Procedure Plus an Evaluation and Management Service Reimbursement Methodology
Effective September 1, 2011, for BlueChoice®, HMO Blue® Texas and ParPlan, if a claim (or claims) from the same physician, for the same date of service, for the same member includes both a procedure* (see list of procedures below) and a general ophthalmological service (CPT codes 92002 – 92014) or an evaluation and management service (CPT codes 99201 – 99499), the general ophthalmological service or evaluation and management service will be considered as the primary service and payable at 100% of the allowable amount and the procedure will be considered the secondary service payable at 95% of the allowable amount.
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Procedures |
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Surgery (CPT Codes 10000 – 36399 or 36430 – 69999) |
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Dialysis (CPT Codes 90935 – 90999) |
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Gastroenterology (CPT Codes 91000 – 91299) |
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Ophthalmology (CPT Codes 92015 – 92499) |
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Allergy and Clinical Immunology (CPT Codes 95004 – 95199) |
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Neurology (CPT Codes 95805 – 96117) |
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Chemotherapy Administration (CPT Codes 96400 – 96549) |
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Special Dermatological Procedures (CPT Codes 96900 – 96999) |
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Physical Medicine & Rehabilitation (CPT Codes 97001 – 97799) |
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Acupuncture (CPT Codes 97810 – 97814) |
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Osteopathic Manipulative Treatment (CPT Codes 98925 – 98929) |
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Chiropractic Manipulative Treatment (CPT Codes 98940 – 98943) |
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Moderate (Conscious) Sedation (CPT Codes 99143 – 99150) |
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Orthotic Procedures and Devices (HCPCS Codes L0000 – L4999) |
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Prosthetic Procedures (HCPCS Codes L5000 – L9999) |
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Temporary National Codes (HCPCS Codes S0395, S0400, S0630, S0800, |
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* Changes and updates will be posted under “Procedure Plus an Evaluation and |
