This policy outlines the editing tools and edits adopted and modified to assist in the consistent handling of the claims review and adjudication process.
Blue Cross uses an automated code auditing tool for all medical products to help expedite and improve the accuracy of processing claims on the professional claim.
The types of edits identified through the use of this coding edit application include but are not limited to:
More information on specific edits is found under the policy section.
The Plan coding rules are based on but are not limited to the following guidelines and resources:
Note: The Plan reserves the right to customize coding edits due to mandates and other business reasons
Procedure code unbundling is the submission of multiple procedure codes for a group of specific procedures that are components of a single comprehensive code. Procedure unbundling may occur in one of two ways:
A professional claim could be submitted that has procedure codes for both the individual components, and the procedure code for the comprehensive procedure. Blue Cross would re-bundle the individual component codes into the comprehensive procedure code for payment.
Procedure unbundling could also occur when a professional claim is submitted with only the individual components of the comprehensive code. In this situation, the software will recognize the relationship between the comprehensive code and its individual components. Then, it will automatically add the comprehensive code to the claim and re-bundle the individual components into that comprehensive code for payment.
Mutually Exclusive Procedures
Mutually exclusive procedures exist when a claim is submitted for two or more procedures that are not usually performed on the same patient, on the same date of service. In mutually exclusive relationships, the most clinically intense code is recognized for payment. Clinical intensity is generally based on the total Relative Value Unit (RVU) for the procedures submitted.
Incidental is defined as a procedure carried out at the same time as a primary procedure but is clinically integral to the performance of the primary procedure, and therefore, should not be reimbursed separately.
Medically Unlikely Edits
Blue Cross edits procedure code units on outpatient and professional claims, excluding HME/DME, through MUEs. The number of units for codes that qualify for submission of multiple units may be subject to limits.
MUEs will ensure the following elements are valid and medically likely based on the procedure code submitted.
MUEs occur in the pre-adjudication phase of processing. If the claim submission does not pass (or fails for greater than one unit per day) it will stop and be rejected back to the provider.
MUE edits are applied to claims based on the values posted by CMS. The Plan reserves the right to apply MUE edits outside of the CMS values when it is deemed clinically appropriate. A listing of the Plan’s Professional (codes submitted on a CMS-1500 Claim Form) MUEs that differ from the CMS values can be located on the Medically Unlikely Edits Revisions Addendum.
Medical Visits on the Same Day as Surgery
Related E/M services are not reimbursed separately when submitted with a procedure performed on the same day, as this is package to the surgical procedure. Modifiers may be appended to the E/M service(s) that are not related to the surgical procedure. Please refer to the current year’s CPT manual for E/M services and surgery guidelines.
Some of the related CPT modifiers would include:
-24 unrelated E/M service by the same physician during a postoperative period
-25 significant, separately identifiable E/M service by the same physician on the day of a procedure or other service
Providers should add these modifiers when a patient’s condition requires a significant, separately identifiable service above and beyond the usual care associated with the procedure.
Global Surgical Package – Pre- and Post- Operative
As defined by CPT, the surgical “package” includes the surgical operation, local infiltration, metacarpal/digital block or topical anesthesia when used, and the normal, uncomplicated follow-up care visits. These services, when billed in addition to surgery, are denied as included in the surgical allowance. The surgical package includes all normal and uncomplicated care including pre- and postoperative visits as part of the reimbursement for the surgical procedure. Preoperative visits are defined as visits by the surgeon or another practitioner in the same practice on the day of a surgery for minor procedures and the day before or day of major surgical procedures.
Blue Cross does not consider new patient codes exceptions to the package. A new patient is not reason alone to exclude the visit from the global package. Blue Cross follows the same postoperative timeframes associated with surgical procedures as CMS, which are 10 or 90 days. Postoperative timeframes can be found in the Federal Register. Routine postoperative medical visits rendered within the postoperative timeframe and related to the surgery will not be recognized for separate reimbursement as an unbundled component of the total surgical package.
Modifiers -55 and -56
Used to report pre- and postoperative care rendered for surgical procedures.
Used to indicate that the E/M service resulted in the initial decision to perform surgery either the day before a major surgery (90 day global) or the day of a major procedure.
Our coding software makes the following assumptions when determining payment for multiple scope procedures billed on the same date of service:
Medical and Surgical Supplies
Medical and surgical supplies used during an outpatient or physician office visit are included as incidental to the E/M service or procedure performed and will not be separately reimbursed.
The Plan applies the ICD-10-CM Excludes 1 and Excludes 2 guidelines in its claim’s adjudication process. Definitions are as follows:
An Excludes 1 note is a “pure” excludes. It means “Not Coded Here.” An Excludes 1 note indicates that the code excluded should never be used at the same time as the code above the Excludes 1 note. An Excludes 1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. The code excluded should never be reported with the applicable codes listed above the excludes notation.
An Excludes 2 note represents “Not Included Here”. An Excludes 2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes 2 note appears under a code, it may be acceptable to use both the code and the excluded code together if supported by medical documentation.
Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.