Description
This policy outlines the correct coding editing rules adopted and modified to assist in the consistent handling of the claims review and adjudication process.
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Definition
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Unbundling
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Submission of multiple procedure codes for a group of specific procedures that are components of a single comprehensive code.
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Mutually Exclusive Procedures
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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.
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Incidental Procedures
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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.
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Policy
Blue Cross Blue Shield of North Dakota (BCBSND) uses an automated code auditing tool for all medical claims to help expedite and improve the accuracy of claims processing.
BCBSND uses edits to identify claims billed with incorrect coding include but not limited to:
- Unbundling services
- Separate Procedure
- Fragmentation
- Mutually exclusive procedures
- Incidental services
- Duplicate billing
- Obsolete or invalid codes
BCBSND coding edits and rules are based on but are not limited to the following guidelines and resources:
- National Correct Coding Initiative (NCCI) including Medically Unlikely Edits (MUE)
- American Medical Association (AMA)
- American Hospital Association (AHA)
- Healthcare Common Procedure Coding System (HCPCS)
- Current Procedure Terminology (CPT)
- World Health Organization (WHO) ICD-10
- The National Center for Health Statistics (NCHS) ICD-10-CM
- Centers for Medicare & Medicaid Services (CMS) ICD-10-PCS
- National and State Medical Societies and Associations
- BCBSND enhanced clinical editing processes
Similar Codes
When two or more procedure codes represent services considered to be similar in nature to one another, the procedure codes are identified as “similar codes” in BCBSND’s processing system. “Similar codes” are defined as any code(s) that should not be reported with or appended to another code on the same date of service when:
- When there is an AMA CPT parenthetic note indicating, “Do not report (code) in addition to (code).”
- Example: It is not appropriate to bill an obstetrical ultrasound and a non-obstetrical ultrasound on the same date of service.
Note: This is not applicable to UB-04 claims.
Claim Submission of Services Guidelines
Claims must report the most specific Place of Service (POS) code when describing where the patient was physically located when the services were rendered. The POS reported by the physician and other qualified healthcare provider (QHP) should be assigned based on the same setting in which the patient received the service.
Note: This is not applicable to UB-04 claims.
National Correct Coding Initiative (NCCI) Editing
BCBSND follows CMS’ NCCI which focuses on correct coding methodologies through editing to reduce incorrect payment on the following incorrect coding.
Procedure-to-Procedure (PTP) Editing
BCBSND uses the following CMS Quarterly Data files for claim editing:
Claim Type
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CMS Quarterly Date File Used
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Quarterly Effective Date |
Professional Claims
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CMS’ NCCI PTP Quarterly File
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Effective the 1st Day of Each Quarter
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Facility Outpatient Claims Reimbursed through EAPG
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CMS’ 3M NCCI File Editing
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Effective through Quarterly Release of CMS’ 3M File receipt. Health Care News (HCN) article will be submitted notifying of quarterly file release and quarterly effective dates.
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Facility Outpatient Claims not Reimbursed through EAPG
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Compilation of Medicare OCE NCCI PTP quarterly file and Medicare Facility NCCI PTP file.
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Effective through Quarterly Release of CMS’ Optum File receipt. HCN article will be submitted notifying of quarterly file release and effective dates.
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The PTP files contain columns for code pair editing:
- Column 1 - Comprehensive code known as “Code 1” of a code pair
- Column 2 - Mutually exclusive code known as “Code 2” of a code pair. Code 2 is an inherent component of Code 1, as Code 2 is either a bundled, incidental, component, or fragment of Code 1
- Effective Date – Date Code Pair was created
- Deleted Date – Date Code pair was terminated
- Modifier – Contains either a 0, 1, or 9 indicator which identifies if a modifier may be appended to allow separate reimbursement of Code 2
- Indicator 0 – Appending a modifier to Code 2 will not allow separate reimbursement
- Indicator 1 – Appending an appropriate modifier to Code 2 will allow separate reimbursement
- Indicator 9 – It is not applicable to add a modifier to Code 2
- PTP Edit Rationale – Indicates reason for PTP editing
Claims received with both a Code 1 and Code 2 procedure will reject the Code 2 procedure code when the Modifier indicator is 0 or 9, even when a modifier is appended. If the claim contains a valid modifier (e.g. 25, 58, 59, 76, 77, 78, or 91) on the Code 2 procedure and the Modifier indicator is 2, the service will receive separate reimbursement. Providers must reference the Current Procedural Terminology (CPT) Manual for appropriate modifier use for the procedure code billed.
