Clinical Payment and Coding Policies

Refer to the COVID-19 Preparedness page for temporary information related to servicing members in response to COVID-19.

Refer to Telemedicine and Telehealth Services for additional information related to telehealth coverage effective Jan. 1, 2021.

Clinical payment and coding policies (CPCPs) are based on criteria developed using healthcare professionals and industry standard guidelines.

  • CPCPs are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.
  • CPCPs are neither intended to address every aspect of a reimbursement situation nor cover all issues related to reimbursement for services rendered to Blue Cross and Blue Shield of Texas enrollees. BCBSTX reserves the right to modify a CPCP at any time by publishing a new version.
  • Certain CPCPs may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If a conflict arises between a CPCP and any plan document under which a member is entitled to Covered Services, the plan document will govern.
  • If a conflict arises between a CPCP and any provider contract pursuant to which a provider participates in and/or provides Covered Services to eligible member(s) and/or plans, the provider contract will govern.
  • “Plan documents” include, but are not limited to, Certificates of Health Care Benefits, Benefit Booklets, Summary Plan Descriptions, and other enrollee benefit Coverage Documents. Blue Cross and Blue Shield of Texas (BCBSTX) (the Plan) may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case. BCBSTX has full and final discretionary authority for their interpretation and application to the extent provided under any applicable plan documents.
  • Claims should be coded appropriately according to industry-standard coding guidelines. For Current Procedural Terminology (CPT®) and/or Healthcare Common Procedure Coding System (HCPCS) codes that have been replaced by a new code(s), or the criteria for the codes has materially changed, Providers must submit the new code(s) which accurately reflects the services provided.
  • For CPCP effective dates for in-network BCBSTX providers, please refer to the effective date listed on the CPCP. For out-of-network providers in Texas, the CPCP is effective as of the date the policy is posted to the BCBSTX provider website.

View the current policies below:

For Clinical Payment and Coding policy effective dates for in-network providers, please refer to the effective date listed on the policy. Disclosure notices subject to Title 28 of the Texas Administrative Code are posted at least 90 days in advance of the effective date of the change. All other disclosures will be provided with as much notice as is practicable and in compliance with applicable law. For out-of-network providers, the policy will be effective on the date the policy is posted to the provider website.

