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November 2013

Changes to hospital outpatient surgical procedures reimbursement policy explained

Benefits for outpatient facility services that need a Current Procedural Terminology or Health Care Procedure Coding System procedure code are based only on the reported procedure code, and not the related revenue code.

Keep the following in mind:

  • When a surgical procedure code can’t be paid based on the group’s benefits, it will be rejected, which may affect a provider’s reimbursement.
  • When two or more surgical procedures are performed and only one of the procedures is a member benefit. BCBSM will pay for that procedure, which is covered based on the approved amount.

Currently, there are no changes to how multiple surgical procedures are reported, or when two or more surgical procedures are performed during the same visit and two or more of the procedures are payable benefits. BCBSM will continue to reimburse facilities at 125 percent of the payable highest-fee procedure.

If you have any questions about this policy, please contact your provider consultant. 

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2012 American Medical Association. All rights reserved.
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