Clinical Payment and Coding Policies

Clinical payment and coding policies are based on criteria developed by specialized professional societies, national guidelines (e.g. Milliman Care Guidelines (MCG)) and the CMS Provider Reimbursement Manual. Additional sources are used and can be provided upon request. The clinical payment and coding guidelines are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.

Certain policies may not be applicable to Members who are participants in an employer’s self-funded employee benefit plan for which BCBSNM acts in an administrative capacity and certain insured products. Refer to the Member's Membership Certificate, Benefit Booklet, Benefit Plan, Summary of Benefits and Coverage, or other coverage document (together “Coverage Documents”) to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. In the event of a conflict between any policy and the Member’s Coverage Document, the Coverage Document will govern.

In the event of conflict between a clinical payment and coding policy and any Coverage Document, the Coverage Document will govern.

In the event of conflict between a clinical payment and coding policy and any provider contract pursuant to which a provider participates in and/or provides Covered Services to Member(s), the provider contract will govern.

Conformance to clinical payment and coding policy is not a guaranty of payment. All other requirements, including but not limited to eligibility at the time of service, medical necessity, and other terms, conditions, limitations and exclusions set forth in the Member’s Coverage Document, continue to apply.

Current Policies

Policy name	Policy Number & Version	Posted Date	Effective Date
Observation Services Tool for Applying MCG Care Guidelines	CPCP001 v.2	08/30/2021	09/06/2021
Inpatient/Outpatient Unbundling Policy	CPCP002 v.1	01/19/2022	02/21/2022
Evaluation and Management of Emergency Department Coding	CPCP003 v.1	12/30/2021	01/10/2022
Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy	CPCP004 v.1	01/19/2022	02/21/2022
Coordinated Home Care Policy	CPCP005 v.1	11/29/2021	01/01/2022
Preventive Services Policy	CPCP006 v.1	01/05/2022	01/01/2022
Implant Payment and Coding Policy	CPCP007 v.1	07/24/2020	09/01/2020
Psychological and Neuropsychological Testing	CPCP008 v.1	05/03/2021	06/01/2021
Co-Surgeon/Team Surgeon Modifiers	CPCP009 v.1	10/25/2021	11/17/2021
Anesthesia Clinical Payment and Coding Information	CPCP010 v.3	10/22/2021	12/20/2021
Applied Behavioral Analysis	CPCP011 v.1	11/19/2021	12/20/2021
Hernia Repair	CPCP012 v.7	06/30/2020	08/01/2020
Increased Procedural Services (Modifier 22)	CPCP013 v.1	07/12/2021	07/01/2021
Global Surgical Package	CPCP014 v.1	07/12/2021	08/01/2021
Multiple Surgical Procedures	CPCP015 v.1	09/17/2021	10/18/2021
Chiropractic Services	CPCP016 v.1	01/19/2022	02/21/2022
Wasted/Discarded Drugs and Biologicals Guideline	CPCP017 v.3	01/19/2022	02/21/2022
Outpatient Facility and Hospital Claims: Revenue Codes Requiring CPT^® or HCPCS Codes	CPCP018 v.1	12/30/2021	01/24/2022
Home Infusion	CPCP019 v.3	09/17/2021	10/18/2021
Drug Testing CPCP	CPCP020 v.3	12/30/2021	12/29/2021
Laboratory Panel Billing Guideline	CPCP021 v.1.1	08/30/2021	09/06/2021
Pneumatic Compression Devices – Outpatient Use	CPCP022 v.2	01/19/2022	02/21/2022
Modifier Reference Guideline	CPCP023 v.4	05/03/2021	06/01/2021
Evaluation and Management (E/M) Coding – Professional Provider Services	CPCP024 v.3	01/28/2022	02/28/2022
Corrected Claim Submissions	CPCP025 v.2	06/01/2020	07/01/2020
Therapeutic, Prophylactic and Diagnostic Injection and Infusion Coding	CPCP026 v.3	09/17/2021	10/18/2021
Inpatient Readmission	CPCP027 v.2	12/30/2021	01/24/2022
Non-Reimbursable Experimental, Investigational and /or Unproven Services (EIU)	CPCP028 v.2	01/19/2022	04/15/2022
Medical Record Documentation Guideline	CPCP029 v.5	10/22/2021	11/15/2021
Point-of-Care Ultrasound Examination Guideline	CPCP030 v.1	07/12/2021	08/01/2021
Trauma Activation – Facility Services	CPCP031 v.1	07/12/2021	07/01/2021
Intraoperative Neurophysiology Monitoring (IONM) Coding and Reimbursement Guideline	CPCP032 v.3	08/30/2021	09/06/2021
Telemedicine and Telehealth Services	CPCP033 v.10	04/05/2021	03/18/2021
Unbundling Policy-Professional Providers	CPCP034 v.2	09/17/2021	10/18/2021
Unlisted/Not Otherwise Classified (NOC) Coding Policy	CPCP035 v.3	10/15/2021	10/25/2021
Paravertebral Facet Injection Procedure Coding & Billing Policy	CPCP036 v.8	11/19/2021	12/13/2021

