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Claim Coding Alert: Emergency Spine Surgery Services

Horizon Blue Cross Blue Shield of New Jersey is aware of an issue that is impacting our ability to process professional claims for certain spine surgery services performed on an inpatient basis. This affects certain Horizon BCBSNJ patients¹ who are admitted to the hospital through the Emergency Room (ER).

Based on our Musculoskeletal Program for Spine Surgery claim processing logic, professional claims that include certain spine surgery procedures (those included as part of this program) will be denied if an approved Prior Authorization/Medical Necessity Determination (PA/MND) does not exist in eviCore healthcare’s files.

Coding Elements to Include on Emergency Spine Surgery Claims
To prevent unnecessary denials of claims, please include one of the following coding elements on your CMS1500 claim submission or 837P transaction to indicate that the patient in question was admitted to the hospital through the ER.

  • Append modifier ET to the spine surgery services on the claim submission/transaction, or
  • Include HCPCS code G9752 on a separate bill line of the claim/transaction.

By including one of the above noted coding elements on spine surgery claims provided to certain Horizon BCBSNJ patients¹, eviCore healthcare will know to review the emergent inpatient stay authorization and process the claim accordingly.

Claims/transactions for inpatient spine surgery services performed on impacted patients¹ who are admitted through the ER and that do not include one of these coding elements will be denied by eviCore healthcare.

If you have questions, please contact your Network Specialist.

¹ Horizon BCBSNJ collaborates with eviCore healthcare to conduct PA/MND for certain Spine Surgery services (the “Program”) for members enrolled in Horizon BCBSNJ fully insured products, as well as, ASO accounts that have elected the Program.

Published on: May 10, 2018, 14:22 PM ET
Last updated on: May 10, 2018, 14:25 PM ET