Page 1
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 1 of 26
SIGNFICANT EDITS (1/1/10 – 10/31/10)
Blue Cross and Blue Shield of Texas (BCBSTX) utilizes an automated code auditing system that is designed to review reported codes to ensure that the correct procedure codes are identified for reimbursement. Claims are audited to review for potential incorrect billing. The following codes represent those procedures that are reported in high volume and that are not separately payable when billed in conjunction with other procedures. For additional information about specific coding scenarios or customized edits, access Clear Claim Connection (CCC) through the BCBSTX Provider website. Additional codes may be denied or reduced. Charge is an exact duplicate of a charge already processed on this claim. 11750 77003 87040 95904 17003 77052 87660 95925 20553 77080 87804 95926 59025 80053 88172 96372 64614 80101 88291 97110 64623 82270 88305 97112 69210 82550 88321 97140 70553 82553 88342 97813 72020 82803 89190 98940 72100 82947 90471 98941 72148 82962 90472 99070 73030 83901 90806 99212 73050 83914 92015 99213 73560 84484 92020 99214 76514 84591 92025 99232 76805 85025 92083 A0394 76830 86003 92135 A0398 76856 86235 92507 A4595 76942 86317 94010 G0431 77002 86920 94360
Page 2
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 2 of 26
Charge exceeds the priced amount for this service. (Participating/Network Physician or other Professional Provider)
00100 0073T 01360 10021 11403 00103 00740 01380 10022 11404 00104 00750 01382 10040 11406 00120 00752 01392 10060 11420 00126 00770 01400 10061 11421 00140 00790 01402 10080 11422 00142 00797 01462 10120 11423 00144 00800 01464 10121 11424 00145 00810 01470 10140 11426 00160 00830 01472 10160 11440 00170 00832 01480 10180 11441 00190 00840 01610 1034F 11442 00192 00846 01620 1035F 11443 00210 00851 01622 11000 11601 00220 00860 01630 11012 11602 00300 00862 01638 11040 11603 00320 00865 01710 11041 11604 00350 00872 01730 11042 11606 00400 00873 01740 11043 11622 00402 00902 01810 11044 11623 00404 00910 01820 11055 11641 00410 00912 01830 11056 11642 00450 00914 01844 11100 11643 00520 00918 01916 11101 11719 00528 00920 01922 11200 11720 00532 00930 01924 11201 11721 00534 00940 01926 11300 11730 00537 00942 01930 11301 11732 00540 00944 01935 11302 11740 00541 00948 01936 11303 11750 00560 00952 01960 11305 11755 00562 01112 01961 11306 11760 00566 01200 01965 11307 11765 00567 01202 01967 11308 11771 00600 01210 01968 11310 11772 00620 01214 01991 11311 11900 00630 01230 01992 11312 11901 00635 01250 01996 11400 11921 00670 01270 0500F 11401 11970 00700 01320 0501F 11402 11975
Page 3
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 3 of 26
11976 15734 20000 22845 26600 11981 15823 20206 22846 26605 11982 16020 20225 22851 26608 12001 17000 20526 22852 26615 12002 17003 20550 22855 26720 12004 17004 20551 23120 26725 12011 17110 20552 23130 26727 12013 17111 20553 23350 26750 12021 17250 20600 23410 26770 12031 17260 20605 23412 27093 12032 17261 20610 23420 27095 12034 17262 20612 23430 27096 12041 17263 20670 23472 27130 12042 17271 20680 23500 27245 12051 17272 20900 23515 27301 12052 17280 20926 23600 27370 13100 17281 20930 23650 27446 13101 17282 20931 23700 27447 13102 17311 20936 24342 27487 13121 17312 20937 24359 27570 13122 17313 20938 24530 27650 13131 17314 21310 24538 27687 13132 17340 21320 24640 27691 13151 19000 21555 24650 27698 13152 19001 21556 25000 27750 13160 19102 21800 25111 27759 14000 19103 21930 25115 27786 14020 19120 21931 25246 27792 14040 19125 22216 25447 27814 14041 19290 22554 25560 27822 14060 19295 22558 25565 27829 14061 19301 22585 25600 28080 14301 19302 22600 25605 28090 15002 19303 22612 25606 28119 15100 19307 22614 25607 28120 15260 19318 22630 25608 28122 15330 19342 22632 25609 28124 15340 19350 22840 26055 28190 15365 19357 22842 26116 28232 15430 19380 22843 26160 28270
Page 4
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 4 of 26