Laboratory Management Policies

Policy name	CPCP Number	Posted Date	Effective Date
Flow Cytometry	CPCPLAB001	2/1/2022	5/1/2022
Cervical Cancer Screening	CPCPLAB002	2/1/2022	5/1/2022
Vitamin D	CPCPLAB003	2/1/2022	5/1/2022
Hemoglobin A1c	CPCPLAB004	2/1/2022	5/1/2022
Prostate Biopsies	CPCPLAB005	2/1/2022	5/1/2022
Prostate Specific Antigen Testing	CPCPLAB006	2/1/2022	5/1/2022
Preventive Screening in Adults	CPCPLAB007	2/1/2022	5/1/2022
Diagnostic Testing of Iron Homeostasis & Metabolism	CPCPLAB008	2/1/2022	5/1/2022
Testosterone Testing	CPCPLAB009	2/1/2022	5/1/2022
Vitamin B12 and Methylmalonic Acid Testing	CPCPLAB010	2/1/2022	5/1/2022
ANA/ENA Testing	CPCPLAB011	2/1/2022	5/1/2022
Pre-Operative Testing	CPCPLAB012	2/1/2022	5/1/2022
Allergen Testing	CPCPLAB013	2/1/2022	5/1/2022
Prenatal Screening	CPCPLAB014	2/1/2022	5/1/2022
Hepatitis C	CPCPLAB015	2/1/2022	5/1/2022
Pediatric Preventive Screening	CPCPLAB016	2/1/2022	5/1/2022
Celiac Disease Testing	CPCPLAB017	2/1/2022	5/1/2022
Helicobacter Pylori Testing	CPCPLAB018	2/1/2022	5/1/2022
Thyroid Disease Testing	CPCPLAB019	2/1/2022	5/1/2022
Cardiovascular Disease Risk Assessment	CPCPLAB020	2/1/2022	5/1/2022
Prenatal Screening for Fetal Aneuploidy	CPCPLAB022	2/1/2022	5/1/2022
Diagnosis of Idiopathic Environmental Intolerance	CPCPLAB023	2/1/2022	5/1/2022
Epithelial Cell Cytology in Breast Cancer Risk Assessment	CPCPLAB024	2/1/2022	5/1/2022
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis	CPCPLAB025	2/1/2022	5/1/2022
Fecal Calprotectin Testing	CPCPLAB026	2/1/2022	5/1/2022
Testing for Diagnosis of Active or Latent Tuberculosis	CPCPLAB027	2/1/2022	5/1/2022
Immune Cell Function Assay	CPCPLAB028	2/1/2022	5/1/2022
Intracellular Micronutrient Analysis	CPCPLAB029	2/1/2022	5/1/2022
In Vitro Chemoresistance and Chemosensitivities Assays	CPCPLAB030	2/1/2022	5/1/2022
Measurement of Thromboxane Metabolites for ASA Resistance	CPCPLAB031	2/1/2022	5/1/2022
Oral Screening Lesion Identification Systems and Genetic Screening	CPCPLAB032	2/1/2022	5/1/2022
Diagnostic Testing of Influenza	CPCPLAB033	2/1/2022	5/1/2022
Salivary Hormone Testing	CPCPLAB034	2/1/2022	5/1/2022
Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease	CPCPLAB035	2/1/2022	5/1/2022
Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases	CPCPLAB036	2/1/2022	5/1/2022
Serum Tumor Markers for Malignancies	CPCPLAB037	2/1/2022	5/1/2022
Urinary Tumor Markers for Bladder Cancer	CPCPLAB038	2/1/2022	5/1/2022
Vectra DA Blood Test for Rheumatoid Arthritis	CPCPLAB039	2/1/2022	5/1/2022
Molecular Testing for Chronic Heart Failure	CPCPLAB040	2/1/2022	5/1/2022
Erectile Dysfunction	CPCPLAB041	2/1/2022	5/1/2022
ZIKA Virus Risk Assessment	CPCPLAB042	2/1/2022	5/1/2022
Evaluation of Dry Eyes	CPCPLAB043	2/1/2022	5/1/2022
Lyme Disease	CPCPLAB044	2/1/2022	5/1/2022
Pathogen Panel Testing	CPCPLAB045	2/1/2022	5/1/2022
Cardiac Biomarkers for Myocardial Infarction	CPCPLAB046	2/1/2022	5/1/2022
Pancreatic Enzyme Testing for Acute Pancreatitis	CPCPLAB047	2/1/2022	5/1/2022
Folate Testing	CPCPLAB048	2/1/2022	5/1/2022
General Inflammation Testing	CPCPLAB049	2/1/2022	5/1/2022
Urine Culture Testing for Bacteria	CPCPLAB050	2/1/2022	5/1/2022
Diagnostic Testing of Common Sexually Transmitted Infections	CPCPLAB051	2/1/2022	5/1/2022
Testing for Mosquito- or Tick-Related Infections	CPCPLAB052	2/1/2022	5/1/2022
?-Hemolytic Streptococcus Testing	CPCPLAB053	2/1/2022	5/1/2022
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing	CPCPLAB055	2/1/2022	5/1/2022
Gamma-glutamyl Transferase	CPCPLAB056	2/1/2022	5/1/2022
Coronavirus Testing in the Outpatient Setting	CPCPLAB057	2/1/2022	5/1/2022
Venous and Arterial Thrombosis Risk Testing	CPCPLAB058	2/1/2022	5/1/2022
Diagnosis of Vaginitis including Multi-target PCR Testing	CPCPLAB059	2/1/2022	5/1/2022
Genetic Testing for Adolescent Idiopathic Scoliosis	CPCPLAB060	2/1/2022	5/1/2022
Testing for Alpha-1 Antitrypsin Deficiency	CPCPLAB061	2/1/2022	5/1/2022
Identification of Microorganisms using Nucleic Acid Probes	CPCPLAB063	2/1/2022	5/1/2022
Nerve Fiber Density Testing	CPCPLAB064	2/1/2022	5/1/2022
Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection	CPCPLAB065	2/1/2022	5/1/2022
DNA Ploidy Cell Cycle Analysis	CPCPLAB066	2/1/2022	5/1/2022
Testing of Homocysteine Metabolism-Related Conditions	CPCPLAB067	2/1/2022	5/1/2022
Onychomycosis Testing	CPCPLAB068	2/1/2022	5/1/2022
Immunohistochemistry	CPCPLAB069	2/1/2022	5/1/2022
Prescription Medication and Illicit Drug Testing in the Outpatient Setting	CPCPLAB070	2/1/2022	5/1/2022