CPT copyright 2020 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Policy Name Policy NumberPostedEffective DateArchived Documents
Anesthesia Clinical Payment and Coding Information PDF Document Effective 12/29/2021 CPCP010 09/27/2021 12/29/2021 View Archive
Anesthesia Clinical Payment and Coding Information PDF Document Effective through 12/28/2021 CPCP010 04/20/2020 07/20/2020 View Archive
Applied Behavior Analysis PDF Document CPCP011 12/02/2020 03/03/2021 View Archive
Chiropractic Services PDF Document CPCP016 10/07/2020 10/15/2020 View Archive
Co-Surgeon/Team Surgeon Modifiers PDF Document CPCP009 10/07/2020 10/15/2020 View Archive
Coordinated Home Care /Private Duty Nursing Policy Guideline PDF Document CPCP005 10/07/2020 10/15/2020 View Archive
Corrected Claim Submission PDF Document CPCP025 05/09/2020 08/15/2020 View Archive
Drug Testing Clinical Payment and Coding Policy - Effective 12/01/2021, refer to MED209.070 Prescription Medication and Illicit Drug Testing in the Outpatient Setting on the Medical Policies page CPCP020 Retired 11/30/2021 Retired 11/30/2021 View Archive
Drug Testing Clinical Payment and Coding Policy PDF Document Effective 09/01/2021 through 11/30/2021 CPCP020 08/31/2021 09/01/2021 View Archive
Emergency Department Services Evaluation and Management (E/M) Services Coding – Facility Services CPCP003 11/19/2020 02/25/2021 View Archive
Evaluation and Management (E/M) Coding – Professional Provider PDF Document CPCP024 10/01/2020 01/01/2021 View Archive
Global Surgical Package PDF Document CPCP014 05/24/2021 05/26/2021 View Archive
Hernia Repair PDF Document CPCP012 06/29/2021 10/01/2021 View Archive
Home Infusion PDF Document Effective 12/20/20201 CPCP019 09/17/2021 12/20/2021 View Archive
Home Infusion PDF Document Effective through 12/19/2021 CPCP019 07/09/2020 10/10/2020 View Archive
Implant Payment and Coding Policy PDF Document CPCP007 07/09/2020 10/10/2020 View Archive
Increased Procedural Services (Modifier 22) PDF Document CPCP013 05/11/2021 08/12/2021 View Archive
Inpatient Readmissions PDF Document CPCP027 03/18/2020 06/20/2020 N/A
Inpatient/Outpatient Unbundling Policy CPCP002 12/14/2020 03/18/2021 View Archive
Intraoperative Neurophysiology Monitoring (IONM) Coding and Reimbursement Guideline CPCP032 08/10/2021 11/10/2021 N/A
Lab Management Program CPCP037 08/24/2021 12/01/2021 N/A
Laboratory Panel Billing Effective 11/10/2021 CPCP021 08/10/2021 11/10/2021 View Archive
Laboratory Panel Billing Effective through 11/09/2021 CPCP021 06/10/2021 06/10/2021 View Archive
Medical Record Documentation Guideline Effective 12/01/2021- Note: – policy now includes same Medical Record Documentation as listed in the current CPCP020 Drug Testing Clinical Payment and Coding Policy CPCP029 10/06/2021 12/01/2021 View Archive
Medical Record Documentation Guideline Effective through 11/30/2021 CPCP029 04/08/2021 07/12/2021 View Archive
Modifier Reference Guideline CPCP023 04/10/2021
Updated – 05/21/2021
07/15/2021 View Archive
Multiple Surgical Procedures – Professional Provider Services Effective 12/1/2021 CPCP015 08/31/2021 12/01/2021 View Archive
Multiple Surgical Procedures - Professional Provider Services Effective through 11/30/2021 CPCP015 08/07/2020 11/10/2020 View Archive
Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy PDF Document (Note: on 2/15/2021, the 90-day effective date was corrected from 5/5/2021 to 4/5/2021) CPCP004 12/29/2020 04/05/2021 View Archive
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) PDF Document CPCP028 05/14/2021
(Updated 07/01/2021)
08/15/2021 View Archive
Observation Services Policy Effective 11/4/2021 CPCP001 08/02/2021 11/04/2021 View Archive
Observation Services Tool for Applying MCG Care Guidelines Effective through 11/03/2021 CPCP001 06/08/2020 06/15/2020 View Archive
Outpatient Facility and Hospital Claims: Revenue Codes Requiring CPT or HCPCS Codes CPCP018 11/05/2020 02/10/2021 View Archive
Point-of-Care Ultrasound Examination Policy PDF Document CPCP030 06/10/2021 06/10/2021 View Archive
Pneumatic Compression Devices – Outpatient Use PDF Document CPCP022 09/18/2020 10/01/2020 View Archive
Preventive Services Policy PDF Document CPCP006 09/30/2021 10/01/2021 View Archive
Psychological and Neuropsychological Testing PDF Document CPCP008 04/08/2021 07/12/2021 View Archive
Surgical and Non-Surgical Services Guide PDF Document TXCPCP03 04/08/2021 07/12/2021 N/A
Telemedicine and Telehealth Services PDF Document CPCP033 03/26/2021 03/25/2021 View Archive
Therapeutic, Prophylactic and Diagnostic Injection and Infusion Coding CPCP026 09/17/2021 12/20/2021 N/A
Trauma Activation CPCP031 05/24/2021 08/26/2021 View Archive
Unbundling Policy – Professional Providers CPCP034 08/11/2021 11/12/2021 N/A
Unlisted/Not Otherwise Classified (NOC) Coding Policy CPCP035 10/06/2021 01/08/2022 N/A
Wasted/Discarded Drugs and Biologicals Guideline CPCP017 10/07/2020 01/10/2021 View Archive