When separate claims are received for the same date of service, one claim containing Code 1 and the other claim containing Code 2 of a code pair; the first claim received will receive reimbursement. The second claim will only receive reimbursement in the below situations.
- Claim two contained a Code 1 of a code pair and the paid claim contained a Code 2 with an appropriate modifier appended and the NCCI file lists the Code 2 with a modifier indicator of 1.
- Claim two contains a Code 2 of a code pair and the paid claim contained a Code 1 with an appropriate modifier appended and the NCCI file lists the Code 2 with a modifier indicator of 1.
- Claim two contains a Code 2 of a code pair and the paid claim contained a Code 2 with an appropriate modifier appended and the NCCI file lists the Code 2 with a modifier indicator of 1.
Medically Unlikely Edits (MUEs)
BCBSND edits procedure code units on professional claims, excluding Home Medical Equipment (HME)/Durable Medical Equipment (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.
- Unit is based on the code’s unit of measurement
- Multiple units of service reported per code are medically likely
- Multiple units assigned for per date of service (DOS) codes are medically likely. DOS codes are usually indicated by words such as each or per
MUE edits are applied to claims based on the values posted by CMS. BCBSND reserves the right to apply MUE edits outside of the CMS values when it is deemed clinically appropriate. A listing of the 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.
MUEs occur in the pre-adjudication phase of processing. If the claim submission does not pass editing due to units submitted being greater than the MUE value for the code, it will be rejected back to the provider.
MUEs are broken into three Medicare Adjudication Indicator (MAI) categories.
MAI
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Description and Guidelines
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1
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Description: Procedure codes with a DOS claim line edit based on standard coding frequencies set by CMS and NCCI.
Guidelines: Providers should append the appropriate modifiers to lines for services provided in excess of the MUE when the service is distinct and separately identifiable (e.g. 25, 58, 59, 76, 77, 78 or 91). If a MUE rejection is received on a procedure code with a MAI of 1, providers should review the medical records and submit a claims adjustment to add a valid modifier only when the documentation supports the service was distinct and separately identifiable.
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2
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Description: Procedure codes with an absolute DOS edit based on correct coding.
Guidelines: Procedure codes with a MAI of “2” have been rigorously reviewed and vetted within CMS and obtain this MAI designation because the unit of service (UOS) on the same DOS in excess of the MUE value would be considered impossible. Codes with this MAI have limitations created by anatomical code designation, NCCI policy, or based on the code descriptors. Due to this, procedure codes with a MUE MAI of 2 will not be overturned if an appeal is submitted.
Example: Reporting more than one unit of service for CPT 94002 " ventilation assist and management . . . initial day" would be invalid as the code description indications the services is a per day code.
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3
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Description: Procedure codes with a per DOS edit based on clinical benchmarks.
Guidelines: Procedure codes billed in excess of the MUE will be rejected. Providers should review the procedure code(s) with the medical records and submit an appeal if the medical record(s) support the service billed and the medical records support a medically reasonable and necessary service.
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Evaluation and Management (E&M) 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.
Scope Edits
BCBSND’s claims processing software makes the following assumptions when determining payment for multiple scope procedures billed on the same date of service:
- A diagnostic scope is always incidental to a surgical scope
- A diagnostic scope with biopsy is always incidental to a surgical scope
- A diagnostic scope with or without biopsy is always incidental to an open surgical procedure in the same area
- A diagnostic scope re-bundles to a diagnostic scope with biopsy unless the code description makes the distinction with biopsy vs. without biopsy
- CPT code descriptions such as complete versus partial, with vs. without, complex vs. simple, etc. means there are two mutually exclusive codes for the procedures
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.
Multiple Evaluation and Management (E&M) Visits Performed by the Same Specialty on the Same Day
If more than one evaluation and management service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported.
Limitations & Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
History