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Correct Coding Update: Other Medical and Surgical Services during a Postoperative Period

Horizon Blue Cross Blue Shield of New Jersey continues to enhance our claim auditing for professional claims.

Effective February 1, 2020, Horizon BCBSNJ will update our claim auditing to systemically process professional claims for certain medical and surgical services in accordance with the Centers for Medicare & Medicaid Services (CMS), National Correct Coding Initiative (NCCI) guidelines noted below.

Other Medical and Surgical Services during a Postoperative Period

  • Deny 0-, 10- or 90-day surgical procedures performed within 90 days of a 90-day surgical procedure.
  • Deny separate reimbursement for services typically considered part of a minor 10-day surgical procedure. Deny 0-day and 10-day surgical procedures performed within 10 postoperative days of a 10-day procedure.
  • Deny separate reimbursement for services typically considered part of a major 90-day surgical procedure.
  • Deny 0-day and 10-day surgical procedures performed within 10 postoperative days of a 10-day surgical procedure when submitted by the same Provider ID, regardless of Tax ID and specialty.
  • Deny 0-, 10- or 90-day surgical procedures billed by the same Provider ID, regardless of Tax ID and specialty within 90 days of a 90-day surgical procedure.

These guidelines will apply to claims finalized February 1, 2020 and after for services rendered to:

  • Patients enrolled in Horizon BCBSNJ fully insured plans for all dates of service.
  • Patients enrolled in New Jersey State Health Benefits Program/School Employees Health Benefits Program (SHBP/SEHBP) plans for dates of service January 1, 2020 and after.

If you have any questions, call Physician Services at 1-800-624-1110, Monday through Friday, between 8 a.m. and 5 p.m., Eastern Time.

The NCCI guidelines above were included as part of claim adjustment efforts designed to ensure that history claims were processed in accordance with nationally recognized coding and code-editing guidelines. Claim adjustments were announced within the News and Legal Notices section of our website on September 14, 2017, January 5, 2018, September 21, 2018, and September 10, 2019.

Published on: December 30, 2019, 08:00 a.m. ET
Last updated on: December 30, 2019, 07:30 a.m. ET