28285 29823 31600 36415 38792 28289 29824 31622 36416 39502 28292 29826 31624 36430 40490 28296 29827 31625 36471 40812 28299 29828 31628 36475 41010 28300 29848 31629 36476 41899 28308 29873 32405 36478 42145 28470 29875 32421 36479 42415 28485 29876 32422 36514 42700 28490 29877 32480 36522 42820 28510 29879 32551 36555 42821 28750 29880 33208 36556 42825 28820 29881 33225 36558 42826 29065 29882 33249 36561 42830 29075 29888 33405 36569 43200 29085 29893 33508 36571 43235 29105 29898 33517 36589 43239 29125 30130 33518 36590 43242 29130 30140 33519 36591 43244 29200 30200 33521 36592 43245 29240 30300 33530 36593 43246 29260 30465 33533 36598 43247 29280 30520 33534 36600 43248 29345 30901 33967 36620 43249 29405 30903 35301 36821 43251 29425 31231 35476 37204 43255 29445 31233 36000 37205 43258 29450 31237 36140 37206 43259 29505 31238 36147 37620 43260 29515 31255 36200 37765 43262 29520 31256 36215 37766 43264 29530 31267 36216 38206 43268 29540 31276 36217 38220 43269 29550 31500 36218 38221 43280 29580 31505 36245 38500 43281 29581 31525 36246 38505 43450 29799 31536 36247 38510 43644 29806 31541 36248 38525 43760 29807 31575 36406 38724 43770 29822 31579 36410 38746 43775
Page 5
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 5 of 26
44005 49000 51798 57150 58543 44120 49021 52000 57160 58545 44139 49080 52005 57240 58550 44140 49180 52204 57250 58552 44143 49320 52224 57260 58555 44145 49322 52235 57265 58558 44160 49424 52260 57267 58561 44180 49500 52276 57280 58563 44204 49505 52281 57288 58565 44205 49507 52310 57420 58570 44207 49520 52332 57421 58571 44213 49560 52351 57425 58573 44950 49561 52352 57452 58605 44955 49565 52353 57454 58611 44960 49568 52601 57455 58660 44970 49585 52648 57456 58661 45300 49587 53660 57460 58662 45330 49650 53661 57461 58670 45331 49652 53850 57500 58671 45378 49654 54056 57505 58720 45380 49905 54150 57511 58925 45382 50200 54160 57520 58940 45383 50230 54161 57522 58970 45384 50392 54200 58100 58974 45385 50545 54235 58110 59000 46040 50590 54640 58120 59020 46050 51600 55040 58140 59025 46083 51700 55250 58146 59151 46200 51701 55700 58150 59200 46221 51702 55845 58180 59320 46260 51703 55866 58260 59400 46320 51705 55876 58262 59409 46600 51720 56405 58300 59410 46900 51725 56420 58301 59425 46930 51726 56501 58322 59426 47000 51728 56515 58340 59430 47001 51729 56605 58350 59510 47562 51741 56606 58353 59514 47563 51784 57061 58541 59515 47600 51797 57100 58542 59610
Page 6
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 6 of 26
59812 64417 65205 69433 70543 59820 64418 65210 69436 70544 59841 64421 65220 69610 70545 60100 64425 65222 69620 70546 60220 64435 65426 69631 70547 60240 64445 65855 69801 70548 60500 64446 66761 69990 70549 61510 64447 66821 70030 70551 61795 64448 66982 70100 70552 62270 64450 66984 70110 70553 62272 64455 67028 70140 71010 62273 64470 67040 70150 71020 62282 64472 67041 70160 71021 62284 64475 67042 70200 71022 62290 64476 67105 70210 71030 62310 64479 67108 70220 71035 62311 64480 67113 70250 71090 62318 64483 67145 70260 71100 62319 64484 67210 70310 71101 62368 64490 67228 70330 71110 63020 64491 67311 70336 71111 63030 64492 67314 70350 71120 63035 64493 67332 70355 71250 63042 64494 67500 70360 71260 63044 64495 67515 70370 71270 63045 64510 67800 70450 71275 63047 64520 67810 70460 71550 63048 64550 67820 70470 71552 63056 64612 67840 70480 71555 63075 64613 67904 70481 72010 63076 64614 68761 70482 72020 63081 64622 68801 70486 72040 63082 64623 68810 70487 72050 63090 64626 68840 70488 72052 63091 64627 69100 70490 72069 63650 64632 69200 70491 72070 64400 64640 69210 70492 72072 64405 64708 69220 70496 72074 64415 64718 69401 70498 72080 64416 64721 69420 70540 72090
Page 7
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 7 of 26
