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Correct coding/code-editing to be applied

We help ensure that outpatient facility claims are submitted and processed in accordance with nationally recognized coding and code-editing guidelines. This includes guidelines implemented by the Centers for Medicare & Medicaid Services (CMS), National Correct Coding Initiative (NCCI), Outpatient Code Editor (OCE), American Medical Association (AMA) Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS) and the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM).

Per the guidelines of our new reimbursement policy, Outpatient Facility Code Edits: Bundling and Revenue Codes, Horizon will apply the claim edits in the categories listed below to outpatient claims submitted by hospitals and ancillary facilities for services provided on and after August 1, 2021.

  1. Bundled Services

Will not be considered for separate reimbursement when submitted on outpatient claims. These codes will not be considered for separate reimbursement if they are the only services billed for a date of service or if they are billed with other services for the same date of service.

  1. Typically packaged codes

May not be considered for separate reimbursement when submitted on outpatient claims if other non-laboratory procedure codes are billed for the same date of service. These codes will only be considered for separate reimbursement if they are the only services billed for a date of service or if they are billed with clinically unrelated services for the same date of service.

  1. Lab codes when billed with other services

May not be considered for separate reimbursement when submitted on outpatient claims if other non-laboratory procedure codes are billed for the same date of service. These codes will only be considered for separate reimbursement if they are the only services billed for a date of service or if they are billed ONLY with other laboratory procedure codes for the same date of service.

  1. Revenue codes require HCPCS code

These revenue codes will only be considered for reimbursement on outpatient claims if billed with appropriate HCPCS code(s).

If the coding on claims submitted on or after August 1, 2021 is incorrect or submitted in error, you may submit a corrected claim. Horizon reserves the right to adjust claims for outpatient services provided on and after August 1, 2021 that are not processed according to these claim editing guidelines.

This applies to patients enrolled in fully insured commercial, Medicare Advantage (including Braven Health℠ and Administrative Services Only (ASO) employer group plans that have opted into these guidelines, including the SHBP/SEHBP.

We encourage you to review the guidelines and claim editing details included in our Outpatient Facility Code Edits: Bundling and Revenue Codes reimbursement policy at HorizonBlue.com/reimburse.

Published on: July 1, 2021, 12:19 p.m. ET
Last updated on: June 30, 2021, 01:22 a.m. ET