This policy outlines the Medicaid Expansion correct coding editing rules adopted and modified to assist in the consistent handling of the claims review and adjudication process. This policy applies to claims with a Date of Service (DOS) on or after 07/01/2022.

Definition

Add-On Code (AOC)

Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code that describes a service that, with rare exception, is performed in conjunction with another primary service by the same practitioner.

Incidental Procedures

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 (MUE)

Represents the maximum units of service that would be reported under a HCPCS/CPT code in most circumstances for a single patient on a single date of service.

Note: Not all HCPCS/CPT codes have an MUE value.

Procedure-to-Procedure (PTP)

PTP code pair edits are automated prepayment edits that prevent improper payment when certain codes are submitted together.

Scope Edits

Claims processing software identifies when multiple scope procedures are billed with one or more scope procedures being incidental, similar, mutually exclusive or unbundled to another scope procedure.

Similar Code

When two or more procedure codes represent services considered to be similar in nature to one another. Any code(s) that should not be reported with or appended to another code on the same date of service.

Unbundling

Submission of multiple procedure codes for a group of specific procedures that are components of a single comprehensive code.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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. 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

1^st Day of Each Quarter

Durable Medical Equipment (DME)

DME Services

1^st 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.

PTP Modifier Indicator

Description

(Not Allowed)

No modifiers associated with NCCI allow you to use this PTP code pair. When no modifiers are allowed, only the Column 1 code will be paid for the same patient on the same day.

(Allowed)

Use the NCCI-associated modifiers with this PTP code pair; when appropriate

(Not Applicable)

This indicator is used for all code pairs that have a deletion date that is the same as the effective date. There’s no active edit for this PTP code pair.

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 1, the service will receive separate reimbursement. Providers must reference the CPT Manual for appropriate modifier use for the procedure code billed.

Note: Providers should check CMS Medicaid NCCI Policy information to ensure adding a modifier is appropriate for their specific situation, as this information may outline when a modifier is not acceptable and why.

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.

Medically Unlikely Edits

MUE edits are applied to claims based on the values posted by Medicaid. The number of units for codes that qualify for submission of multiple units may be subject to limits. MUEs are coding edits, not medical necessity edits.

A claim line billed over the Medicaid MUE value will result in the entire line rejecting. However, if services are rendered in excess of the MUE value and are deemed medically appropriate then the services must be billed as follows:

Divide the Units of Service (UOS) by the MUE value to indicate the number of claim lines to be billed.
Append appropriate modifier(s) to any additional claim lines.

Note: An MUE value of “0” is not reimbursable and will be rejected.

Add-on Codes

Add-on codes (AOC) describe additional intra-service work associated with the primary procedure or service. The CPT Manual identifies AOCs with a “+” symbol and includes a comprehensive list of all the CPT AOCs in Appendix D. AOCs can also be identified by specific language in the code descriptor, such as “each additional” or “(List separately in addition to primary procedure)”. HCPCS codes do not identify AOCs with the “+” symbol but must be identified entirely on the basis of the specific phrases included in the code description nomenclature.

AOCs must be reported in conjunction with an appropriate primary code by the same billing provider on the same date of service. If the primary code is submitted with a date of service spanning more than one day the AOC will be rejected. AOCs should never be reported as a stand-alone procedure or service. AOCs are exempt from the multiple procedure concept, and therefore, modifier 51 cannot be appended.

The one exception to this is, BCBSND recognizes vaginal delivery may span over multiple days. Due to this BCBSND, allows the following codes to be billed on the same date of service or one day after the parent code’s date of service 01967 [Neuraxial labor analgesia/anesthesia for planned vaginal delivery]:

01968 [Anesthesia for cesarean delivery following neuraxial labor analgesia/anesthesia]
01969 [Anesthesia for cesarean hysterectomy following neuraxial labor analgesia/anesthesia]

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.

Note: Similar Codes are identified within the Current AMA CPT Manual indicating: “Do not report (code) in addition to (code)”

Limitations & Exclusions

While reimbursement is considered, payment determination is subject to, but not limited to:

Medicaid Expansion Program
Provider Participation Agreement
Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits 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

Date

Updates

4/25/2022

Policy created

4/26/2023

Annual review performed on policy. Corrected a statement from “A claim that contains a valid modifier on the Code 2 procedure and the Modifier indicator is 2, the service will receive separate reimbursement.” to “A claim that contains a valid modifier on the Code 2 procedure and the Modifier indicator is 1, the service will receive separate reimbursement.” and added a note for providers to check CMS Medicaid NCCI information for further information on when a modifier is/isn’t appropriate.

6/27/2023

Updated the policy number from NDRP-GC-027 to NDRP-GC-030. Added information about 99417, 99358 & 99359 not being allowed to be billed on Medicaid claims processed on or after 9/1/2023.

4/3/2024

Annual review completed. Changed policy title from Correct Coding Guidelines to Correct Coding Policy, added legal disclaimer “All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.” under new Policy Application section, added “to be reviewed for” to instances of “to allow” and “will allow”, changed “Revised Date:” to “Revision Effective Date:” and added 76, 77 & 91 (Repeat and Duplicate Services) guidelines to the Cross References section. Added Add-on code section, updated table of contents and dates.

8/13/2024

Some format changes made, updated verbiage, added PTP Code Pair Table, removed Evaluation and Management (E/M) Services section as this information will be called out in the new Evaluation and Management (E/M) policy once completed, and removed Scope Edits section as this information can be found in our Multiple Procedures Payment Reduction for Medical and Surgical Services reimbursement policy. Added additional Cross References.

Disclaimer

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.

Our Partners in Health:
Members
Employers
Producers

Fargo (Headquarters)
4510 13th Ave. S.
Fargo, N.D., 58121

Medical Policies Quick Search

Correct Coding Policy - Medicaid Expansion

Contents

Description

Policy Application

Policy

National Correct Coding Initiative (NCCI) Editing

Procedure-to-Procedure (PTP) Editing

PTP Code Pair Tables

Medically Unlikely Edits

Add-on Codes

Similar Codes

Limitations & Exclusions

Cross References

History

Disclaimer