72100 73030 73700 74430 76010 72110 73040 73701 74450 76080 72114 73050 73702 74455 76098 72120 73060 73706 74475 76140 72125 73070 73718 74480 76376 72126 73080 73720 74740 76377 72128 73090 73721 75561 76380 72129 73100 73722 75565 76506 72131 73110 73723 75571 76510 72132 73115 74000 75574 76512 72141 73120 74010 75625 76513 72142 73130 74020 75630 76514 72146 73140 74022 75635 76519 72147 73200 74150 75650 76536 72148 73201 74160 75662 76604 72149 73218 74170 75665 76645 72156 73220 74175 75671 76700 72157 73221 74181 75680 76705 72158 73222 74183 75685 76770 72170 73223 74185 75710 76775 72190 73500 74220 75716 76776 72191 73510 74230 75724 76800 72192 73520 74240 75726 76801 72193 73525 74241 75774 76802 72194 73530 74245 75820 76805 72195 73540 74246 75825 76810 72197 73542 74247 75827 76811 72200 73550 74249 75894 76812 72202 73560 74250 75896 76813 72220 73562 74270 75898 76814 72240 73564 74280 75940 76815 72265 73565 74300 75960 76816 72270 73580 74305 75962 76817 72275 73590 74328 75964 76818 72285 73600 74330 75978 76819 72291 73610 74400 75984 76820 72295 73620 74410 75989 76821 73000 73630 74415 75992 76825 73010 73650 74420 76000 76826 73020 73660 74425 76001 76827
Page 8
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 8 of 26
76828 77080 78223 80061 82009 76830 77081 78264 80069 82010 76831 77082 78267 80074 82024 76856 77263 78268 80076 82030 76857 77280 78278 80100 82040 76870 77290 78300 80101 82042 76872 77295 78306 80102 82043 76873 77300 78315 80154 82044 76880 77301 78320 80156 82055 76885 77315 78451 80158 82085 76937 77321 78452 80162 82088 76942 77328 78454 80164 82103 76946 77331 78465 80170 82104 76948 77332 78472 80176 82105 76950 77333 78478 80178 82106 76970 77334 78480 80184 82107 76977 77336 78492 80185 82108 76998 77338 78580 80186 82120 77001 77370 78584 80195 82131 77002 77401 78585 80196 82136 77003 77404 78588 80197 82139 77011 77413 78596 80198 82140 77012 77414 78707 80200 82145 77014 77416 78708 80201 82150 77021 77417 78725 80202 82157 77031 77418 78802 80299 82164 77032 77421 78803 80400 82172 77051 77427 78804 80415 82175 77052 77432 78806 80500 82180 77055 77470 78808 80502 82205 77056 77523 78812 81000 82232 77057 77785 78815 81001 82239 77059 77786 78816 81002 82247 77071 78006 79005 81003 82248 77072 78007 80047 81005 82261 77073 78010 80048 81007 82270 77074 78018 80050 81015 82271 77075 78070 80051 81025 82272 77077 78195 80053 81050 82274 77078 78215 80055 82003 82300
Page 9
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 9 of 26
82306 82626 82626 83873 84133 82307 82627 82627 83874 84134 82308 82651 82651 83880 84140 82310 82652 82652 83883 84144 82330 82664 82664 83887 84146 82340 82668 82668 83890 84152 82360 82670 82670 83891 84153 82365 82671 82671 83892 84154 82374 82672 82672 83893 84155 82375 82677 82677 83894 84156 82378 82679 82679 83896 84157 82379 82705 82705 83898 84163 82384 82725 82725 83900 84165 82390 82728 82728 83901 84166 82397 82731 82731 83902 84207 82435 82746 82746 83903 84238 82436 82747 82747 83904 84244 82438 82760 82760 83907 84252 82465 82776 82776 83908 84255 82491 82784 82784 83909 84260 82492 82785 82785 83912 84270 82495 82787 82787 83913 84295 82507 82800 82800 83914 84300 82520 82803 82803 83916 84305 82523 82805 82805 83918 84311 82525 82810 82810 83921 84315 82530 82941 82941 83925 84378 82533 82945 82945 83930 84392 82540 82947 82947 83935 84402 82542 82948 82948 83945 84403 82550 82950 82950 83970 84425 82552 82951 82951 83986 84432 82553 82952 82952 83992 84436 82565 82955 82955 84030 84437 82570 82962 82962 84066 84439 82575 82977 82977 84075 84442 82595 82978 82978 84080 84443 82607 82985 82985 84100 84445 82608 83001 83001 84105 84446 82610 83002 83002 84132 84450
Page 10
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 10 of 26
84460 85049 85670 86317 86663 84466 85060 85705 86318 86664 84478 85097 85730 86334 86665 84479 85210 85732 86335 86666 84480 85220 86000 86336 86671 84481 85240 86001 86337 86677 84482 85245 86003 86340 86684 84484 85246 86005 86341 86689 84512 85247 86021 86353 86694 84520 85250 86022 86355 86695 84540 85300 86023 86357 86696 84550 85301 86038 86359 86698 84560 85302 86039 86360 86701 84585 85303 86060 86361 86703 84590 85305 86063 86376 86704 84591 85306 86077 86403 86705 84597 85307 86079 86430 86706 84600 85347 86140 86431 86707 84630 85362 86141 86480 86708 84681 85370 86146 86580 86709 84702 85378 86147 86592 86710 84703 85379 86148 86593 86735 84830 85380 86157 86606 86738 84999 85384 86160 86609 86747 85002 85385 86161 86611 86753 85004 85390 86162 86612 86756 85007 85396 86171 86615 86757 85008 85460 86200 86617 86759 85009 85461 86215 86618 86762 85013 85520 86225 86622 86765 85014 85525 86226 86628 86774 85018 85540 86235 86631 86777 85025 85576 86255 86632 86778 85027 85597 86256 86635 86780 85032 85610 86294 86638 86781 85041 85611 86300 86641 86787 85044 85613 86301 86644 86788 85045 85651 86304 86645 86789 85046 85652 86308 86648 86790 85048 85660 86316 86658 86800
