Audience: Physicians and other Health Care Practitioners
Excellus BlueCross BlueShield is implementing the following administrative policy effective December 15, 2022, to define the coverage and billing guidelines for non-physician practitioner nursing facility care visits billed by providers. This policy is in line with Centers for Medicare & Medicaid Services, Current Procedural Terminology (CPT®), and New York State Department of Health guidelines. It will apply to all participating and non-participating practitioners and the Commercial (HMO, PPO, POS, ASO/ASC, and Indemnity), and Medicare Advantage lines of business.
Administrative Policy 44 – Non-Physician Practitioner Nursing Facility Care Visits
- The Health Plan will not reimburse the initial nursing facility care visit CPT codes 99304, 99305, and 99306, when billed by a nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist (CNS) in place of service 31 (skilled nursing facility).
- The Health Plan will reimburse the initial nursing facility care visit CPT codes 99304, 99305, and 99306 when billed by a physician.
- The Health Plan will reimburse the initial nursing facility care visit CPT codes 99304, 99305, and 99306 when billed by an NP, PA, or CNS not employed by the facility in place of service 32 (nursing facility).
- The Health Plan will reimburse the subsequent nursing facility care visit CPT codes 99307, 99308, 99309, 99310 when billed by NP, PA, or CNS with place of service 31 and 32 (skilled nursing facility, nursing facility).
This policy will be reviewed pre-payment. Pre-payment review means claims are reviewed prior to payment. A pre-payment review results in an initial determination.
This policy is a billing and reimbursement requirements and information policy. These services are subject to audit and policy updates at the discretion of Excellus BCBS. Members are held harmless for all denials resulting from this administrative policy. Access Individual Administrative Policies.
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