Reimbursement policy updates for facilities

As a reminder, based on our October 1, 2023, provider notice, effective with dates of service on or after January 1, 2024, Anthem Blue Cross will implement the following updates:

New reimbursement policy: Bundled Services and Supplies — Facility

Anthem will implement a new facility reimbursement policy titled Bundled Supplies and Services — Facility. This policy identifies certain services and/or supplies ineligible for separate reimbursement when reported by a facility. These identified services and/or supplies are an integral component to the overall procedure.

The Related Coding section of the policy lists and describes the CPT® and HCPCS Level II codes that are considered always bundled and not eligible for reimbursement when they are reported as a stand-alone service or with another service. No modifiers will override the denial for the always bundled services and/or supplies.

Reimbursement policy update: Treatment Rooms — Facility

Anthem will expand the current policy to include two additional revenue codes (760 and 769) and add HCPCS code G0463 to the Related Coding section. The code description for G0463 is hospital outpatient clinic visits or assessment and management of a patient. G0463 is not eligible for reimbursement when reported with revenue code 760, 761, or 769.

Reimbursement policy update: Place of Service and Evaluation and Management —Facility

Anthem will update the policy language to indicate the following:

• The title of the policy will be renamed place of service — facility.
• Professional services billed under revenue codes 960 to 989 are non-reimbursable when submitted on a UB-04.
• Preventive counseling CPT codes 99401 to 99404, 99411, and 99412 are non-reimbursable when billed in an outpatient setting.

As a reminder, evaluation and management (E/M) services and professional services (excluding E/M services rendered in the emergency room and billed with ER revenue codes) must be billed on a
CMS-1500 form.

To view the reimbursement policies, log in to Availity.com, select Anthem in the Payer Spaces menu, then select Information Center. Select Administrative Support, then select the Reimbursement Policies — Facility and Professional link. Reimbursement policies are listed in alphabetical order.

If you are not registered for Availity, go to Availity.com and go to the upper right-hand corner to complete the registration process.

To view the reimbursement policies, log in to anthem.com/ca. Go to For Providers > Policies, Guidelines & Manuals. Scroll down to Reimbursement Policies and select Access Policies. Policies are listed in alphabetical order.

In addition, several facility edits will be implemented with effective dates of service on or after January 1, 2024, to ensure that correct coding guidelines are being followed when submitting UB-04 claim forms. These edits are essential for ensuring accurate and efficient billing processes to support member benefits, data collection, and correct payment in accordance with provider contracts.

The edits that will be implemented are as follows:

1. Revenue codes that are required by National Uniform Billing Committee (NUBC) guidelines to be submitted with a CPT or HCPCS code will be denied if the appropriate CPT/HCPCS is not submitted. Please ensure that facility claims are submitted in accordance with Anthem’s outpatient facility revenue code billing requirements — facility policy.
2. Revenue codes that are submitted with an inappropriately cross-walked CPT or HCPCS code according to NUBC guidelines will be denied.
3. Claims submitted with units above the medically unlikely units according to the National Correct Coding Initiative (NCCI) medically unlikely edits (MUE) may be denied as these edits are being adopted as a correct coding best practice by Anthem.
4. Edits supporting the policies outlined in this article.

These edits aim to streamline billing procedures, enhance data accuracy, and align with the evolving healthcare landscape. It is essential that all healthcare facilities and on campus providers comply with these requirements to avoid any disruptions or delays in reimbursement processes.

To assist you in understanding and implementing these changes effectively, we have compiled the following resources and policies for reference:

1. NUBC guidelines: NUBC.org
2. CMS NCCI FAQ Library: cms.gov/ncci-medicare/medicare-ncci-faq-library
3. For the below policies, you can easily access these policies on Anthem’s website by selecting Policies, Guidelines & Manuals from the menu and scrolling down to reimbursement policies. You can also go to anthem.com/provider/policies/reimbursement:

       a. Outpatient Facility Revenue Code Billing Requirements — Facility, Policy ID C-18003

       b. Place of Service — Facility, Policy ID C-15004

       c. Bundled Services and Supplies — Facility, Policy ID C-23001

       d. Clinic Charges — Facility, Policy ID C-14002

       e. Treatment Rooms with Office Evaluation and Management Services, Policy ID C-20005

We strongly encourage all healthcare providers to review the NUBC guidelines and CMS National Correct Coding Initiative MUEs, as well as the policies listed above. It is essential that your billing department or team implement these guidelines promptly to ensure compliance and minimize any potential revenue disruptions.