCS payment rules, revenue code information summarized
Over the past few months, we’ve provided you with information about BCBSM’s transition to fee-based pricing for hospital outpatient services (see the December 2012, November 2012 and July 2012 issues of The Record), which is scheduled to begin April 1, 2013.
In order to help you prepare for the conversion and billing, we’re summarizing the facility service type, categories and associated revenue codes. The charts below give you billing information that will be in effect April 1, 2013.
Facility Service Type |
Category |
Description |
2 or E |
SUR |
Surgery (including maternity) |
5 or K |
LAB |
Laboratory – clinical/anatomical |
9 |
AOR |
Other |
A |
DMP |
Used Durable Medical Equipment/Prosthetic & Orthotic |
G |
DMP |
New Durable Medical Equipment/Prosthetic & Orthotic |
I |
INA |
Drug Administration |
J |
DMP |
Rental Durable Medical Equipment/Prosthetic & Orthotic |
K |
RAD |
Radiology/Radiopharmaceutical |
R |
IND |
Drugs |
S |
ERT |
Emergency Room & Trauma |
T |
THE |
Physical Therapy, Occupational Therapy, Speech and Language Pathology Evaluation |
V |
THV |
Physical Therapy, Occupational Therapy, Speech and Language Pathology Visit |
W |
TXR |
Treatment Room |
Z |
OBR |
Observation Room |
Description |
Revenue codes that require HCPCS codes |
Surgery (including maternity) |
0360, 0361, 0369, 0490, 0499, 0700, 0750, 0769, 0790
Codes that require a surgical HCPCS if surgery is performed in this room: 0450, 0451, 0452, 0456, 0510, 0511, 0512, 0513, 0514, 0515, 0516, 0519, 0761 |
Laboratory – clinical/anatomical |
0300, 0301, 0302, 0303, 0304, 0305, 0306, 0307, 0309, 0310, 0311, 0312, 0314, 0319, 0923, 0924, 0925 |
Other |
0270, 0271, 0272, 0279, 0280, 0289, 0370, 0379, 0380, 0381, 0382, 0383, 0384, 0385, 0386, 0387, 0389, 0390, 0391, 0392, 0399, 0410, 0412, 0413, 0419, 0450, 0451, 0452, 0456, 0459, 0460, 0469, 0470, 0471, 0472, 0479, 0480, 0481, 0482, 0483, 0489, 0500, 0509, 0510, 0511, 0512, 0514, 0515, 0516, 0517, 0519, 0530, 0531, 0539, 0540, 0545, 0621, 0622, 0623, 0730*, 0731, 0732, 0739, 0740, 0780, 0920, 0921, 0922, 0929, 0940, 0942, 0943, 0949, 0951, 0952, 2101, 2105, 2106 |
Durable Medical Equipment/Prosthetic & Orthotic |
0274, 0291, 0292, 0293, 0946, 0947 |
Drug Administration |
0260, 0331, 0332, 0335, 0771 |
Drug/Pharmacy |
0250, 0251, 0252, 0253, 0254, 0255, 0256, 0257, 0258, 0259, 0262, 0631, 0632, 0633, 0634, 0635, 0636, 0637 |
Radiopharmaceutical |
0255, 0343, 0349 |
Radiology |
0255, 0320, 0321, 0322, 0323, 0324, 0329, 0330, 0333, 0339, 0340, 0341, 0342, 0343, 0344, 0349, 0350, 0351, 0352, 0359, 0400, 0401, 0402, 0403, 0404, 0409, 0610, 0611, 0612, 0614, 0615, 0616, 0618, 0619, 0860, 0861 |
Emergency Room & Trauma |
0450, 0451, 0452, 0459, 0681, 0682, 0683, 0684, 0689 |
Surgery (Maternity) |
Refer to “Surgery” |
Treatment Room |
0761 |
Observation Room |
0762 |
Physical Therapy, Occupational Therapy, Speech and Language Pathology Evaluation |
0424, 0434, 0444 |
Physical Therapy, Occupational Therapy, Speech and Language Pathology Visit |
0421, 0431, 0441 |
Payment Rules |
ALT |
Alternative code exists |
PAY |
Pay |
EXP |
Experimental |
OBS |
Obsolete |
PHY |
Physician’s service only |
PRP |
Payment included in related procedure |
NCB |
Noncovered benefit |
NMN |
Not medically necessary |
UNL |
Unlisted procedure code |
Bilateral Indicator |
“P” denotes that the procedure can be performed bilaterally. |
*Note: Ambulatory surgery facilities must report the applicable EKG HCPCS code when reporting revenue code 0730. Other applicable revenue code and HCPCS code information for laboratory, radiology and surgery services is included above.
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