Provider reimbursement policies

Blue Cross and Blue Shield of Minnesota and Blue Plus (Blue Cross) has developed reimbursement policies that provide coding and reimbursement requirements for healthcare services.

Coding and reimbursement processes are subject to all terms of the Provider Service Agreement as well as changes, updates and other requirements of coding rules and guidelines. All codes are also subject to federal HIPAA rules, and in the case of medical code sets (HCPCS, CPT, ICD-10-CM), only codes valid for the date of service will be accepted. These policies are superseded by benefits and/or by state or federal requirements.

The reimbursement policies are separated by line of business (Commercial, Medicaid or Medicare). If there is not a policy for a specific line of business refer to the following sources:

  • Medicaid: Refer to Minnesota Health Care Program (MHCP) Provider Manual for guidance. NOTE: Blue Cross Medicaid Reimbursement Policies became effective 1/1/2024.
  • Medicare: Refer to Centers for Medicare & Medicaid Services (CMS) for guidance.

Commercial

Commercial Evaluation and Management - 002 Same Day Same Service - Opens in a new window - Opens PDF in a new window

Commercial Evaluation and Management - 004 Hospital Inpatient and Observation Care Services - Opens in a new window - Opens PDF in a new window

Commercial Evaluation and Management - 005 Standby and On-Call Services - Opens in a new window - Opens PDF in a new window

Commercial Evaluation and Management - 006 Prolonged Services - Opens in a new window - Opens PDF in a new window

Commercial Evaluation and Management - 011 Preventive Medicine Services - Opens in a new window - Opens PDF in a new window

Commercial Evaluation and Management - 012 Consultation Services - Opens in a new window - Opens PDF in a new window

Commercial Evaluation and Management - 013 New Patient - Opens in a new window - Opens PDF in a new window

Medicaid

Medicaid Evaluation and Management - 002 Same Day Same Service - Opens in a new window - Opens PDF in a new window

Medicaid Evaluation and Management - 013 New Patient - Opens in a new window - Opens PDF in a new window

Medicaid Evaluation and Management - 014 Online Digital Evaluation and Management Services - Opens in a new window - Opens PDF in a new window

Medicare

Medicare Evaluation and Management - 002 Same Day Same Service - Opens in a new window - Opens PDF in a new window

Medicare Evaluation and Management - 004 Hospital Inpatient and Observation Care Services - Opens in a new window - Opens PDF in a new window

Medicare Evaluation and Management - 005 Standby and On-Call Services - Opens in a new window - Opens PDF in a new window

Commercial

Commercial General Coding - 003 Code Editing Policy - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 005 Unlisted Procedure Code - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 007 Telehealth and Virtual Care Services - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 009 Max Units Per Day - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 010 Chiropractic Services - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 011 Urgent Care-After Hours Care-Extended Hours - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 016 Drug Wastage - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 018 Myocardial Perfusion (Cardiovascular Stress Test) - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 019 Professional and Technical Components for Applicable Services - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 025 Maternity - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 031 Home Infusion - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 038 Injection and Infusion Services - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 069 Ambulance Services - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 071 Bundled Services - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 072 Performance Measurement Codes - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 073 Clinical Trial - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 074 Cellular and Gene Therapy Products - Opens in a new window

Commercial General Coding - 076 Procedure Codes Not Applicable to Commercial Products - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 078 Community Health Worker - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 079 Hair Removal for Gender Affirming Procedures - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 080 Skilled Nursing Services in the Home - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 081 Inappropriate Diagnosis Code - Opens in a new window - Opens PDF in a new window

Commercial General Coding - 082 Spravato (esketamine) - Opens in a new window - Opens PDF in a new window

Medicaid

Medicaid General Coding - 003 Code Editing Policy - Opens in a new window - Opens PDF in a new window

Medicaid General Coding - 005 Unlisted Procedure Code Policy - Opens in a new window - Opens PDF in a new window

Medicaid General Coding - 009 Maximum Units Per Day - Opens in a new window - Opens PDF in a new window

Medicaid General Coding - 071 Bundled Services - Opens in a new window - Opens PDF in a new window

Medicaid General Coding - 073 Clinical Trial - Opens in a new window - Opens PDF in a new window

