Clinical Payment and Coding Policies



Clinical payment and coding policies are based on criteria developed by specialized professional societies, national guidelines (e.g. Milliman Care Guidelines (MCG)) and the CMS Provider Reimbursement Manual. Additional sources are used and can be provided upon request. The clinical payment and coding guidelines are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.

Certain policies may not be applicable to Members who are participants in an employer’s self-funded employee benefit plan for which BCBSNM acts in an administrative capacity and certain insured products. Refer to the Member's Membership Certificate, Benefit Booklet, Benefit Plan, Summary of Benefits and Coverage, or other coverage document (together “Coverage Documents”) to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. In the event of a conflict between any policy and the Member’s Coverage Document, the Coverage Document will govern.

In the event of conflict between a clinical payment and coding policy and any Coverage Document, the Coverage Document will govern.

In the event of conflict between a clinical payment and coding policy and any provider contract pursuant to which a provider participates in and/or provides Covered Services to Member(s), the provider contract will govern.

Conformance to clinical payment and coding policy is not a guaranty of payment. All other requirements, including but not limited to eligibility at the time of service, medical necessity, and other terms, conditions, limitations and exclusions set forth in the Member’s Coverage Document, continue to apply.




Policy name

Policy Number & Version

Posted Date

Effective Date

Observation Services Tool for Applying MCG Care Guidelines PDF Document

CPCP001 v.2

08/30/2021

09/06/2021

Inpatient/Outpatient Unbundling Policy  PDF Document

CPCP002 v.1

12/23/2020

02/01/2021

Evaluation and Management of Emergency Department Coding PDF Document

CPCP003 v.1

12/28/2020

01/01/2021

Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy PDF Document

CPCP004 v.1

01/25/2021

02/01/2021

Coordinated Home Care Policy PDF Document

CPCP005 v.1

11/11/2020

12/01/2020

Preventive Services Policy PDF Document

CPCP006 v.2

07/12/2021

07/01/2021

Implant Payment and Coding Policy PDF Document

CPCP007 v.1

07/24/2020

09/01/2020

Psychological and Neuropsychological Testing PDF Document

CPCP008 v.1

05/03/2021

06/01/2021

Co-Surgeon/Team Surgeon Modifiers PDF Document

CPCP009 v.1

11/11/2020

11/01/2019

Anesthesia Clinical Payment and Coding Information PDF Document

CPCP010 v.2

05/01/2020

06/01/2020

Applied Behavioral Analysis PDF Document

CPCP011 v.3

12/23/2020

02/01/2021

Hernia Repair PDF Document

CPCP012 v.7

06/30/2020

08/01/2020

Increased Procedural Services (Modifier 22) PDF Document

CPCP013 v.1

07/12/2021

07/01/2021

Global Surgical Package PDF Document

CPCP014 v.1

07/12/2021

08/01/2021

Multiple Surgical Procedures PDF Document

CPCP015 v.1

09/17/2021

10/18/2021

Chiropractic Services PDF Document

CPCP016 v.1

11/11/2020

12/01/2020

Wasted/Discarded Drugs and Biologicals Guideline PDF Document

CPCP017 v.3

11/11/2020

12/01/2020

Outpatient Facility and Hospital Claims: Revenue Codes Requiring CPT® or HCPCS Codes PDF Document

CPCP018 v.2

12/28/2020

01/01/2021

Home Infusion PDF Document

CPCP019 v.3

09/17/2021

10/18/2021

Drug Testing CPCP - Retiring 11/30/2021. Refer to Medical Policy MED209.070 for dates of service on/after 12/1/2021 PDF Document

CPCP020 v.2

09/30/2020

11/01/2020

Laboratory Panel Billing Guideline  PDF Document

CPCP021 v.1.1

08/30/2021

09/06/2021

Pneumatic Compression Devices – Outpatient Use PDF Document

CPCP022 v.2

11/11/2020

11/01/2020

Modifier Reference Guideline PDF Document

CPCP023 v.4

05/03/2021

06/01/2021

Evaluation and Management (E/M) Coding – Professional Provider Services PDF Document

