Code Description - Blue Cross NC

1 Revenue Code Listing Below revenue codes must be filed with appropriate CPT and HCPCS codes for Outpatient and ambulatory Surgery UB-04 or 837-Institutional Healthcare Claims. Code Description 0254 Pharmacy 0255 Pharmacy 0260 IV Therapy 0274 Prosthetic/Orthotic Devices* 0290 DME General Classification* 0291 DME Rental* 0292 DME New* 0293 DME Used* 0294 DME Supplies/Drugs* 0295 RESERVED** 0296 RESERVED** 0297 RESERVED** 0298 RESERVED** 0299 DME Other* 0300 Laboratory 0301 Laboratory 0302 Laboratory 0305 Laboratory 0309 Laboratory 0310 Laboratory Pathology 0311 Laboratory Pathology 0312 Laboratory Pathology 0314 Laboratory Pathology 0319 Laboratory Pathology 0320 Radiology - Diagnostic 0321 Radiology - Diagnostic 0322 Arthography 0323 Radiology - Diagnostic 0324 Radiology - Diagnostic 0329 Radiology - Diagnostic 0330 Radiology - Therapeutic and/or Chemotherapy Administration 0331 Radiology - Therapeutic

2 And/or Chemotherapy Administration 0332 Radiology - Therapeutic and/or Chemotherapy Administration 0333 Radiology - Therapeutic and/or Chemotherapy Administration 0335 Radiology - Therapeutic and/or Chemotherapy Administration 0340 Nuclear Medicine 0341 Nuclear Medicine 0342 Nuclear Medicine 1 *Revenue Codes added to edit I-359 in July 2015 **Revenue codes reserved for future use by NUBC Revenue Code Listing Below revenue codes must be filed with appropriate CPT and HCPCS codes for Outpatient and ambulatory Surgery UB-04 or 837-Institutional Healthcare Claims. 0349 Nuclear Medicine 0350 CT Scan 0351 CT Scan 0352 CT Scan 0359 CT Scan 0360 Operating Room Services 0361 Operating Room Services 0362 Operating Room Services 0369 Operating Room Services 0381 Blood and Blood Components 0382 Blood and Blood Components 0383 Blood and Blood Components 0384 Blood and Blood Components 0386 Blood and Blood Components 0387 Blood and Blood Components 0389 Blood and Blood Components 0390 Administration, Processing, and Storage for Blood and Blood Components 0391 Administration, Processing, and Storage for Blood and Blood Components 0392 Administration, Processing, and Storage for Blood and Blood Components 0399 Administration, Processing.

3 And Storage for Blood and Blood Components 0400 Other Imaging Services 0401 Other Imaging Services 0402 Other Imaging Services 0404 Other Imaging Services 0409 Other Imaging Services 0410 Respiratory Services 0412 Respiratory Services 0413 Respiratory Services 0419 Respiratory Services 0420 Physical Therapy 0421 Physical Therapy 0422 Physical Therapy 0423 Physical Therapy 0424 Physical Therapy 0429 Physical Therapy 0430 Occupational Therapy 0431 Occupational Therapy 2 *Revenue Codes added to edit I-359 in July 2015 **Revenue codes reserved for future use by NUBC Revenue Code Listing Below revenue codes must be filed with appropriate CPT and HCPCS codes for Outpatient and ambulatory Surgery UB-04 or 837-Institutional Healthcare Claims. 0432 Occupational Therapy 0433 Occupational Therapy 0434 Occupational Therapy 0439 Occupational Therapy 0440 Speech Therapy - Language Pathology 0441 Speech Therapy - Language Pathology 0442 Speech Therapy - Language Pathology 0443 Speech Therapy - Language Pathology 0444 Speech Therapy - Language Pathology 0449 Speech Therapy - Language Pathology 0450 Emergency Room 0451 Emergency Room 0452 Emergency Room 0456 Emergency Room 0459 Emergency Room 0460 Pulmonary Function 0469 Pulmonary Function 0470 Audiology 0471 Audiology 0479 Audiology 0480 Cardiology 0481 Cardiology 0482 Cardiology 0483 Cardiology 0489 Cardiology 0490 ambulatory Surgical Care 0510 Clinic 0511 Clinic 0512 Clinic 0513 Clinic 0514 Clinic 0515 Clinic 0516 Clinic

