Policy
Blue Cross Blue Shield of North Dakota (BCBSND) uses an automated code auditing tool for all medical claims to expedite and improve the accuracy of claims processing.
BCBSND uses edits to identify claims billed with incorrect coding include but not limited to:
- Duplicate Billing
- Fragmentation
- Incidental Services
- Mutually Exclusive Procedures
- Obsolete or Invalid Codes
- Separate Procedure
- Unbundling Services
BCBSND coding edits and rules are based on but are not limited to the following resources:
- American Hospital Association (AHA)
- American Medical Association (AMA)
- BCBSND Enhanced Clinical Editing Processes
- Centers for Medicare & Medicaid Services (CMS) ICD-10-PCS
- Current Procedure Terminology (CPT)
- Healthcare Common Procedure Coding System (HCPCS)
- Medicaid Enterprise Systems (MES)
- Medicaid National Correct Coding Initiative (NCCI) including Medically Unlikely Edits (MUE)
- National & State Medical Societies and Associations
- The National Center for Health Statistics (NCHS) ICD-10-CM
- World Health Organization (WHO) ICD-10
National Correct Coding Initiative (NCCI) Editing
BCBSND follows the Medicaid CMS NCCI editing for Medicaid Expansion claims which focuses on correct coding methodologies and prevent improper reimbursement. NCCI edits dictate that when two related procedure codes are billed for the same member, by the same provider and on the same date of service, only the most comprehensive of those codes is reimbursable. Therefore, physicians should not report multiple CPT codes when a single, more comprehensive code represents all the services performed.
The table below indicates the Medicaid NCCI PTP and MUE edits data files that should be referenced depending on the claim type as well as the effective date for each quarterly update.
Claim Type
|
Medicaid NCCI PTP & MUE Edits Data File Used
|
Effective Date
|
Professional
|
Practitioner Services
|
1st Day of Each Quarter
|
Durable Medical Equipment (DME)
|
DME Services
|
1st Day of Each Quarter
|
Ambulatory Surgical Center (ASC)
|
Practitioner Services
|
Effective through Quarterly
3M Release
|
Outpatient
Enhanced Ambulatory Patient Group (EAPG)
|
Outpatient Hospital Services
|
Effective through Quarterly
3M Release
|
Outpatient
Non EAPG
|
Outpatient Hospital Services
|
Effective through Quarterly
Optum Release
|
Procedure-to-Procedure Editing
The Column One/Column Two Correct Coding Edits tables include code pairs that should not be reported together for any of these reasons:
- Anesthesia service included in surgical procedure
- CPT "separate procedure" definition
- CPT Manual or CMS manual coding instructions
- Gender-specific (formerly Designation of sex) procedures
- HCPCS/CPT procedure code definition
- Laboratory panel
- Misuse of column two code with column one code
- More extensive procedure
- Mutually exclusive procedures
- Sequential procedure
- Standard preparation / monitoring services for anesthesia
- Standards of medical / surgical practice
PTP Code Pair Tables
- 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 on the Code 2 procedure and the Modifier indicator is 2, the service will receive separate reimbursement. Providers must reference the 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 with an appropriate modifier and the paid claim contained a Code without a modifier appended and the NCCI file lists the Code 2 with a modifier indicator of 1.
