ClaimsXten Editing Rules

Reimbursement Policy:
ClaimsXten Editing Rules

Effective Date:
December 10, 2010

Last Revised Date:
August 30, 2017

Purpose:
The purpose of this policy is to provide an overview of the processes and procedures involved in our use of Change Healthcare’s (formerly McKesson’s) clinically based claims editing solution, ClaimsXten® (CXT), to help ensure that our code and claim editing rules are accurate and consistent with standard business practices and enables us to process claims efficiently and provide accurate reimbursement.

Scope:
All products are included, except:

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
  • ITS Host Medicare Advantage (non-PPO)
  • ITS Host Medicare Advantage PPO non-Par

All Insured and Administrative Services Only (ASO) accounts are included.

Definitions:

Editing - The practice by which one or more rule recommendations are made to Current Procedural Terminology (CPT®) codes or HCPCS Level II codes included in a claim that result in:

  • Reimbursement being made based on some, but not all, of the CPT/HCPCS codes included in the claim.
  • Reimbursement being made based on different CPT/HCPCS codes than those included in the claim
  • Reimbursement for one or more of the CPT/HCPCS codes included in the claim being decreased by application of multiple procedure logic.
  • Reimbursement for one or more of the CPT/HCPCS codes being denied, or any combination of the above.

History Editing - ClaimsXten is able to identify previously submitted claims within our claim processing system’s claim history that may be related to new claim submissions and that may result in adjustments to previously processed claims.

Example: An E&M service is submitted on a claim and then a surgery for the same service date is submitted on a different claim for the same member by the same provider. If a determination that the reimbursement for the E&M service paid in history is considered to be included in the reimbursement for the surgery, then an adjustment of the E&M claim will be necessary, and this may result in an overpayment recovery.

This history editing capability allows Horizon BCBSNJ to systemically adjudicate claims based on the guidelines of our reimbursement policies including, but not limited to, global surgery, multiple visits per day, pre/post-operative visits, new patient visits, frequency rules, incidental, mutually exclusive and rebundle edits, and maternity services. This systemic adjudication may result in previously processed claims being adjusted if a related claim triggers history edits.

Significant Edit - An edit that Horizon BCBSNJ reasonably believes will cause the denial or reduction in payment for a particular CPT Code or HCPCS Level II Code more than two-hundred and fifty (250) times per year on the initial review of submitted claims. A list of Horizon BCBSNJ's Significant Claim Edits is available online.

Policy:
ClaimsXten allows Horizon BCBSNJ to utilize the software's clinical and rules-based logic to:

  • Assess provider claims information including CPT/HCPCS procedure codes against a series of edit programs.
  • Assess claims information, including CPT and Health Care Common Procedure Coding System (HCPCS) service codes to detect coding irregularities, conflicts or errors.
  • Recommend CPT/HCPCS procedure code combinations.
  • Implement Horizon BCBSNJ’s coding guidelines, Coverage Policies, and Reimbursement Policies.
  • Put into practice the Centers for Medicare & Medicaid Services (CMS) coding and modifier guidelines and the National Correct Coding Initiative (NCCI) Incidental and Mutually Exclusive edits.
  • The edits that are associated with a rule causes an audit action on a claim that directs how procedure codes and procedure code combinations will be adjudicated.
  • The edits associated with the ClaimsXten rules identify, for example and without limitation: age and gender specific procedures; duplicate codes; incidental procedures; unbundled/rebundled procedures; mutually exclusive and/or redundant procedures; place, time and type of service requirements; incorrect coding of specific codes; service utilization requirements, such as the administration of anesthesia and/or use of an assistant surgeon; and services integrally related to a surgery (global surgery). A list and description of ClaimsXten claims editing rules and guidelines that have been adopted by Horizon BCBSNJ and the associated edits thereto can be found in Section III below.
  • ClaimsXten incorporates coding edits and rules derived from a number of sources including, but not limited to, the CMS, NCCI, American Medical Association Complete Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS®), American Society of Anesthesiology (ASA), coding guidelines developed by national medical specialty societies, input from Change Healthcare physician consultants, and Horizon BCBSNJ’s guidelines.
  • The edits associated with the ClaimsXten rules will be applied to all professional claims. Select edits will also be applied to Non-Inpatient Facility (UB) claims.
  • Horizon BCBSNJ reserves the right to make customizations to its ClaimsXten software tool. Horizon BCBSNJ will communicate and publish any such significant customizations prior to their implementation.

Procedure:

A. Documentation and Reporting

Providers are responsible for determining the most appropriate CPT and/or HCPCS codes, applicable modifiers, as appropriate, and ICD-9 or ICD-10 Diagnosis codes for the health care supplies or services they provide. The code(s) and modifier(s) must be valid for the dates of service reported, and describe the services provided. All claims submitted by a provider must be in accordance with the reporting guidelines and instructions contained in the AMA CPT Manual, “CPT® Assistant,” HCPCS, and ICD-9-CM (or ICD-10 when applicable) publications.

