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Claim Editing Update: MUEs for Professional Medicare Advantage Claims

Effective November 6, 2017, Horizon Blue Cross Blue Shield of New Jersey will update the population of HCPCS/CPT codes for which we apply certain claim-editing rules when processing professional claims for services provided to members enrolled in Horizon BCBSNJ Medicare Advantage (MA) plans (“Members”).

Horizon BCBSNJ employs guidelines from different sources to help ensure that our code and claim editing rules are accurate and consistent with standard business practice:

  • We work with Change Healthcare (formerly McKesson), and use Change Healthcare’s ClaimsXten, a clinically based claims-editing solution.
  • We also follow the guidelines of nationally recognized sources, such as the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (CCI), Outpatient Code Editor (OCE), American Medical Association (AMA) Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases Clinical Modification (ICD-CM).

Presently, in the processing of professional claims, we follow Change Healthcare guidelines in regard to the maximum number of units of service allowable for certain HCPCS/CPT codes for services rendered by the same provider for the same Member on the same date of service.

Beginning November 6, 2017, Horizon BCBSNJ will also follow CMS’s Medically Unlikely Edits (MUE) guidelines in the processing of professional claims for services provided to Members on and after November 6, 2017, that include certain HCPCS/CPT codes for which Change Healthcare does not provide guidelines (but for which CMS does)1.

This modification, while it will result in the expansion of the number of HCPCS/CPT codes for which MUEs are considered for Members, will not change the type of claim edits that we have applied in the past. Also, it will not have any impact on the frequency-related claim edits for members enrolled in any other Horizon BCBSNJ (non-MA) plans.

The CMS MUE guidelines we will follow identify claim lines where the MUE has been exceeded for a CPT/HCPCS code with MUE adjudication indicator (MAI) of 1, 2 or 3, reported by the same provider, for the same member, on the same date of service. Date ranges will be evaluated to determine if the MUE has been met or not as part of CMS MUE guidelines.

For more information about MUEs, please visit CMS’s National Correct Coding Initiative Edits page and review the NCCI Policy Manual for Medicare Services, Chapter 1, Section V (Medically Unlikely Edits).

Visit CMS’s Medically Unlikely Edits page to review the HCPCS/CPT codes included on CMS’s Practitioner Services MUE Table.

1 Not all HCPCS/CPT codes have an MUE value.

CPT® is a registered trademark of the American Medical Association.

Published on: August 3, 2017, 10:51 a.m. ET
Last updated on: August 3, 2017, 11:03 a.m. ET