Medicaid General Coding - 074 Cellular and Gene Therapy Products - Opens in a new window

Medicaid General Coding - 079 Hair Removal for Gender Affirming Procedures - Opens in a new window - Opens PDF in a new window

Medicaid General Coding - 081 Inappropriate Diagnosis Code - Opens in a new window - Opens PDF in a new window

Medicaid General Coding - 082 Spravato (esketamine) - Opens in a new window - Opens PDF in a new window

Medicare

Medicare General Coding - 003 Code Editing Policy - Opens in a new window - Opens PDF in a new window

Medicare General Coding - 005 Unlisted Procedure Code - Opens in a new window - Opens PDF in a new window

Medicare General Coding - 009 Max Units Per Day - Opens in a new window - Opens PDF in a new window

Medicare General Coding - 011 Urgent Care-After Hours Care-Extended Hours - Opens in a new window - Opens PDF in a new window

Medicare General Coding - 079 Hair Removal for Gender Affirming Procedures - Opens in a new window - Opens PDF in a new window

Medicare General Coding - 081 Inappropriate Diagnosis Code - Opens in a new window - Opens PDF in a new window

Commercial

Commercial Surgery/Interventional Procedure - 001 Assistant at Surgery - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 002 Bilateral Procedures - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 003 Co-Surgeon and Team Surgeons - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 004 Modifier 22 - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 005 Multiple Surgical Reduction - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 006 Fracture Care - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 007 Global Surgical Package - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 008 Multiple Endoscopic Procedures - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 011 Insertion and Removal of Tympanic Ventilation Tubes - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 013 Computer Assisted Navigation in Orthopedic Surgery - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 019 Once in a Lifetime Procedures - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 021 Mohs Micrographic - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 022 Wrong Surgical and Other Invasive Procedures - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 023 Robotic-Assisted Surgery - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 024 Split Surgical Package - Opens in a new window - Opens PDF in a new window

Commercial Surgery/Interventional Procedure - 025 Intraoperative Neurophysiological Monitoring (IONM) - Opens in a new window - Opens PDF in a new window

Medicaid

Medicaid Surgery/Interventional Procedure - 002 Bilateral Procedures - Opens in a new window - Opens PDF in a new window

Medicaid Surgery/Interventional Procedure - 003 Co-Surgeon and Team Surgeons - Opens in a new window - Opens PDF in a new window

Medicaid Surgery/Interventional Procedure - 004 Modifier 22 - Opens in a new window - Opens PDF in a new window

Medicaid Surgery/Interventional Procedure - 005 Multiple Surgical Reduction - Opens in a new window - Opens PDF in a new window

Medicaid Surgery/Interventional Procedure - 007 Global Surgical Package - Opens in a new window - Opens PDF in a new window

Medicaid Surgery/Interventional Procedure - 019 Once in a Lifetime Procedures - Opens in a new window - Opens PDF in a new window

Medicaid Surgery/Interventional Procedure - 022 Wrong Surgical and Other Invasive Procedures - Opens in a new window - Opens PDF in a new window

Medicaid Surgery/Interventional Procedure - 024 Split Surgical Package - Opens in a new window - Opens PDF in a new window

Medicare

Medicare Surgery/Interventional Procedure - 004 Modifier 22 - Opens in a new window - Opens PDF in a new window

Medicare Surgery/Interventional Procedure - 006 Fracture Care - Opens in a new window - Opens PDF in a new window

Medicare Surgery/Interventional Procedure - 007 Global Surgical Package - Opens in a new window - Opens PDF in a new window

Medicare Surgery/Interventional Procedure - 011 Insertion and Removal of Tympanic Ventilation Tubes - Opens in a new window - Opens PDF in a new window

Medicare Surgery/Interventional Procedure - 019 Once in a Lifetime Procedures - Opens in a new window - Opens PDF in a new window

Medicare Surgery/Interventional Procedure - 022 Wrong Surgical and Other Invasive Procedures - Opens in a new window - Opens PDF in a new window

Medicare Surgery/Interventional Procedure - 023 Robotic-Assisted Surgery - Opens in a new window - Opens PDF in a new window

Medicare Surgery/Interventional Procedure - 024 Split Surgical Package - Opens in a new window - Opens PDF in a new window