BCBSNC Reimbursement Policy - Imaging for Low Back Pain

For NC Providers Only

BCBSNC has issued a new reimbursement policy, which is based, in part, on the following NCQA HEDIS^TM Standard.

For patients between the ages of 18-75
with a primary diagnosis of low back pain, in the absence of certain red flags,
imaging studies within 28 days of the initial diagnosis of low back pain are not
considered clinically appropriate.

The new BCBSNC policy is effective June 18, 2023, and states:

• Regardless of the patient's age, unless the patient represents with one of the "red flags" listed below or has uncomplicated low back pain that has lasted for more than 28 days, imaging services (X-ray, CT scan, or MRI) billed within 28 days of a principal diagnosis of uncomplicated LBP are not eligible for reimbursement.
  
  

• If the patient presents with one of the 'red flags' listed below or has uncomplicated low back pain lasting more than 28 days, imaging services may be performed without waiting the 28 days, but when billing for the imaging study, the service must be appended with a KX modifier to indicate the presence of a 'red flag' or to indicate that the low back pain has lasted more than 28 days.
  
  Note:  It is NOT necessary to report the 'red flag' diagnosis on the claim form, but the healthcare record must include evidence of the 'red flag' diagnosis.

 With one exception, this reimbursement policy applies to all BCBS plans, including but not limited to:

• State Health Plan (SHP)
  
• Federal Employee Program (FEP)
  
• Self-funded plans (Administrative Services Only (ASO))
  
• Out of state BCBS plans (fully insured and Blue Card host claims)

(Exceptions:  It does not apply to Blue Cross NC members who seek care in other states.)

Non-Covered Service Waiver: If you believe x-rays are clinically appropriate, but those x-rays are not consistent with the above BCBSNC Policy, you may bill the patient for the needed x-rays, provided that you first obtain a signed non-covered service waiver from the patient in which he/she agrees to pay for the x-rays, and provided the signed waiver is on file in the patient's healthcare record.

Red Flags:

If the patient presents with one of the following "red flags", imaging studies within the first 28 days of the low back pain diagnosis ARE considered clinically appropriate:

• Cancer
  
• Recent Trauma
  
• IV Drug Abuse
  
• Neurologic Impairment
  
• HIV
  
• Spinal Infection
  
• Major Organ Transplant
  
• Prolonged Use of Corticosteroids
  
• Osteoporosis
  
• Fragility Fracture
  
• Lumbar Surgery
  
• Spondylopathy
  
• Palliative Care
  
• Hospice
  
• Frailty and Advanced Illness (must have both; applies to patients 66 years of age and older)
  
• Malignant Neoplasm
  
• History of Malignant Neoplasm
  
• Other Neoplasms
  
• IV Drug Use

Relevant to this new BCBSNC Policy, low back pain diagnoses include, but are not limited to, the diagnoses listed below:

• Low back pain
  
• Segmental and somatic dysfunction of lumbar region
  
• Segmental and somatic dysfunction of sacral region
  
• Radiculopathy, lumbar region
  
• Radiculopathy, lumbosacral region
  
• Lumbago with sciatica, left side
  
• Lumbago with sciatica, right side
  
• Intervertebral disc disorder with radiculopathy, lumbosacral region
  
• Other intervertebral disc displacement, lumbar region
  
• Other intervertebral disc degeneration, lumbar region
  
• Other intervertebral disc degeneration, lumbosacral region
  
• Spondylosis without myelopathy or radiculopathy, lumbar region
  
• Spondylosis without myelopathy or radiculopathy, lumbosacral region
  
• Sprain of ligaments of lumbar spine, initial encounter

Non-Covered Service Waiver: Again, if you believe x-rays are clinically appropriate, but are not consistent with the new BCBSNC Policy, before taking the x-rays, first have the patient sign a non-covered service waiver agreeing to pay for the x-rays, and be sure to keep the waiver on file in the patient's healthcare record. 

Click here for the list of ICD-10 codes which

represent the "red flag" diagnoses.