Page 11
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 11 of 26
86803 87116 87329 87651 88189 86804 87118 87335 87653 88230 86805 87140 87337 87660 88235 86807 87147 87338 87797 88237 86812 87149 87339 87798 88262 86850 87158 87340 87799 88264 86870 87169 87341 87800 88269 86880 87172 87350 87801 88271 86885 87176 87385 87802 88273 86886 87177 87390 87803 88274 86900 87181 87400 87804 88275 86901 87184 87420 87807 88280 86903 87185 87425 87808 88285 86905 87186 87427 87810 88289 86920 87205 87430 87850 88291 86921 87206 87449 87880 88300 86922 87207 87450 87899 88302 86923 87209 87480 87901 88304 86927 87210 87481 87902 88305 87015 87220 87490 88104 88307 87040 87230 87491 88108 88309 87045 87252 87493 88112 88311 87046 87253 87496 88141 88312 87070 87254 87497 88142 88313 87071 87255 87498 88143 88314 87073 87260 87500 88148 88319 87075 87271 87510 88150 88321 87076 87272 87511 88155 88323 87077 87275 87517 88160 88325 87081 87276 87521 88161 88329 87084 87279 87522 88164 88331 87086 87280 87529 88172 88332 87088 87281 87535 88173 88333 87101 87299 87536 88174 88334 87102 87300 87590 88175 88342 87103 87301 87591 88182 88346 87106 87320 87621 88184 88347 87107 87324 87640 88185 88348 87109 87327 87641 88187 88358 87110 87328 87650 88188 88360
Page 12
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 12 of 26
88361 90658 90816 92136 92583 88365 90660 90817 92140 92584 88367 90662 90818 92225 92585 88368 90663 90819 92226 92586 88720 90669 90846 92235 92587 88738 90670 90847 92250 92588 89050 90675 90853 92270 92591 89051 90680 90862 92283 92604 89055 90681 90870 92285 92610 89060 90691 90935 92286 92611 89190 90696 90937 92287 92630 89230 90698 90945 92310 92950 89320 90700 90960 92504 92960 89321 90701 90961 92506 92971 89322 90703 90962 92507 92973 89325 90707 90966 92508 92978 90378 90710 90969 92511 92980 90384 90713 90970 92520 92981 90465 90714 91010 92526 92982 90466 90715 91034 92540 93000 90467 90716 91035 92541 93005 90468 90717 91065 92542 93010 90470 90718 91105 92543 93012 90471 90721 91110 92544 93014 90472 90723 91122 92545 93015 90473 90732 92002 92546 93016 90474 90733 92004 92547 93017 90632 90734 92012 92548 93018 90633 90736 92014 92550 93040 90634 90744 92015 92551 93041 90636 90746 92020 92552 93042 90645 90801 92025 92553 93224 90646 90802 92060 92555 93225 90647 90804 92070 92556 93226 90648 90805 92081 92557 93227 90649 90806 92082 92567 93230 90650 90807 92083 92568 93231 90655 90808 92100 92570 93232 90656 90809 92120 92579 93233 90657 90812 92135 92582 93235
Page 13
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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93236 93544 94150 95165 95936 93237 93545 94200 95170 95937 93268 93555 94240 95180 95951 93270 93556 94250 95199 95953 93271 93609 94260 95250 95955 93272 93613 94350 95251 95956 93279 93620 94360 95805 95957 93280 93621 94370 95810 95970 93282 93623 94375 95811 95972 93283 93641 94620 95812 95974 93284 93651 94621 95813 95978 93288 93660 94640 95816 95990 93289 93662 94644 95819 95991 93290 93701 94660 95822 95992 93291 93720 94664 95831 96040 93293 93798 94667 95832 96101 93294 93875 94668 95851 96102 93295 93880 94680 95852 96103 93296 93882 94681 95860 96110 93297 93886 94690 95861 96111 93303 93922 94720 95863 96116 93304 93923 94750 95864 96118 93306 93924 94760 95865 96119 93307 93925 94761 95867 96120 93308 93926 94762 95868 96150 93312 93930 94770 95870 96151 93320 93931 95004 95874 96152 93321 93965 95010 95900 96155 93325 93970 95015 95903 96360 93350 93971 95024 95904 96361 93351 93975 95028 95920 96365 93501 93976 95044 95921 96366 93503 93978 95075 95922 96367 93505 93979 95115 95925 96368 93508 93990 95117 95926 96372 93510 94002 95120 95927 96373 93526 94003 95125 95928 96374 93539 94010 95130 95929 96375 93540 94060 95144 95930 96401 93543 94070 95145 95934 96402
