Outpatient facility claim update: correct coding/code-editing to be applied
Horizon BCBSNJ continually looks for ways to make our claims processes more efficient and up to date, so that is easier for you to do business with us.
Beginning January 22, 2021, Horizon BCBSNJ will change the way we process certain outpatient facility claims to help ensure that the codes submitted are 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).
Beginning January 22, 2021, Horizon BCBSNJ will apply the claim-editing guidelines listed in the table below to outpatient facility claims submitted for services provided to patients enrolled in:
- Horizon BCBSNJ insured commercial plans
- Horizon BCBSNJ and Braven HealthSM Medicare Advantage plans
- Administrative Services Only (ASO) employer group plans that have opted-in to these guidelines, including the State Health Benefits Program/School Employees’ Health Benefits Program (SHBP/SEHBP)
| Category | Guideline | Action |
|---|---|---|
| CMS Coverage Policies | Services Not Recognized by Medicare | Deny CMS defined Services Not Recognized by Medicare when billed with Bill Type 0120-012Z, 0130-013Z or 0140-014Z. |
| Device and Supply | Implant Procedure Requires Implant Device | Deny a device-dependent procedure when billed without any qualifying device code based on CMS guidelines. |
| Maximum Units | Daily Max Units (Regardless of Modifier) | Deny excess units when any provider bills more than one unit of service for certain procedures regardless of appended modifier and with the same revenue code. |
| Maximum Units for Modifier 52 or 73 | Adjust units and deny multiple lines of the same CPT code to allow only one unit of service for any procedure code billed with Bill Type 0120-012Z (Hospital-inpatient), 0130-013Z (Outpatient Hospital), 0140-014Z (Hospital-laboratory services provided to non-patients), or 0830-083Z (Ambulatory Surgical Center), and modifier 52 or 73 is appended (CMS 1450). | |
| Maximum Units Per Day for Outpatient Hospitals | Deny excess units when any provider bills a certain number of units that exceed the daily assigned allowable unit(s) for that procedure for the same member. | |
| Observation Services | Bill Types | Deny observation services if billed with a bill type other than 13X or 85X. |
| Place of Service | Outpatient Radiology Services | Deny 70010-79999 (Radiology services) when billed with Bill Type 0140-014Z (Hospital-laboratory services to non-patients). |
| Revenue Code | Blood Products, Storage and Processing | Deny P9010-P9040, P9043, P9044, P9048, P9051-P9060, P9070-P9071, P9073 (Blood product) when billed with Revenue Code 0380-0389 and the same blood product code has not been billed with Revenue Code 0390-0399. |
| Emergency Room Services and EMTALA Screening | Deny Revenue Code 0452 when billed without Revenue Code 0451. | |
| Revenue Code-HCPCS Code Links | Deny the claim line when the revenue code is 0278 (Other implants) and the HCPCS code does not match. | |
| Revenue Code-HCPCS Code Links | Deny the claim line when the revenue code is 0636 (Drugs requiring detailed coding) and the HCPCS code does not match. | |
| Room and Board | Deny Room and Board revenue codes when billed in an outpatient hospital setting. | |
| Therapy Services Modifiers GN, GO and GP | Deny occupational therapy revenue codes (0430-0439) when billed without the appropriate therapy service modifier (GO). |
The coding and code-editing guidelines to be implemented will not impact claims submitted for services provided to patients enrolled in the following programs/plans/products:
- BlueCard® (please contact the member’s local BCBS Plan regarding requirements)
- Federal Employee Program® (FEP®)
- Horizon NJ Health plans (Medicaid Managed Care, NJ FamilyCare, Horizon NJ TotalCare (HMO D-SNP), Managed Long Term Services & Supports program)
If the coding on claims submitted on and after January 22, 2021 is incorrect or submitted in error, you may submit a corrected claim.
You also have the right to submit medical record documentation that validates your claim submission as part of an appeal of a specific claim payment determination. To do so, please complete a copy of the New Jersey Department of Banking and Insurance’s (DOBI) required form, Application to Appeal a Claims Determination. Mail completed claim forms along with medical record information that support your rationale for appeal to:
Appeals Department
PO Box 10129
Newark, NJ 07101-3129
If you have questions, please call Institutional Services at 1-888-666-2535, weekdays, between 8 a.m. and 5 p.m., Eastern Time.
CPT® is a registered mark of the American Medical Association.
BlueCard® and the Federal Employee Program® and FEP® names are registered marks of the Blue Cross and Blue Shield Association. Products are provided by Horizon Insurance Company and/or Horizon NJ Health. Communications are issued by Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for all its companies. Both are independent licensees of the Blue Cross and Blue Shield Association.