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POLICY

Application of Policy

This policy is applicable to all providers participating in Blue Cross & Blue Shield of Mississippi Office Facility Program (includes Single Specialty Facilities).

These claims filing requirements are applicable to all lines of business, including Local Underwritten Business, self-funded groups, State & School Employees' Health Insurance Plan, Children's Health Insurance Program (CHIP), Federal Employee Program (FEP), Medicare Supplement contracts and out-of-state Blue Cross and Blue Shield subscribers (BlueCard).

Filing Guidelines

Blue Cross & Blue Shield of Mississippi (BCBSMS) requires that Office Facility claims be filed on a HCFA-1500 form. The claim should be filed using the Office Facility provider identification number that you were assigned. No professional services should be filed on the same claim form as the Office Facility services.

Coding Guidelines

BCBSMS requires the use of modifier -SG (ambulatory surgical center facility service) when filing Office Facility services. Modifier -SG should be appended to the primary surgical procedure, "add-on" procedures, "modifier -51 exempt" procedures, and any radiological procedures approved for coverage. A comprehensive list of  "add-on"; and "modifier -51 exempt" procedures can be found in Appendix D and E in the back of the CPT manual. Modifier -51 or -50 should be appended to multiple or bilateral procedures, respectively. These services should be filed with place of treatment code 24 (ambulatory surgical center).

Coding Examples

To assist your staff in coding claims, please find below examples of various coding scenarios.

• Single Procedure

  • Example #1

    Code/Modifier	DOS	Charge	POT
    67916-SG	01/15/04	$1000	24

  • Example #2

    Code/Modifier	DOS	Charge	POT
    G0105-SG	03/15/04	$ 900	24

• Multiple Procedures

  • Example #1

    Code/Modifier	DOS	Charge	POT
    45380-SG	02/14/04	$ 800	24
    43239-51	02/14/04	$ 800	24

• Multiple Procedures with Add-on Procedure

  • Example #1

    Code/Modifier	DOS	Charge	POT
    14041-SG	04/25/04	$ 700	24
    13101-51	04/25/04	$ 700	24
    13102-SG (add-on)	04/25/04	$ 500	24

• Add-on Procedure with Fluoroscopic Guidance
  
  
  • Example #1

    Code/Modifier	DOS	Charge	POT
    64483-SG	03/16/04	$1000	24
    64484-SG (add-on)	03/16/04	$ 800	24
    76005-SG	03/16/04	$ 200	24

• Multiple Procedures with Modifier -51 Exempt Procedure

  • Example #1

    Code/Modifier	DOS	Charge	POT
    12056-SG	02/28/04	$ 640	24
    17304 (Mod-51 exempt)	02/28/04	$ 500	24
    10040-51	02/28/04	$ 500	24

• Bilateral Procedures
  
  
  • Example #1

    Code/Modifier	DOS	Charge	POT
    66984-SG	07/25/04	$1500	24
    66984-50	07/25/04	$ 750	24

  • Example #2

    Code/Modifier	DOS	Charge	POT
    66984-SG	07/25/04	$1500	24
    67316-51	07/25/04	$ 750	24
    67316-50	07/25/04	$ 750	24

POLICY EXCEPTIONS

None

POLICY GUIDELINES

POLICY HISTORY

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