Page 14
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 14 of 26
96409 97139 99100 99251 99385 96411 97140 99135 99252 99386 96413 97150 99140 99253 99387 96415 97530 99144 99254 99391 96416 97532 99145 99255 99392 96417 97535 99149 99281 99393 96450 97597 99173 99282 99394 96521 97598 99183 99283 99395 96522 97602 99195 99284 99396 96523 97605 99199 99285 99397 96567 97606 99201 99291 99401 96900 97750 99202 99292 99402 96910 97760 99203 99305 99404 96912 97762 99204 99306 99406 96920 97799 99205 99307 99408 96921 97802 99211 99308 99420 96922 97803 99212 99309 99429 97001 97810 99213 99310 99460 97002 97811 99214 99315 99462 97003 97813 99215 99334 99463 97004 97814 99217 99335 99464 97010 98925 99218 99336 99465 97012 98926 99219 99337 99468 97014 98927 99220 99339 99469 97016 98928 99221 99348 99471 97018 98940 99222 99349 99472 97022 98941 99223 99354 99476 97024 98942 99231 99355 99477 97026 98943 99232 99356 99478 97032 98960 99233 99357 99479 97033 99000 99234 99358 99480 97034 99001 99235 99359 99601 97035 99002 99236 99364 99602 97036 99024 99238 99367 A4206 97039 99050 99239 99374 A4208 97110 99051 99241 99375 A4209 97112 99053 99242 99381 A4211 97113 99058 99243 99382 A4212 97116 99070 99244 99383 A4213 97124 99091 99245 99384 A4215
Page 15
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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A4216 A4406 A4652 A6545 A9512 A4217 A4407 A4670 A6550 A9516 A4218 A4409 A4860 A7000 A9517 A4220 A4414 A4927 A7002 A9537 A4221 A4419 A4930 A7003 A9541 A4222 A4424 A5054 A7004 A9552 A4223 A4425 A5061 A7005 A9554 A4230 A4432 A5063 A7006 A9555 A4232 A4450 A5120 A7007 A9560 A4235 A4452 A5500 A7013 A9561 A4245 A4456 A5512 A7014 A9576 A4253 A4466 A5513 A7015 A9577 A4256 A4483 A6021 A7016 A9578 A4258 A4550 A6203 A7027 A9579 A4259 A4556 A6209 A7028 A9900 A4300 A4557 A6212 A7029 A9901 A4305 A4558 A6216 A7030 A9999 A4310 A4559 A6219 A7031 B4034 A4320 A4562 A6222 A7032 B4035 A4322 A4565 A6234 A7033 B4036 A4332 A4570 A6250 A7034 B4087 A4338 A4580 A6251 A7035 B4088 A4344 A4590 A6252 A7036 B4100 A4349 A4595 A6255 A7037 B4150 A4351 A4604 A6257 A7038 B4152 A4352 A4606 A6260 A7039 B4153 A4353 A4614 A6266 A7045 B4154 A4355 A4615 A6402 A7046 B4155 A4357 A4616 A6403 A7520 B4160 A4358 A4617 A6407 A7525 B4161 A4362 A4618 A6443 A7526 B4185 A4364 A4620 A6446 A9274 B4216 A4367 A4624 A6448 A9276 B9002 A4368 A4627 A6449 A9277 B9998 A4371 A4628 A6450 A9278 E0100 A4385 A4629 A6451 A9279 E0105 A4388 A4630 A6452 A9500 E0110 A4390 A4648 A6453 A9502 E0112 A4394 A4649 A6454 A9503 E0114 A4402 A4651 A6457 A9505 E0118
Page 16
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 16 of 26
E0135 E0731 G0123 J0295 J1051 E0143 E0745 G0124 J0456 J1055 E0149 E0747 G0127 J0460 J1060 E0155 E0748 G0145 J0461 J1070 E0156 E0760 G0179 J0475 J1080 E0163 E0776 G0180 J0500 J1094 E0165 E0780 G0181 J0559 J1100 E0168 E0781 G0202 J0560 J1110 E0181 E0784 G0204 J0570 J1170 E0188 E0791 G0206 J0580 J1200 E0189 E0855 G0237 J0585 J1212 E0190 E0910 G0238 J0595 J1245 E0191 E0935 G0250 J0610 J1250 E0202 E0951 G0268 J0637 J1260 E0260 E0955 G0283 J0640 J1267 E0265 E0961 G0289 J0641 J1335 E0277 E0971 G0328 J0670 J1390 E0424 E0973 G0365 J0690 J1440 E0431 E0978 G0402 J0692 J1441 E0434 E0990 G0430 J0694 J1453 E0439 E1028 G0431 J0696 J1459 E0441 E1140 G8427 J0697 J1561 E0442 E1150 G8443 J0698 J1562 E0443 E1260 G8445 J0702 J1566 E0444 E1353 G8446 J0704 J1568 E0445 E1390 G8447 J0713 J1569 E0463 E1392 G8448 J0725 J1580 E0470 E1399 G8457 J0743 J1610 E0471 E2201 G8553 J0780 J1626 E0482 E2365 G9141 J0834 J1630 E0562 E2402 G9142 J0878 J1642 E0565 E2601 J0129 J0881 J1644 E0570 G0008 J0133 J0885 J1650 E0600 G0101 J0152 J0894 J1652 E0601 G0102 J0170 J0945 J1710 E0607 G0103 J0207 J0970 J1720 E0619 G0105 J0256 J1000 J1745 E0630 G0108 J0278 J1020 J1750 E0673 G0109 J0280 J1030 J1756 E0730 G0121 J0290 J1040 J1785
Page 17