CPCP024 v.3

12/28/2020

01/01/2021

Corrected Claim Submissions PDF Document

CPCP025 v.2

06/01/2020

07/01/2020

Therapeutic, Prophylactic and Diagnostic Injection and Infusion Coding PDF Document

CPCP026 v.3

09/17/2021

10/18/2021

Inpatient Readmission PDF Document

CPCP027 v.2

04/01/2020

04/04/2020

Non-Reimbursable Experimental, Investigational and /or Unproven Services (EIU) PDF Document

CPCP028 v.2

07/12/2021

07/21/2021

Medical Record Documentation Guideline PDF Document

CPCP029 v.1

05/03/2021

06/01/2021

Point-of-Care Ultrasound Examination Guideline PDF Document

CPCP030 v.1

07/12/2021

08/01/2021

Trauma Activation – Facility Services PDF Document

CPCP031 v.1

07/12/2021

07/01/2021

Intraoperative Neurophysiology Monitoring (IONM) Coding and Reimbursement Guideline PDF Document

CPCP032 v.3

08/30/2021

09/06/2021

Telemedicine and Telehealth Services PDF Document

CPCP033 v.10

04/05/2021

03/18/2021

Unbundling Policy-Professional Providers PDF Document

CPCP034 v.2

09/17/2021

10/18/2021

Laboratory Management Program PDF Document

CPCP037 v.1

09/06/2021

12/01/2021


Policy name

Effective Date


CPCP001 v5 PDF Document

04/01/2018-12/14/2019

CPCP001 v4 PDF Document

12/15/2019-06/30/2020

CPCP001 v1 PDF Document

07/01/2020-09/05/2021


CPCP002 v5

03/30/2017-05/06/2018

CPCP002 v6  

05/07/2018-09/07/2018

CPCP002 v7

09/07/2018-12/02/2018

CPCP002 v8 PDF Document

12/03/2018-06/06/2019

CPCP002 v5 PDF Document

06/07/2019-11/30/2019

CPCP002 v6 PDF Document

12/01/2019-01/31/2021


CPCP003 v7 PDF Document

12/03/2018-03/31/2020

CPCP003 v4 PDF Document

04/01/2020-12/31/2020


CPCP004 v1 PDF Document

09/07/2018-05/14/2019

CPCP004 v3 PDF Document

05/15/2019-06/30/2020

CPCP004 v1 PDF Document

07/01/2020-01/31/2021


CPCP005 v6 PDF Document

12/01/2018-10/31/2019

CPCP005 v6 PDF Document

11/01/2019-11/30/2020


CPCP006

08/23/2017-01/21/2018

CPCP006

01/22/2018-05/14/2018

CPCP006

05/15/2018-09/06/2018

CPCP006

09/07/2018-01/31/2019

CPCP006 v1 PDF Document

02/01/2019-09/30/2019

CPCP006 v1 PDF Document

10/01/2019-10/14/2019

CPCP006 v2 PDF Document

10/15/2019-12/31/2019

CPCP006 v6 PDF Document

01/01/2020-03/31/2020

CPCP006 v1 PDF Document

04/04/2020-6/30/2020

CPCP006 v2 PDF Document

07/01/2020-09/30/2020

CPCP006 v1 PDF Document

10/01/2020-12/31/2020

CPCP006 V2 PDF Document

01/01/2021-01/14/2021

CPCP006 V1 PDF Document

01/15/2021-03/31/2021

CPCP006 V2 PDF Document

04/01/2021-06/30/2021


CPCP007 v2

04/25/2018-09/06/2018

CPCP007 v3 PDF Document

09/07/2018-12/16/2018

CPCP007 v4 PDF Document

12/17/2018-06/06/2019

