Recommended Clinical Review Procedure Code List Changes for Certain Members Effective May 15, 2024

We’re updating our lists of codes requiring Recommended Clinical Review, for some commercial members, to reflect new, replaced or removed codes.

Fighting Fraud, Waste and Abuse

Every year, analysts and investigators for BCBSTX review claims data, industry trends and investigative results to identify potential areas of fraud, waste and abuse. We share this information with you in letters mailed to your office. The current letters show instances of potential billing abuse around COVID-19 testing and vaccinations. The letters will remind you to comply with BCBSTX’s policies and requirements.

HealthSelect of Texas^® In-Area Participants PCP Referral Requirement for In-Network Benefits

Participants enrolled in the HealthSelect of Texas In-Area medical plan are required to have a designated PCP on file with BCBSTX to receive in-network benefits. Prior authorization is also required for some services. For in-network benefits to apply, specialty providers must have a valid referral on file with BCBSTX before submitting a prior authorization. If a referral and a prior authorization are required, and the participant does not have a valid referral on file from their PCP with BCBSTX before rendering the authorized services, claims may be processed at the lower out-of-network benefit level. For more information, refer to the ERS Tools page.

Hospitals, Routine Services and Supplies

Providers usually include routine services and supplies in charges related to other procedures or services. As such, those services/supplies are considered non-billable for separate reimbursement. The following guidelines identify items, supplies and services that are not separately billable. (Note: This is not an all-inclusive list.) 

• Any supplies, items and services that are necessary or otherwise integral to the provision of a specific service and/or the delivery of services in a specific location are considered routine services and not separately billable in the inpatient and outpatient environments.
• All items and supplies that may be purchased over the counter are not separately billable.
• All reusable items, supplies and equipment that are provided to all patients during an inpatient or outpatient admission are not separately billable.
• All reusable items, supplies and equipment that are provided to all patients admitted to a given treatment area or units are not separately billable.
• All reusable items, supplies and equipment that are provided to all patients receiving the same service are not separately billable

Technical and Professional Components

Modifier 26 denotes professional services for lab and radiological services. Modifier TC denotes technical components for lab and radiological services. These modifiers should be used in conjunction with the appropriate lab and radiological procedures only. Note: When a health care provider performs both the technical and professional services for a lab or radiological procedure, they must submit the total service, not each service individually.

Clinical Payment and Coding Policy Updates

Our website’s Clinical Payment and Coding Policies describe payment rules and methodologies for CPT^®, HCPCS and ICD-10 coding for claims submitted as covered services. This information is a resource for our payment policies and does not address all reimbursement-related issues. We may add and modify clinical payment and coding policies. The following policy was added or updated:

• CPCP028 Non-Reimbursable, Experimental, Investigational and/or Unproven Services (EIU) Update - Effective 05/15/2024