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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J1815 J2790 J7050 J9045 K0001 J1885 J2795 J7060 J9055 K0003 J1890 J2796 J7070 J9060 K0004 J1940 J2805 J7120 J9062 K0006 J1950 J2820 J7192 J9070 K0007 J1956 J2916 J7193 J9080 K0108 J2001 J2920 J7195 J9090 K0195 J2010 J2930 J7300 J9091 K0552 J2020 J2941 J7302 J9093 K0603 J2060 J2997 J7307 J9095 K0738 J2150 J3010 J7308 J9130 K0739 J2175 J3030 J7321 J9140 K0823 J2180 J3120 J7322 J9170 L0172 J2185 J3130 J7323 J9171 L0174 J2248 J3150 J7324 J9178 L0625 J2250 J3240 J7325 J9181 L0627 J2260 J3243 J7506 J9185 L0630 J2270 J3250 J7510 J9190 L0631 J2275 J3260 J7605 J9201 L0637 J2300 J3300 J7609 J9202 L1810 J2323 J3301 J7610 J9206 L1820 J2353 J3302 J7611 J9208 L1830 J2355 J3303 J7612 J9209 L1832 J2357 J3315 J7613 J9214 L1843 J2360 J3360 J7614 J9217 L1845 J2400 J3370 J7615 J9250 L1902 J2405 J3410 J7620 J9260 L1906 J2430 J3415 J7626 J9263 L1907 J2469 J3420 J7644 J9264 L1930 J2505 J3430 J7799 J9265 L1960 J2510 J3470 J8540 J9305 L1970 J2543 J3475 J9000 J9310 L1971 J2550 J3480 J9001 J9330 L2112 J2650 J3487 J9017 J9350 L2114 J2675 J3488 J9025 J9355 L2116 J2700 J3490 J9031 J9360 L2200 J2765 J3590 J9033 J9370 L2210 J2778 J7030 J9035 J9375 L2270 J2780 J7040 J9040 J9390 L2275 J2785 J7042 J9041 J9395 L2280
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A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 18 of 26
L2397 L7520 Q9967 S9343 V5008 L2425 L8000 S0020 S9345 V5010 L2780 L8020 S0023 S9348 V5011 L2795 L8030 S0028 S9359 V5160 L2810 L8420 S0032 S9366 V5257 L2820 L8470 S0077 S9367 V5261 L2830 L8680 S0181 S9370 V5266 L2999 P9603 S0260 S9374 L3000 P9612 S0315 S9375 L3010 Q0081 S0316 S9379 L3020 Q0091 S0395 S9460 L3030 Q0111 S0612 S9465 L3100 Q0112 S0620 S9490 L3170 Q0138 S0621 S9500 L3260 Q0163 S0625 S9501 L3265 Q4006 S1015 S9502 L3650 Q4008 S1016 S9503 L3660 Q4010 S2068 S9537 L3670 Q4012 S2083 S9542 L3675 Q4014 S2140 S9558 L3760 Q4018 S3620 S9343 L3807 Q4021 S5001 S9345 L3808 Q4022 S5010 S9348 L3906 Q4024 S5501 S9359 L3908 Q4038 S5502 S9366 L3913 Q4040 S8101 S9367 L3923 Q4046 S8110 S9370 L3925 Q4049 S8120 S9374 L3931 Q4050 S8121 S9375 L3933 Q4051 S8950 S9379 L3962 Q4106 S9061 S9460 L3999 Q9953 S9088 S9465 L4350 Q9954 S9090 S9490 L4360 Q9957 S9140 S9500 L4386 Q9960 S9141 S9501 L4396 Q9961 S9152 S9502 L5620 Q9962 S9208 S9503 L5637 Q9963 S9338 S9537 L5673 Q9965 S9341 S9542 L5910 Q9966 S9342 S9558
Page 19
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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Charge exceeds the priced amount for this service. – T43 (Non-Participating/Non-Network Physician or other Professional Provider) 00140 11721 31575 64622 73130 00142 11730 36000 64623 73140 00160 12001 36415 64627 73221 00170 12002 36416 66821 73510 00300 12011 36556 66984 73550 00320 12013 36620 67028 73560 00400 12032 41899 69210 73562 00532 17000 43235 69990 73564 00630 17003 43239 70355 73590 00670 17004 43644 70450 73600 00740 17110 43770 70486 73610 00790 17311 44970 70551 73620 00797 20550 45378 70553 73630 00810 20552 45380 71010 73721 00830 20553 45385 71020 74000 00840 20605 47562 71250 74020 00873 20610 47563 71260 74022 00902 22554 49505 72010 74150 00910 22585 49568 72020 74160 00940 22612 51798 72040 74170 00952 22614 59025 72050 74240 01400 22845 59410 72070 76140 01402 22851 59430 72100 76376 01480 25020 59514 72110 76536 01630 25600 62270 72125 76645 01810 27130 62310 72141 76700 01830 27447 62311 72148 76705 01922 29105 63030 72170 76770 01961 29125 63047 72192 76801 01967 29240 63048 72193 76805 01991 29515 63075 72194 76811 01992 29530 63076 72275 76815 01996 29540 64415 73030 76816 07914 29826 64418 73060 76817 10060 29827 64450 73070 76819 10061 29848 64483 73080 76830 11042 29880 64484 73090 76856 11100 29881 64493 73100 76880 11101 29888 64494 73110 76942 11720 31500 64495 73120 76950
Page 20
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Page 20 of 26
