Empire BlueCross BlueShield Professional Reimbursement Policy

Empire BlueCross BlueShieldProfessional Reimbursement Policyhistory editing may identify the paid E/M visit code as part of the global surgicalallowance. An adjustment of the E/M claim is made for overpayment recovery.Significant Edit: an edit that, based on experience with submitted claims, will cause, on initialreview of submitted claims, the denial or reduction in payment for a particular CPT″/ HCPCS codemore than two-hundred and fifty (250) times per year in any state in which Health Plan operates.POLICY HISTORY04/07/2009 Adopted by Enterprise Professional Reimbursement Committee11/03/2009 Revised11/18/2009 Revised07/06/2010 Revised07/12/2011 Revised04/03/2012 Revised06/05/2012 Revised08/07/2012 Revised02/05/2013; 03/05/2013; Revised0702/20131 CPT © is a registered trademark of the American Medical Association22013 Relative Value Guide, American Society of Anesthesiologists page xi3 Current Procedural Terminology, cpt ® 2013 Professional Edition, pg. xi4ClaimsXten is a registered trademark of McKesson Information Solutions LLC]Clear Claim Connection TM is a registered trademark of McKesson Information Solutions LLCUse of Reimbursement Policy:State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, take precedence over ReimbursementPolicy and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services arerendered must be used. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically.© 2013 Empire BlueCross BlueShield No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by anymeans, electronic, mechanical, photocopying, or otherwise, without permission from Empire BlueCross BlueShield.NY 0027 Page 10 of [10]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.