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
Practitioners in Group Practice
Practitioners in the same group practice, who are in the same specialty, must bill and be reimbursed as though they were a single practitioner. If more than one service is provided on the same day to the same patient by the same practitioner or by another practitioner within the group with the same specialty, the services must be reviewed as if a single practitioner rendered the services. In this situation, providers must follow NCCI Coding rules to ensure appropriate billing and coding is appended. Providers should refer to the current year’s CPT and HCPCS manual for additional coding guidelines.
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. The Medicaid NCCI program includes 2 types of edits: NCCI Procedure-to-Procedure (PTP) edits and Medically Unlikely Edits. Medicare add-on Code (AOC) Edits will apply to Medicaid Expansion claims.
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 (PTP) Editing
PTP code pair edits are automated prepayment edits that prevent improper payment when certain codes are reported together. Each edit has a Column One and Column Two HCPCS/CPT code. If a provider reports the two codes of an edit pair for the same member on the same date of service, the Column One code is eligible for payment, but the Column Two code is denied or offset unless a clinically appropriate NCCI PTP-associated modifier is also reported.
PTP Code Pair Tables
The Column 1/Column 2 Correct Coding edit tables contain PTP code pairs. The indicator 0 or 1 shows whether a Medicaidn NCCI PTP associated modifier allows the PTP code pair to bypass the edit. The following Modifier Indicators Table provides a definition of each of these indicators.
