November 2019

Time-Based Measurement Standard to Follow AMA: A Change in the Coding of Physical Medicine Service Units

On July 22, 2019, Blue Cross and Blue Shield of Illinois (BCBSIL) changed its time measurement standard for billing physical medicine services based on a regulation that was passed by the Illinois legislature. The regulation requires BCBSIL to move from the Centers for Medicare & Medicaid Services (CMS) to the American Medical Association (AMA) measurement standard for billing time-based services, such as physical medicine services. These are time-based codes within the Physical Medicine and Rehabilitation section of the Current Procedural Terminology (CPT^®) code book.

When billing for time-based services, use the CPT codes in the AMA code book, except as required by federal law for Medicare and Medicaid patients. The AMA guidelines will apply to these physical medicine services:

97110, 97113, 97116, 97530, 97533, 97535, 97537, 97542, 97750, G0515

Services billed after July 22, 2019, will be paid retroactively using the new procedure code billing process.

As always, it’s critical to check eligibility and benefits first, prior to rendering care and services to confirm coverage, network status and other important details. When you check eligibility and benefits online by submitting an electronic 270 transaction through the Availity^® Provider Portal or your preferred web vendor portal, you may determine if benefit preauthorization/pre-notification may be required.

Payment may be denied if you perform procedures without benefit preauthorization when benefit preauthorization is required. If this happens, you may not bill our members.

The material presented here is for informational/educational purposes only, is not intended to be medical advice or a definitive source for coding claims and is not a substitute for the independent medical judgment of a physician or other health care provider. Health care providers are encouraged to exercise their own independent medical judgment based upon their evaluation of their patients’ conditions and all available information, and to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. References to other third party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly.

Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized/pre-notified for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have questions, contact the number on the member’s ID card. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by third party vendors such Availity. The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.