  • The member’s medical records must support the services described by the reported CPT/HCPCS code.
  • Horizon BCBSNJ reserves the right to perform audits or investigations to confirm appropriate billing of services provided to our members.
  • If a ClaimsXten denial related to one of the rules listed below is received on an Explanation of Payment/voucher, it is recommended that the billing provider review the originally submitted claim information prior to initiating an appeal. If a coding error is detected, we ask that the appropriate corrected claim information be submitted.

B. Updates

ClaimsXten will be updated on a quarterly basis. In addition to adding new CPT codes, HCPCS codes, and NCCI edits, Change Healthcare also adds or revises claim editing information based on their ongoing review of the entire knowledge base. This ongoing process helps to ensure that the default clinical content used in ClaimsXten is clinically appropriate and withstands the scrutiny of both payers and providers.

  • The effective dates for any edits based on a change in the use of a CPT code, HCPCS code, or modifier by AMA or CMS, or other similar organization, shall be 30 days’ after providers are notified of such change(s) and shall apply to all claims with dates of service on and after the effective date. In the event of the introduction of, or discontinuance of, a code or edit, Horizon BCBSNJ reserves the right to provide shorter notification, if at all. In these circumstances, the effective date(s) shall be reviewed with Horizon BCBSNJ’s Legal Department.
  • Updates may also reflect the addition of new/revised Horizon BCBSNJ associated edits and changes including those pertaining to a Horizon BCBSNJ vendor or business partner, that are identified through Horizon BCBSNJ’s regular review or due to inquiry. Additionally, these updates may include edits associated with specific Horizon BCBSNJ reimbursement policies. If these are determined, upon our review to be material adverse changes, Horizon BCBSNJ shall provide 90 days’ advance notice prior to the implementation of changes that may adversely impact the processing of claims with dates of service on or after the effective date.

C. ClaimsXten Rules

Most ClaimsXten rules utilize “same provider” editing which result in the denial of separate reimbursement being provided for services rendered on the same day or across dates of service by the same provider. This editing identifies “same provider” as any provider billing with the same group tax identification (TIN) number [and/or by individual provider ID number]. Rules that audit across different providers will indicate such.

The following is a list of ClaimsXten rules adopted by Horizon BCBSNJ. This list, subject to change or revision, is not a comprehensive list of all Horizon BCBSNJ claim edits, but rather those implemented via CXT. Reference to more specific Horizon BCBSNJ reimbursement policy, where applicable, is indicated.

Age and Gender-Specific Codes Rule: This claim editing logic identify when an age specific procedure code is reported for a patient whose age falls outside the designated age range, or when a gender-specific procedure and/or diagnosis code is submitted for a patient of the opposite sex. Age and Gender designations are assigned to select codes based on code descriptions or on publications and guidelines from sources such as professional specialty societies, CMS and the AMA.

When an age or gender inconsistency is identified on a claim, the code(s) in question will be denied. Where an appropriate replacement procedure code exists, the inappropriate procedure code will be denied and a new claim line with the appropriate procedure code may be added to the claim and processed accordingly.

Sourcing: AMA, CMS Integrated Outpatient Code Editor (I/OCE), Medicare Code Editor (MCE)
Application: Professional and Non-Inpatient Facility claims.

Anesthesia Crosswalk Rules: All anesthesia services should be submitted using appropriate ASA (American Society of Anesthesiologists) procedure codes. Non-ASA procedure codes submitted will be denied.

If there is a one-to-one crosswalk between a submitted non-ASA anesthesia procedure code and an ASA procedure code, the non-ASA procedure code will be denied and a new claim line with the appropriate ASA procedure code will be added to the claim and processed accordingly.

If multiple ASA procedure codes exist for the non-ASA procedure, the appropriate ASA procedure code must be resubmitted.

If the non-ASA anesthesia procedure code is not eligible to be cross walked to an ASA procedure code, it will be denied and it cannot be resubmitted.

Certain non-anesthesia services, when rendered by anesthesiologists, are excluded from this rule including, but not limited to, pain management and insertion of arterial lines when the anesthesiologist is performing the service.

Sourcing: American Society of Anesthesiologists
Application: Professional claims

Assistant Surgeon/Assistant at Surgery Rule: In accordance with Horizon BCBSNJ’sAssistants at Surgery policy, ClaimsXten identifies procedure codes appended with an assistant surgeon modifier (80, 81, 82, AS) that do not typically require an assistant surgeon. Determination of eligibility will be made based on the following.

We follow the American College of Surgeons (ACS) “Always Pay/Never Pay” guidelines.

If the ACS guideline is “Sometimes Pay,” we refer to CMS “Always Pay/Never Pay” guidelines.

If the CMS guideline is also “Sometimes Pay,” Change Healthcare logic (based on analysis of clinical necessity regarding the use of an assistant surgeon) or a Horizon BCBSNJ Medical Director will make the determination as to whether reimbursement will be allowed for the assistant surgeon by ClaimsXten.

