Blue Review
A newsletter for physician, professional, facility, ancillary and Medicaid providers

September 2017

Changes to Billing and Documentation Information and Requirements

Blue Cross and Blue Shield of Texas (BCBSTX) is implementing changes to clarify existing policies related to billing and documentation requirements for the following plans:

  • Blue Choice PPOSM
  • Blue Advantage HMOSM
  • Blue EssentialsSM
  • Blue PremierSM
  • Blue Cross Medicare Advantage (PPO)SM
  • Blue Cross Medicare Advantage (HMO)SM

The policy changes below are effective Sept. 15, 2017. They are also reflected in the provider manuals found on the BCBSTX provider website at Standards and Requirements/Manuals/Section E/Filing Claims.

Billing, Documentation and Requirements
Permissible Billing
BCBSTX does not permit pass-through billing, splitting all-inclusive bills or under-arrangement billing. Billing practices where a provider or entity submits claims by or for another provider not otherwise addressed in the provider’s agreement or in the policy are also not allowed.

Pass-through Billing
Pass-through billing occurs when the ordering physician, professional provider, facility or ancillary provider requests and bills for a service, but the service is not performed by the ordering physician, professional provider, facility or ancillary provider. The performing physician, professional provider, facility or ancillary provider is required to bill for the services they render unless otherwise approved by BCBSTX.

BCBSTX does not consider the following scenarios to be pass-through billing:

  • The service of the performing physician, professional provider, facility or ancillary provider is performed at the place of service of the ordering physician or professional provider, and billed by the ordering physician or professional provider.
  • The service is provided by an employee of a physician, professional provider, facility or ancillary provider (i.e., physician assistant, surgical assistant, advanced nurse practitioner, clinical nurse specialist, certified nurse midwife or registered first assistant who is under the direct supervision of the ordering physician or professional provider).
  • The service is billed by the ordering physician or professional provider.

The following modifiers should be used by the supervising physician when he or she is billing for services rendered by a physician assistant (PA), advanced practice nurse (APN) or certified registered nurse first assistant (CRNFA):

  • AS modifier: A physician should use the AS modifier when billing on behalf of a PA, APN or CRNFA, including their National Provider Identifier, for services provided when the PA, APN or CRNFA is acting as an assistant during surgery. The AS modifier should only be used if the PA, APN or CRNFA assists at surgery.
  • SA modifier: A supervising physician should use the SA modifier when billing on behalf of a PA, APN or CRNFA for non-surgical services. The SA modifier should be used when the PA, APN or CRNFA is assisting with any other procedure that does not include surgery.

Under-arrangement Billing
Under-arrangement billing, and other similar billing or service arrangements are not permitted by BCBSTX. Under-arrangement billing refers to situations where services are performed by a physician, facility or ancillary provider, but the services are billed under the contract of another physician, facility or ancillary provider, rather than under the contract of the physician, facility or ancillary provider that performed the services.

All-inclusive Billing
Any testing performed on patients treated by a physician, professional provider, facility or ancillary provider that is paid on an all-inclusive rate should not be billed separately by the facility or any other provider. The testing is a part of the per diem or outpatient rates paid to a facility for such services.

The physician, professional provider, facility or ancillary provider may, at their discretion, use other providers to deliver services included in their all-inclusive rate, but remain responsible for costs and liabilities of those services that will be paid by the facility and not billed directly to BCBSTX.

For all-inclusive billing, all testing and services that share the same date of service for a patient must be billed on one claim. Split billing is a violation of network participation provider agreements.

Other Requirements and Monitoring
CLIA Certification Requirement
Facilities and providers who perform laboratory testing on human specimens for health assessment or the diagnosis, prevention or treatment of disease are regulated under the Clinical Laboratory Improvement Amendments (CLIA) of 1988. Therefore, any provider who performs laboratory testing, including urine drug tests, must possess a valid CLIA certificate for the type of testing performed.

Code Review
BCBSTX may monitor how test codes are billed, including the frequency of testing. Abusive billing, insufficient or lack of documentation to support the billing (including a lack of appropriate orders) may result in action taken against the provider’s network participation and/or 100 percent review of medical records for claims submitted.

Limitations and Conditions
Reimbursement is subject to:

  • Medical record documentation, including appropriately documented orders
  • Correct CPT/HCPCS coding
  • Member benefit and eligibility
  • Applicable BCBSTX medical policy

Obligation to Notify BCBSTX of Certain Changes
Physicians, facilities and ancillary providers are required to notify BCBSTX of material changes that impact their contract with BCBSTX including:

  • Change in ownership
  • Acquisitions
  • Change of billing address
  • Change in billing information
  • Divestitures

Assignment
As a reminder, no part of the contract with BCBSTX may be assigned or delegated by a physician, facility or ancillary provider without the express written consent of both BCBSTX and the contracted provider.

If you have any questions or if you need additional information, please contact your BCBSTX Network Management Representative.