Empire BlueCross BlueShield
Professional Reimbursement Policy
Subject: Frequency Editing
NY Policy: 0016
Effective: 08/17/2015 – 08/31/2015
Coverage is subject to the terms, conditions, and limitations of an individual member’s programs or
products and policy criteria listed below.
DESCRIPTION
The Health Plan uses claims processing logic based on ClaimsXten®′ rationale to determine when the use
of multiple units is appropriate. The Health Plan also uses, among other factors, the nomenclature for a
particular Current Procedural Terminology (CPT®″) or Healthcare Common Procedure Coding System
(HCPCS Level II) code or the ability to clinically perform or report a particular service more than one
time on a single date of service or within a particular date span per member per provider in making these
determinations.
POLICY
1. All or any of the following factors identify when a procedure will be limited in units, or number of
times a code is eligible for reimbursement on a single date of service.
a. The description of a procedure code includes the word(s) “bilateral” or “unilateral or bilateral”
b. A procedure code description specifies “unilateral” and there is another CPT code for the bilateral
service or another add-on code for additional services (the unilateral CPT code cannot be
submitted more than once on a single date of service)
c. The description of a procedure code includes a specified time frame (e.g. per 30 day period)
d. The description of a procedure code implies multiplicity (e.g. evaluation(s); muscle(s);
injection(s); area(s); material(s); etc.)
e. The total number of times it is clinically possible or clinically reasonable to perform a given
procedure on a single date of service is limited
• In some circumstances a RT/LT or site specific modifier ( e.g. F5, T3; etc.) will allow a code
to process when used more than once, since these modifiers will identify the specific side or
digit when more than one site is being treated or evaluated.
f. A procedure code is reported more than one time, but typically is not performed more than once
on a single date of service.
2. When a procedure code is submitted with multiple units, and only a single unit is acceptable,
reimbursement will be based on only one unit.
3. The Health Plan will apply all unit/frequency edits pre-adjudication, using both the unit field and
multiple submissions of line items.
NY 0016
Page 1 of [8]
Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association of
Blue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
Association.
Empire BlueCross BlueShield
Professional Reimbursement Policy
4. The Health Plan will apply a frequency edit, when applicable, to a base code which has a related addon code listed in CPT Appendix D. Since the related add-on code(s) describes a phrase such as “each
additional” or “list separately in addition to the primary procedure,” the base code is eligible for
reimbursement only once per date of service (e.g., only one of the following initial vaccine
administration codes —90471 or 90473—is allowed per date of service.)
5. The Health Plan will apply some frequency edits across dates of service.
6. For Durable Medical Equipment (DME), the Health Plan will apply frequency maximums per day
and/or per date span (usually based on the Centers for Medicare & Medicaid Services’ (CMS’s)
Medically Unlikely Edits (MUEs), industry standards, and/or HCPCS description). (See also our
Durable Medical Equipment reimbursement policy.)
7. The Health Plan will apply some frequency maximums per day and/or per date span when
procedures are within the same service grouping (e.g., routine blood collection on the same date of
service will be allowed once per date of service; unattended sleep studies and/or home sleep
studies reported on the same date of service and/or within a seven day period will only be allowed
one time during the seven day period;).
The Health Plan has customized ClaimsXten unit/frequency logic for some procedure codes. Please see
the table in the Coding Section for these customizations.
CODING
The following occurrence restrictions are examples of some frequency edits added to certain codes that
do not fit into one of the categories identified in the policy section above, or the description of the code
includes a designated time frame. Services billed in excess of these restrictions are not eligible for
reimbursement even when billed with an override modifier (e.g., modifier 59 or modifier 91). The
inclusion or exclusion of a specific code does not indicate eligibility for coverage under all
circumstances.
Codes
36415
Category/Description
Collection of venous blood by venipuncture
36416
Collection of capillary blood specimen (eg, finger,
heel, ear stick)
NY 0016
Frequency Limit
1 per date of service**
**first processed per code or code
group; code group for this
frequency limit includes 36415,
36416, and S9529
1 per date of service**
**first processed per code or code
group; code group for this
Page 2 of [8]
Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association of
Blue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
Association.
