Empire BlueCross BlueShield Professional Commercial Reimbursement Policy
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1 Subject: Prolonged Services : Coding NY Policy: 0019 Effective: 10/01/2016 Procedure codes and will be eligible for reimbursement when reported with one or more of the following ICD-10-CM codes: J20.6 J96.00 O10.32 J20.7 J96.01 O10.33 J20.8 J96.02 O11.1 J20.9 J96.20 O11.2 J21.0 J96.21 O11.3 J21.1 J96.22 O11.5 J21.8 J96.90 O16.5 J21.9 J96.91 O21.1 J38.4 J96.92 O21.2 J38.5 J98.01 O21.9 J44.0 K91.0 P28.81 J44.1 K92.0 P29.11 J45.21 O P29.12 J45.22 O P29.81 J45.31 O P84 J45.32 O10.12 P92.01 J45.41 O10.13 P92.09 J45.42 O R00.0 J45.51 O R04.0 J45.52 O R04.2 J O10.22 R04.89 J O10.23 R04.9 J47.0 O R06.01 J47.1 O R06.02 J68.1 O R06.1 NY 0001 Page 1 of [5]
2 R06.2 T36.4X5A T39.4X5A R06.3 T36.5X5A T39.8X5A R06.4 T36.6X5A T39.95XA R06.81 T36.7X5A T40.0X5A R06.82 T36.8X5A T40.1X5A R07.1 T36.95XA T40.2X5A R07.2 T37.0X5A T40.3X5A R07.81 T37.1X5A T40.4X5A R09.01 T37.2X5A T40.5X5A R09.02 T37.3X5A T40.605A R09.2 T37.4X5A T40.695A R11.10 T37.5X5A T40.7X5A R11.11 T37.8X5A T40.8X5A R11.12 T37.95XA T40.905A R11.13 T38.0X5A T40.995A R11.14 T38.1X5A T41.0X5A R11.2 T38.2X5A T41.1X5A R55 T38.3X5A T41.205A R56.00 T38.4X5A T41.295A R56.01 T38.5X5A T41.3X5A R57.0 T38.6X5A T41.45XA R57.1 T38.7X5A T41.5X5A R57.8 T38.805A T42.0X5A R57.9 T38.815A T42.1X5A R65.10 T38.895A T42.2X5A R65.11 T38.905A T42.3X5A R65.20 T38.995A T42.4X5A R65.21 T39.015A T42.5X5A R68.13 T39.095A T42.6X5A T36.0X5A T39.1X5A T42.75XA T36.1X5A T39.2X5A T42.8X5A T36.2X5A T39.315A T43.015A T36.3X5A T39.395A T43.025A NY 0001 Page 2 of [5]
3 T43.1X5A T45.515A T48.205A T43.205A T45.525A T48.295A T43.215A T45.605A T48.3X5A T43.225A T45.615A T48.4X5A T43.295A T45.625A T48.5X5A T43.3X5A T45.695A T48.6X5A T43.4X5A T45.7X5A T48.905A T43.505A T45.8X5A T48.995A T43.595A T45.95XA T49.0X5A T43.605A T46.0X5A T49.1X5A T43.615A T46.1X5A T49.2X5A T43.625A T46.2X5A T49.3X5A T43.635A T46.3X5A T49.4X5A T43.695A T46.4X5A T49.5X5A T43.8X5A T46.5X5A T49.6X5A T43.95XA T46.6X5A T49.7X5A T44.0X5A T46.7X5A T49.8X5A T44.1X5A T46.8X5A T49.95XA T44.2X5A T46.905A T50.0X5A T44.3X5A T46.995A T50.1X5A T44.4X5A T47.0X5A T50.2X5A T44.5X5A T47.1X5A T50.3X5A T44.6X5A T47.2X5A T50.4X5A T44.7X5A T47.3X5A T50.5X5A T44.8X5A T47.4X5A T50.6X5A T44.905A T47.5X5A T50.7X5A T44.995A T47.6X5A T50.8X5A T45.0X5A T47.7X5A T50.905A T45.1X5A T47.8X5A T50.995A T45.2X5A T47.95XA T50.A15A T45.3X5A T48.0X5A T50.A25A T45.4X5A T48.1X5A T50.A95A NY 0001 Page 3 of [5]
4 T50.B15A T88.6XXA T78.00XA T50.B95A T49.5X5A T78.01XA T50.Z15A T49.6X5A T78.02XA T50.Z95A T49.7X5A T78.03XA T67.0XXA T49.8X5A T78.04XA T67.1XXA T49.95XA T78.05XA T67.3XXA T50.0X5A T78.06XA T67.4XXA T50.1X5A T78.07XA T67.5XXA T50.2X5A T78.08XA T67.7XXA T50.3X5A T78.09XA T70.20XA T50.4X5A T78.1XXA T70.29XA T50.5X5A T78.2XXA T78.00XA T50.6X5A T78.3XXA T78.01XA T50.7X5A T78.40XA T78.02XA T50.8X5A T78.41XA T78.03XA T50.905A T78.49XA T78.04XA T50.995A T79.4XXA T78.05XA T50.A15A T88.2XXA T78.06XA T50.A25A T88.52XA T78.07XA T50.A95A T88.59XA T78.08XA T50.B15A T88.6XXA T78.09XA T50.B95A T78.1XXA T50.Z15A T78.2XXA T50.Z95A T78.3XXA T67.0XXA T78.40XA T67.1XXA T78.41XA T67.3XXA T78.49XA T67.4XXA T79.4XXA T67.5XXA T88.2XXA T67.7XXA T88.52XA T70.20XA T88.59XA T70.29XA NY 0001 Page 4 of [5]
5 Use of Reimbursement Policy: State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, take precedence over Reimbursement Policy and must be considered first in determining eligibility for coverage. The member s contract benefits in effect on the date that services are rendered must be used. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically Empire BlueCross BlueShield 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 Empire BlueCross BlueShield. NY 0001 Page 5 of [5]
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