77002 82040 82947 83925 85610 77003 82043 82948 83970 85651 77014 82044 82950 83986 85652 77051 82055 82962 83992 85730 77052 82105 82977 84075 86001 77057 82108 83001 84100 86038 77080 82145 83002 84132 86140 77263 82150 83021 84134 86141 77280 82172 83036 84144 86300 77290 82205 83090 84146 86376 77300 82247 83516 84153 86431 77334 82248 83519 84155 86580 77336 82270 83520 84165 86592 77413 82272 83525 84270 86703 77414 82274 83540 84295 86704 77417 82306 83550 84311 86706 77418 82310 83605 84402 86800 77421 82378 83615 84403 86803 77427 82465 83655 84436 86850 78452 82491 83690 84439 86900 78815 82492 83718 84443 86901 80048 82520 83721 84450 87040 80050 82530 83735 84460 87045 80051 82533 83789 84466 87070 80053 82540 83805 84478 87075 80061 82542 83840 84479 87077 80069 82550 83880 84480 87081 80076 82553 83883 84481 87086 80101 82565 83891 84484 87088 80102 82570 83892 84520 87102 80154 82607 83896 84550 87177 80185 82626 83898 84702 87186 80299 82627 83900 84703 87205 80500 82664 83901 85007 87210 81000 82670 83903 85014 87340 81001 82677 83908 85018 87400 81002 82679 83909 85025 87430 81003 82728 83912 85027 87491 81005 82746 83914 85045 87591 81025 82784 83921 85385 87621
Page 21
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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87798 90857 93543 95927 97124 87804 90862 93545 95928 97140 87880 90935 93555 95929 97150 88112 90960 93556 95934 97530 88142 92004 93880 95937 97750 88175 92012 93922 95955 97810 88300 92014 93923 96101 97811 88302 92015 93925 96118 97813 88304 92083 93970 96152 97814 88305 92135 93971 96360 98925 88307 92136 94010 96361 98926 88311 92226 94060 96365 98927 88312 92250 94240 96366 98940 88313 92506 94375 96367 98941 88342 92507 94620 96372 98942 88347 92508 94640 96374 98943 88367 92526 94720 96375 98960 90465 92551 94760 96409 99000 90466 92557 94761 96411 99050 90471 92567 94762 96413 99051 90472 92585 95004 96415 99053 90473 92587 95015 96417 99058 90658 92950 95024 96521 99070 90715 93000 95115 96523 99100 90718 93005 95117 97001 99140 90801 93010 95125 97002 99144 90804 93012 95165 97003 99145 90805 93015 95810 97010 99173 90806 93016 95811 97012 99183 90807 93018 95831 97014 99201 90808 93040 95832 97016 99202 90809 93042 95860 97022 99203 90812 93232 95861 97024 99204 90816 93236 95870 97026 99205 90817 93271 95900 97032 99211 90818 93293 95903 97035 99212 90845 93306 95904 97110 99213 90846 93320 95920 97112 99214 90847 93325 95925 97113 99215 90853 93510 95926 97116 99217
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A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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99219 99392 A4322 B4035 J0885 J9045 99220 99393 A4351 B9998 J0894 J9171 99221 99394 A4353 E0114 J1030 J9190 99222 99395 A4550 E0143 J1040 J9201 99223 99396 A4556 E0163 J1080 J9265 99231 99397 A4557 E0260 J1100 J9310 99232 99460 A4565 E0431 J1200 K0001 99233 99464 A4595 E0434 J1626 K0003 99235 99469 A4628 E0443 J1642 K0004 99238 99472 A4630 E0470 J1644 K0108 99239 99479 A5120 E0562 J1815 K0195 99241 99480 A5500 E0570 J1885 L0631 99242 99601 A5512 E0571 J2001 L0637 99243 99602 A5513 E0601 J2010 L1830 99244 A0382 A6222 E0607 J2250 L3260 99245 A0392 A6250 E0730 J2270 L3670 99253 A0394 A6402 E0731 J2405 L3908 99254 A0398 A6455 E0776 J2469 L4350 99255 A0422 A7000 E0855 J2505 L7900 99282 A0425 A7002 E1353 J2550 Q0091 99283 A0426 A7003 E1390 J2780 Q0092 99284 A0427 A7004 E1399 J3010 Q1003 99285 A0428 A7005 G0008 J3301 Q9966 99291 A0429 A7015 G0101 J3420 Q9967 99292 A0431 A7030 G0103 J3475 R0070 99306 A0433 A7031 G0105 J3487 R0075 99307 A0434 A7032 G0121 J3490 S0620 99308 A0436 A7033 G0179 J7030 S0621 99309 A4206 A7034 G0180 J7040 S2083 99310 A4216 A7035 G0181 J7050 S8950 99334 A4221 A7036 G0202 J7120 S9338 99335 A4222 A7037 G0204 J7189 V2020 99336 A4232 A7038 G0249 J7198 V5257 99349 A4233 A7039 G0283 J7507 V5261 99350 A4235 A7046 G0431 J7613 99354 A4245 A9500 G9141 J7620 99356 A4253 A9502 J0640 J7626 99385 A4256 A9552 J0696 J7644 99386 A4258 A9579 J0702 J9035 99391 A4259 A9900 J0881 J9041