4 0517 Clinic 0519 Clinic 0520 Free-Standing Clinic 0523 Free-Standing Clinic 0526 Free-Standing Clinic 0529 Free-Standing Clinic 0530 Osteopathic Services 3 *Revenue Codes added to edit I-359 in July 2015 **Revenue codes reserved for future use by NUBC Revenue Code Listing Below revenue codes must be filed with appropriate CPT and HCPCS codes for Outpatient and ambulatory Surgery UB-04 or 837-Institutional Healthcare Claims. 054x Ambulance 0610 Magnetic Resonance Technology (MRT) 0611 Magnetic Resonance Technology (MRT) 0612 Magnetic Resonance Technology (MRT) 0614 Magnetic Resonance Technology (MRT) 0615 Magnetic Resonance Technology (MRT) 0616 Magnetic Resonance Technology (MRT) 0618 Magnetic Resonance Technology (MRT) 0619 Magnetic Resonance Technology (MRT) 0634 Pharmacy 0635 Pharmacy 0636 Pharmacy 0730 EKG/ECG (Electrocardiogram) 0731 EKG/ECG (Electrocardiogram) 0732 EKG/ECG (Electrocardiogram) 0739 EKG/ECG (Electrocardiogram) 0740 EEG (Electroencephalogram) 0750 Gastro-Intestinal (GI)

5 Services 0761 Specialty Room - Treatment/Observation Room 0770 Preventive Care Services 0771 Preventive Care Services 0790 Extra-Corporeal Shock Wave Therapy 0820 Hemodialysis - Outpatient or Home 0821 Hemodialysis - Outpatient or Home 0829 Hemodialysis - Outpatient or Home 0831 peritoneal dialysis - Outpatient or Home 0835 peritoneal dialysis - Outpatient or Home 0840 continuous ambulatory peritoneal dialysis (CAPD) - Outpatient or Home 0841 continuous ambulatory peritoneal dialysis (CAPD) - Outpatient or Home 0845 continuous ambulatory peritoneal dialysis (CAPD) - Outpatient or Home 0850 continuous Cycling Peritioneal dialysis (CCPD) - Outpatient or Home 0851 continuous Cycling Peritioneal dialysis (CCPD) - Outpatient or Home 0859 continuous Cycling Peritioneal dialysis (CCPD) - Outpatient or Home 0880 Miscellaneous dialysis 0881 Miscellaneous dialysis 0889 Miscellaneous dialysis 0900 Behavioral Health Treatment/Services 0901 Behavioral Health Treatment/Services 0905 Behavioral Health Treatment/Services 0906 Behavioral Health Treatment/Services 4 *Revenue Codes added to edit I-359 in July 2015 **Revenue codes reserved for future use by NUBC Revenue Code Listing Below revenue codes must be filed with appropriate CPT and HCPCS codes for Outpatient and ambulatory Surgery UB-04 or 837-Institutional Healthcare Claims.

6 0907 Behavioral Health Treatment/Services 0911 Behavioral Health Treatment/Services 0913 Behavioral Health Treatment/Services 0914 Behavioral Health Treatment/Services 0915 Behavioral Health Treatment/Services 0916 Behavioral Health Treatment/Services 0917 Behavioral Health Treatment/Services 0918 Behavioral Health Treatment/Services 0919 Behavioral Health Treatment/Services 0920 Other Diagnostic Services 0921 Other Diagnostic Services 0922 Other Diagnostic Services 0923 Other Diagnostic Services 0924 Other Diagnostic Services 0929 Other Diagnostic Services 0940 Other Therapeutic Services 0942 Other Therapeutic Services 0943 Other Therapeutic Services 0944 Other Therapeutic Services 0945 Other Therapeutic Services 0949 Other Therapeutic Services 5 *Revenue Codes added to edit I-359 in July 2015 **Revenue codes reserved for future use by NUBC