CPCP007 v4 PDF Document

06/06/2020-08/31/2020


CPCP008 v8 PDF Document

09/07/2018-04/04/2019

CPCP008 v5 PDF Document

04/05/2019-05/31/2020

CPCP008 v2 PDF Document

06/01/2020-05/31/2021


CPCP009 v7 PDF Document

04/30/2018-02/08/2019

CPCP009 v4 PDF Document

02/09/2019-10/31/2019

CPCP009 v2 PDF Document

11/01/2019-11/30/2020


CPCP010 v5

05/08/2018-09/06/2018

CPCP010 v6 PDF Document

09/07/2018-02/08/2019

CPCP010 v4 PDF Document

02/08/2019-03/25/2019

CPCP010 v1 PDF Document

03/26/2019-05/31/2020


CPCP011 v5

04/30/2018-12/31/2018

CPCP011 v9 PDF Document

05/30/2019-05/31/2020

CPCP011 v1 PDF Document

06/01/2020-07/31/2020

CPCP011 v1 PDF Document

08/01/2020-02/02/2021


CPCP012 v6 PDF Document

02/23/2018-03/25/2019

CPCP012 v6 PDF Document

03/26/2019-07/31/2020


CPCP013 v4 PDF Document

05/08/2018-03/25/2019

CPCP013 v4 PDF Document

03/26/2019-05/31/2020

CPCP013 v1 PDF Document

06/01/2020-06/30/2021


CPCP014 v3 PDF Document

02/08/2018-03/25/2019

CPCP014 v4 PDF Document

03/26/2019-6/30/2020

CPCP014 v1 PDF Document

07/01/2020-07/31/21



CPCP015 v6 PDF Document

03/26/2019-8/31/2020

CPCP015 v1 PDF Document

09/01/2020-10/17/2021


CPCP016 v6

05/08/2018-02/11/2019

CPCP016 v7 PDF Document

02/11/2019-08/31/2019

CPCP016 v5 PDF Document

09/01/2019-10/31/2019

CPCP016 v7 PDF Document

11/01/2019-11/30/2020


CPCP017 v5-18 PDF Document

07/30/2018-08/31/2019

CPCP017 v5 PDF Document

09/01/2019-11/30/2019


CPCP018 v3 PDF Document

07/28/2018-08/31/2019

CPCP0018 v4 PDF Document

09/01/2019-09/01/2020

CPCP0018 v1 PDF Document

09/01/2020-12/31/2020


CPCP019 v2 PDF Document

03/26/2020-08/31/2020

CPCP019 v2 PDF Document

09/01/2020-10/17/2021


CPCP020 v4 PDF Document

12/17/2018-04/30/2020

CPCP020 v6 PDF Document

05/01/2020-10/31/2020


CPCP021 v4 PDF Document

02/09/2019-05/23/2019

CPCP021 v4 PDF Document

03/25/2019-6/30/2020

CPCP021 v5 PDF Document

07/01/2020-07/31/2021

CPCP021 v1 PDF Document

08/01/2021-09/05/2021


CPCP022 v7 PDF Document

09/01/2019-10/31/2020


CPCP023 v4 PDF Document

02/09/2019-05/31/2020

CPCP023 v4 PDF Document

06/01/2020-05/31/2021


CPCP024 v2 PDF Document

12/01/2020-12/31/2020


CPCP025 v2 PDF Document

05/01/2020-6/30/2020


CPCP028 v5 PDF Document

09/01/2020-11/30/2020

CPCP028 v8 PDF Document

12/01/2020-01/01/2021

CPCP028 v10 PDF Document

01/01/2021-05/14/2021

CPCP028 v1 PDF Document

05/15/2021-06/30/2021


CPCP029 v1 PDF Document

03/01/2020-05/31/2021


CPCP030 v2 PDF Document

06/30/2020-07/31/2021


CPCP031 v2 PDF Document

07/01/2020-06/30/2021


CPCPG001 v3 PDF Document

02/09/2019-2/29/2020