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A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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Claim paid with Provider as a Participating/Network Physician or other Professional Provider 70450 70553 72157 73718 76700 70470 71250 72158 73721 76770 70486 71260 72191 74150 76831 70543 71270 72192 74160 76856 70544 72141 72193 74170 76857 70547 72146 72194 74175 70549 72148 73218 74183 70551 72156 73221 76604 Charge exceeds the Multiple Surgery Priced amount for this service. (Participating/Network Physician or other Professional Provider) 11040 28270 33233 49650 11721 28285 33241 51600 11730 28308 35473 51728 11750 29260 35474 51729 12031 29280 35476 51741 12032 29520 36000 51784 13101 29530 36005 51795 13132 29540 36010 51797 15002 29550 36011 51798 15004 29580 36147 52000 15823 29807 36148 52005 17003 29822 36215 52332 19102 29823 36216 52352 19103 29824 36245 57240 19295 29826 36247 57250 19303 29828 36471 57260 19318 29873 36475 57282 19350 29875 36556 57283 19357 29876 37205 57288 19380 29877 37765 58100 20526 29879 38220 58558 20550 29880 38525 58563 20551 29881 38571 58662 20552 29882 38792 62284 20553 30130 39502 62290 20600 30140 42830 62310 20605 30520 43235 62311 20610 30930 43239 63030 20680 31233 43248 63047 20926 31237 43249 63650
Page 24
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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22554 31240 43262 63685 22558 31254 43268 64405 22630 31255 43450 64413 22851 31256 45380 64415 23120 31267 45381 64445 23430 31276 45384 64447 26055 31287 45385 64448 27096 31288 47100 64450 27370 31622 49505 64483 27447 31624 49585 64484 Charge exceeds the Multiple Surgery Priced amount for this service. (Non-Participating/Non-Network Physician or other Professional Provider) 20610 29520 29826 43239 64405 29260 29530 29848 64400 64418 29280 29540 41899 64402 64450
Page 25
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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Charge exceeds the MSP priced amount for this service. This is an unbundling reduction as a result of Multiple Service Pricing logic. (Participating/Network Physician or other Professional Provider) 11042 71010 83891 92532 97112 22830 72020 83898 92541 97140 22999 74000 83900 92544 97530 29075 74300 83912 92545 97802 29125 76000 83914 93000 98940 29540 76140 84075 93005 99000 29550 76376 84100 93010 99001 29799 76377 84132 93018 99002 29874 76536 84155 93040 99050 29875 76705 84295 93041 99051 29877 76815 84443 93042 99053 31623 76819 84450 93320 99058 36000 76830 84460 93325 99070 36591 77002 84478 93508 99091 36592 77003 84520 93770 99144 36600 78452 85007 93971 99173 43235 80047 85014 94010 99199 44005 80048 85018 94150 99201 44180 80051 85025 94200 99202 45380 80053 85027 94260 99203 46600 80076 85041 94375 99204 49000 81002 85048 94640 99211 49320 81003 85049 94660 99212 49568 81015 86140 94664 99213 49585 82040 86592 94760 99214 49999 82044 86762 94761 99215 51701 82247 86803 94770 99217 51798 82248 86850 95115 99221 52000 82272 86885 95831 99222 57410 82310 86900 95833 99223 57500 82330 86901 95851 99231 57505 82374 87340 96360 99232 58100 82435 88300 96365 99233 58660 82465 90467 96372 99238 58740 82533 90473 96374 99239 63047 82565 92012 96375 99243 63048 82570 92014 96523 99354 64435 82947 92015 97002 99358 64450 82948 92504 97004 99385 69990 83718 92507 97110 99391
Page 26
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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99394 A4213 A4262 A6411 G8553 99395 A4215 A4263 A9279 J2001 99396 A4216 A4450 E0776 Q0091 99499 A4217 A4452 E0780 Q9962 A4206 A4218 A4556 E0781 S0020 A4207 A4221 A4558 E0791 S8110 A4208 A4222 A4649 G0101 A4209 A4223 A4657 G0102 A4210 A4245 A4927 G0269 A4212 A4246 A4930 G8447 Charge exceeds the MSP priced amount for this service. This is an unbundling reduction as a result of Multiple Service Pricing logic. (Non-Participating/Non-Network Physician or other Professional Provider) 29550 85025 94760 99053 99214 A4556 76000 93005 94761 99070 A0382 77003 93010 94770 99203 A0394 80053 93040 95851 99211 A0398 81003 93041 96374 99212 A0999 84443 93042 99000 99213 A4215 Anesthesia is not covered for this procedure. 99144 99145
Claim paid with Provider as a Non-Participating/Non-Network Physician or other Professional Provider 71260 72193 74170 posted 12/2010