Empire BlueCross BlueShield
Professional Reimbursement Policy
Codes
76942
77002
77003
77012
77021
77338
77600, 77605
Category/Description
Ultrasonic guidance for needle placement (e.g.,
biopsy, aspiration, injections, localization device),
imaging supervision and interpretation
Fluoroscopic guidance for needle placement (eg,
biopsy, aspiration, injection, localization device)
Fluoroscopic guidance and localization of needle or
catheter tip for spine or paraspinous diagnostic or
therapeutic injection procedures (epidural or
subarachnoid)
Computed tomography guidance for needle
placement (eg, biopsy, aspiration, injection,
localization device), radiological supervision and
interpretation
Magnetic resonance guidance for needle placement
(eg, for biopsy, needle aspiration, injection, or
placement of localization device) radiological
supervision and interpretation
Multi-leaf collimator (MLC) device(s) for intensity
modulated radiation therapy (IMRT), design and
construction per IMRT plan
Hyperthermia, externally generated; superficial (i.e.,
heating to a depth of 4 cm or less) or deep (i.e.,
heating to depths greater than 4 cm)
Frequency Limit
frequency limit includes 36415,
36416, and S9529
1 per date of service
1 per date of service
1 per date of service
1 per date of service
1 per date of service
1 per date of service
1 per date of service
80321, 80322
Definitive drug testing: Alcohol biomarkers
1 per date of service
80324, 80325,
80326
80327, 80328
80329, 80330,
80331
80332, 80333,
80334
80335, 80336,
80337
Definitive drug testing: Amphetamines
1 per date of service
Definitive drug testing: Anabolic steroids
Definitive drug testing: Analgesics, non-opioid
1 per date of service
1 per date of service
Definitive drug testing: Antidepressents,
serotonergic class
Definitive drug testing: Antidepressants, tricyclic
and other cyclicals
1 per date of service
80339, 80340,
80341
Definitive drug testing: Antiepileptics, not otherwise
specified
1 per date of service
80342, 80343,
80344
Definitive drug testing: Antipsychotics, not
otherwise specified
1 per date of service
NY 0016
1 per date of service
Page 3 of [8]
Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association of
Blue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
Association.
Empire BlueCross BlueShield
Professional Reimbursement Policy
Codes
80346, 80347
Category/Description
Definitive drug testing: Benzodiazepines
Frequency Limit
1 per date of service
80350, 80351,
80352
Definitive drug testing: Cannabinoids, synthetic
1 per date of service
80361
Definitive drug testing: Opiates
1 per date of service
80362, 80363,
80364
Definitive drug testing: Opioids and opiate analogs
1 per date of service
80369, 80370
Definitive drug testing: Skeletal muscle relaxants
1 per date of service
80375, 80376,
80377
Drug(s) or substance(s), definitive, qualitative or
quantitative, not otherwise specified
1 per date of service
81479
Unlisted molecular pathology procedure
1 per date of service
88305
Level IV – Surgical pathology, gross and
microscopic examination…needle biopsy prostate…
87529
Infectious agent detection by nucleic acid (DNA or
RNA); Herpes simplex virus, amplified probe
technique
Respiratory syncytial virus, monoclonal antibody,
recombinant, for intramuscular use, 50 mg, each
9 units per date of service when
reported for specimens related to
needle biopsy of the prostrate
1 per date of service
90378
4 per date of service
92250
Fundus photography with interpretation and report
1 per date of service
93268, 93270,
93271, 93272
93293, 93294,
93295, 93296
93297, 93298,
93299
93325
Wearable patient activated EKG event recording per
30 day period of time
Transtelephonic rhythm strip pacemaker
evaluation(s) system up to 90 days
Implantable cardiovascular monitor system,
interrogation device evaluation(s) up to 30 days
Doppler echocardiography color flow velocity
mapping
1 per 30 days
94014, 94015,
94016
94774, 94775,
94776, 94777
95250, 95251
Patient-initiated spirometric recording per 30 day
period of time
Pediatric home apnea monitoring event recording per
30 day period of time
Continuous glucose monitoring
1 per 30 days
95165
Professional services for the supervision of
preparation and provision of antigens for
allergen immunotherapy; single or multiple
120 doses per 365 days
NY 0016
1 per 90 days
1 per 30 days
2 per date of service
1 per 30 days
1 per 30 days
Page 4 of [8]
Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association of
Blue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
Association.
