Name of Manual - Blue Cross and Blue Shield of Minnesota

Coding Policies and Guidelines (Coding)
Compatibility
(continued)
Preventive Care
Services
11-10
Revenue Codes
Revenue codes must also be compatible with the type of facility,
place of service and type of claim. On the 837 institutional claim,
this is the claim facility type code and claim frequency code. Some
revenue codes are very specific to the place where the service was
rendered.
For example, the TOB 0111 indicates an original claim for a
hospital inpatient admission through discharge.
Administration of Blue Cross’ preventive care policy includes a
list of defined preventive care services according to evidencebased
guidelines. Payment for listed services would be subject to
the subscriber’s coverage options for preventive care and cancer
screening. Variations in payment may occur based on self-insured
dollar and service limits. Benefits should be verified through use
of the electronic eligibility transaction, our provider web self
service site at www.providerhub.com or through BLUELINE.
Services considered preventive
If a patient presents to have these services performed for
preventive purposes, claims will be adjudicated as preventive care
provided the reason for the visit on the claim is listed as
preventive, regardless of outcome. Blue Cross’ administrative
guidelines are as follows:
Service Frequency (does
not apply to Blue
Plus)
Abdominal Aortic
Aneurysm (AAA)
screening
Vision Screening:
Glaucoma, Acuity,
Refraction
Clinical Practice/
Guidelines
1 per lifetime Blue Cross
1 per year ICSI
Hearing 1 per year ICSI
Standard immunizations Per schedules
determined by
clinical
guidelines
CDC/ACIP
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)