Overview
BlueCross applies code editing rules to evaluate the accuracy and adherence of medical claims to accepted national standards. These rules are based on code editing guidelines such as:
- National Correct Coding Initiative (NCCI)
- Centers for Medicare and Medicaid Services (CMS) guidelines
- American Medical Association (AMA) coding guidelines
- Guidelines published by medical societies/associations such as:
- American Academy of Orthopedic Surgeons (AAOS)
- American College of Obstetricians and Gynecologists (ACOG)
- BlueCross BlueShield of Tennessee clinical expertise
- BlueCross code rules are also based on reimbursement policies such as but not limited to the following:
- Bundled Services Regardless of the Location of Service
- Bundled Services when the Location of Service is the Physician’s Office
- Corneal Topography
- Durable Medical Equipment (Purchase and Rentals)
- Home Pulse Oximetry
- Screening Test for Visual Acuity
- Visual Function Screening
- Quarterly Reimbursement Changes – These reimbursement policies may be viewed in the Commercial Provider Administration Manual and the BlueCare Tennessee Provider Administration Manual.
BlueCross code editing rules will be applied during the claim payment process. Retrospective audits may still be necessary when all associated claims are available for review.
Code editing can occur on multiple levels depending on the combination of codes reported.
BlueCross reserves the right to request supplemental information (e.g. anesthesia record, operative report, medical records, etc.) to determine appropriate application of code bundling rules.
Final reimbursement determinations are based on several factors, including but not limited to, member eligibility on the date of service, medical appropriateness, code edits, applicable member co-payments, coinsurance, deductibles, benefit plan exclusions/limitations, authorization/referral requirements and medical policy/coverage decisions.
CPT® is a registered trademark of the American Medical Association.
Definitions
Comprehensive Code (Column 1)
Generally represents the major procedure or service when reported with another code
Component Code (Column 2)
Generally represents the lesser procedure or service. Reimbursement for a component code is considered included in the reimbursement for the comprehensive code when the service is billed by the same provider for the same patient on the same date of service (i.e., reimbursement for the component code will not be made separately from the comprehensive code).
Retained NCCI
BlueCross edits are based on NCCI logic.
Example: Effective Jan. 1, 2010, the Centers for Medicare and Medicaid Services (CMS) no longer recognize CPT® codes 99241-99245 (office or outpatient consultations) and 99251-99255 (inpatient consultations) under the Medicare Physician’s Fee Schedule.
As a result, CMS termed the edits for these CPT® codes. BlueCross continues to allow providers to bill these consultation codes; therefore, the edits related to these CPT® codes were retained by BlueCross.