Empire BlueCross BlueShield
Professional Reimbursement Policy
Codes
Category/Description
Frequency Limit
antigens (specify number of doses)
95800
Sleep study, unattended, simultaneous recording;
heart rate, oxygen saturation, respiratory analysis
(e.g., by airflow or peripheral arterial tone), and sleep
time
95801
Sleep study, unattended, simultaneous recording;
minimum of heart rate, oxygen saturation, and
respiratory analysis (e.g., by airflow or peripheral
arterial tone)
95806
Sleep study, unattended, simultaneous recording of,
heart rate, oxygen saturation, respiratory airflow, and
respiratory effort (eg, thoracoabdominal movement)
96116
Neurobehavioral status exam (clinical assessment of
thinking, reasoning and judgment, eg, acquired
knowledge, attention, language, memory, planning
and problem solving, and visual spatial abilities), per
hour of the psychologist’s or physician’s time, both
face-to-face time with the patient and time
interpreting test results and preparing the report
Health and behavior assessment/intervention; each
15 minutes
96150, 96151,
96152, 96153,
96154
1 per 7 days **
**first processed per code or code
group; code group for this
frequency limit includes 95800,
95801, 95806, G0398, G0399, and
G0400
1 per 7 days **
**first processed per code or code
group; code group for this
frequency limit includes 95800,
95801, 95806, G0398, G0399, and
G0400
1 per 7 days **
**first processed per code or code
group; code group for this
frequency limit includes 95800,
95801, 95806, G0398, G0399, and
G0400
5 hours/units per 365 days
8 per date of service
96367
Additional sequential infusion, up to 1 hour
6 per date of service
96401
Chemotherapy administration, subcutaneous or
intramuscular; non-hormonal anti-neoplastic
1 per date of service for the
administration of drugs such as
omalizumab (Xolair®), per drug
96416
Initiation of prolonged IV Chemotherapy
administration (more than 8 hours) requiring the use
of a portable or implantable pump
1 per date of service
NY 0016
Page 5 of [8]
Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association of
Blue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
Association.
Empire BlueCross BlueShield
Professional Reimbursement Policy
Codes
97012,97014,
97016, 97018,
97022,97024,
97026, 97028
99183
Category/Description
Physical medicine modalities
Frequency Limit
1 per date of service
Physician attendance and supervision of hyperbaric
oxygen therapy, per session
3 per date of service
99363, 99364
Anticoagulant management…90 days of therapy
1 per 90 days
A4210
Needle-free injection device, each
2 per 365 days
A4230
60 per 90 days
A4244
Infusion set for external insulin pump, non –needle
cannula type
Infusion set for external insulin pump, needle type
Syringe with needle for external insulin pump,
sterile, 3CC
Alcohol or peroxide, per pint
A4245
Alcohol wipes, per box
24 per 90 days
A4250
Urine test or reagent strips or tablets (100 tablets or
strips)
Blood glucose test or reagent strips for home blood
glucose monitor, per 50 strips
Replacement lens shield cartridge for use with laser
skin piercing device, each
4 per 90 days
A4258
Spring-powered device for lancet, each
2 per 365 days
A4259
Lancets, per box of 100
5 per 90 days
A4556
Electrodes…per pair
A4557
Lead wires…per pair
A4595
Electrical stimulator supplies, 2 lead, per month,
(e.g., TENS, NMES)
Gradient compression stocking, below knee, 18-30
mm Hg, each
Gradient compression stocking, below knee, 30-40
mm Hg, each
Gradient compression stocking, below knee, 40-50
2 pair per 30 days (See also our
Bundled Services and Supplies
reimbursement policy for additional
information.)
4 pair per 365 days (See also our
Bundled Services and Supplies
reimbursement policy for additional
information.)
2 per 30 days
A4231
A4232
A4253
A4257
A6530
A6531
A6532
NY 0016
60 per 90 days
60 per 90 days
12 per 90 days
11 per 90 days
1 per 30 days
8 per 365 days
8 per 365 days
8 per 365 days
Page 6 of [8]
Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association of
Blue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
Association.
Empire BlueCross BlueShield
Professional Reimbursement Policy
Codes
Category/Description
Frequency Limit
mm Hg, each
A6533
Gradient compression stocking, thigh length, 18-30
mm Hg, each
Gradient compression stocking, thigh length, 30-40
mm Hg, each
Gradient compression stocking, thigh length, 40-50
mm Hg, each
Gradient compression stocking, full-length/chap
style, 18-30 mm Hg, each
Gradient compression stocking, full-length/chap
style, 30-40 mm Hg, each
Gradient compression stocking, full-length/chap
style, 40-50 mm Hg, each
Gradient compression stocking, waist length, 18-30
mm Hg, each
Gradient compression stocking, waist length, 30-40
mm Hg, each
Gradient compression stocking, waist length, 40-50
mm Hg, each
Gradient compression wrap, nonelastic, below knee,
30-50 mm Hg, each
Gradient compression stocking/sleeve, not otherwise
specified
Oxygen one month’s supply
8 per 365 days
Dynamic knee, extension/flexion device, include soft
interface material
Provision of test materials and equipment for home
INR monitoring … includes: provision of materials
for use in the home and reporting of test results to
physician; testing not occurring more frequently than
once a week; testing materials, billing units of
service include 4 tests
1 per 30 days
G0398
Home sleep study test (HST) with type II portable
monitor, unattended; minimum of 7 channels: EEG,
EOG, EMG, ECG/heart rate, airflow, respiratory
effort and oxygen saturation
G0399
Home sleep test (HST) with type III portable
monitor, unattended; minimum of 4 channels: 2
1 per 7 days **
**first processed per code or code
group; code group for this
frequency limit includes 95800,
95801, 95806, G0398, G0399, and
G0400
1 per 7 days **
**first processed per code or code
A6534
A6535
A6536
A6537
A6538
A6539
A6540
A6541
A6545
A6549
E0441, E0442,
E0443, E0444
E1812
G0249
NY 0016
8 per 365 days
8 per 365 days
8 per 365 days
8 per 365 days
8 per 365 days
8 per 365 days
8 per 365 days
8 per 365 days
8 per 365 days
8 per 365 days
1 per 30 days
3 per 90 days
Page 7 of [8]
Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association of
Blue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
Association.
Empire BlueCross BlueShield
Professional Reimbursement Policy
Codes
Frequency Limit
group; code group for this
frequency limit includes 95800,
95801, 95806, G0398, G0399, and
G0400
1 per 7 days **
**first processed per code or code
group; code group for this
frequency limit includes 95800,
95801, 95806, G0398, G0399, and
G0400
1 per date of service
G0400
Home sleep test (HST) with type IV portable
monitor, unattended; minimum of 3 channels
G0431
Drug screen, qualitative; multiple drug classes by
high complexity test method (e.g., immunoassay,
enzyme assay), per patient encounter
G0434
Drug screen, other than chromatographic; any
number of drug classes, by CLIA waived test or
moderate complexity test, per patient encounter
1 per date of service
J0696
16 per date of service
J7321, J7323,
J7324, J7326
Injection, ceftriaxone sodium, per 250 mg
(Rocephin)
Injection, gamma globulin, intramuscular, over 10cc
Injection, methocarbamol, up to 10 ml (Robaxin)
Etonogestrel (contraceptive) implant system
(Implanon; Nexplanon)
Hyaluronan or derivative…for intra-articular
injection, per dose
J9355
Injection, trastuzumab, 10 mg (Herceptin®)
95 units per date of service
Q4101
Apligraf, per sq cm
44 per date of service
S9529
Routine venipuncture for collection of specimen(s),
single homebound, nursing home, or skilled nursing
facility patient
1 per date of service**
**first processed per code or code
group; code group for this
frequency limit includes 36415,
36416, and S9529
J1560
J2800
J7307
1
Category/Description
respiratory movement/airflow, 1 ECG/heart rate and
1 oxygen saturation]
1 per date of service
3 per date of service
1 per date of service
2 per date of service
CPT © is a registered trademark of the American Medical Association
Use of Reimbursement Policy:
This policy is subject to federal and state laws, to the extent applicable, as well as the terms, conditions, and limitations of a member’s
benefits. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically.
No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, or otherwise, without permission from the health plan. © 2015 Empire BlueCross BlueShield
NY 0016
Page 8 of [8]
Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association of
Blue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield
Association.