Note: The number of instances when a code will default to Change Healthcare’s logic will be very few.

Sourcing: American College of Surgeons (ACS), CMS, Change Healthcare Clinical Review
Application: Professional claims

Base Code Quantity Rule: The claim editing logic within this rule identifies claim lines where a primary service/procedure with a quantity greater than one is submitted, rather than the submission of that primary service procedure with appropriate add-on (“each additional”) code(s). In such situations, the claim line item with the base code quantity greater than one will be denied and replaced with a line item with a quantity of one.

This rule also identifies multiple occurrences of a base code reported on separate claim lines or on separate claims. Additional base code line item(s) or claims will be denied. Services performed in conjunction with the primary procedure should be submitted using the appropriate add-on codes.

Sourcing: AMA, CMS
Application: Professional claims

Add-on code without Base Code Rule: The claim editing logic within this rule will identify add-on procedure codes (those codes denoted with a “+” that can be found in Appendix D in the CPT manual) that are submitted without the related primary service/procedure (base code).

Add-on codes submitted without the base code will be denied. In addition, Add-on codes will be denied if the corresponding base code is denied. Add-on codes must be submitted on the same claim as the parent or base procedure code. This rule also audits that vaccine supply and immune globulin supply codes are submitted with the associated administration procedure code as required by CPT guidelines.

Sourcing: AMA
Application: Professional claims

Bundled Services and Supplies Rule: This claim editing logic identifies certain services and supplies that are considered part of the overall care provided and are not eligible for separate reimbursement. Editing for this rule is based on CMS, Change Healthcare and Health Plan sourcing.

Always Bundled Services and Supplies: The claim editing logic within this rule identifies all inclusive procedure and supply codes that are not eligible for reimbursement even if reported alone. The Medicare Physician Fee Schedule Database (MPFSDB), also known as the National Physician Fee Schedule Relative Value File, indicates these procedures/supplies with a status code indicator of “B.” According to the MPFSDB, “payment for covered services is always bundled into payment for other services not specified. …. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident.”

Supplies for Same Day Surgery: Certain supplies used on the same date of service as surgical procedures will be considered included in the allowance for the surgical procedure and will not be considered for reimbursement in addition to that surgical procedure. This includes, but is not limited to, miscellaneous services such as dressing changes, local incision care, removal of sutures, staples, lines, wires, tubes, drains, catheters, casts, other supplies, including surgical trays, or other items considered to be routine post-surgical services and supplies.

Sourcing: CMS with Change Healthcare Clinical Review

Application: Professional claims

Bilateral Billing Rule: This claim editing logic identifies any claim lines where the submitted procedure code was already billed or is subsequently billed with a modifier 50 for that same date of service. A service performed bilaterally should not be billed twice when reimbursement guidelines require the service to be submitted with a single procedure code appended with a bilateral modifier. ClaimsXten identifies the same code billed twice for the same date of service, where the first code has the bilateral modifier appended. This rule denies the second submission of the procedure code in question regardless of whether it is submitted with or without a bilateral modifier.

Sourcing: CMS

Application: Professional claims

Consultations Rule: A consultation is a service delivered by a physician, at the request of another physician, to recommend care for a condition or to decide if the physician is going to accept responsibility for continued management of the patient’s care or for the care of a precise condition. If the consulting physician accepts responsibility of all or part of the patient’s condition, the correct E&M code for the site of service must be reported. A Consultation can be billed only when requested by another physician or appropriate source.

A consultation or second opinion requested by a patient does not meet the CPT definition of a consultation code and should be reported using appropriate E&M codes, not consultation codes.

Outpatient Consultations: This claim editing logic identifies claim lines with codes for Office or other Outpatient Consultations billed within 6 months of another consultation by the same provider that should be billed with the appropriate level of office visit, established patient or subsequent hospital care codes.

Inpatient Consultations: This claim editing logic also identifies claim lines with codes for Inpatient Consultations billed within 5 days of another Inpatient Consultation by the same provider that should be billed with the appropriate level of subsequent hospital care codes.

When ClaimsXten identifies that a previous consultation has been billed within the specified time frames (as noted above), subsequent consultation services will be denied. In such cases, a new claim with the appropriate E&M code(s) must be submitted.

Sourcing: AMA and Change Healthcare Clinical Review

Application: Professional claims

Code and Modifier Validation Rule: This claim editing logic identifies if a code or modifier is valid. If an invalid procedure, diagnosis code, or modifier/procedure code combination is detected, the line item will be denied.

Procedure validation: Editing for procedure code validation uses AMA guidelines as the reference source. All CPT-4 and/or HCPCS codes must be valid for the date of service being submitted.

Diagnosis code validation: All diagnoses codes must be coded to the highest specificity as documented in the most current version of the International Classification of Diseases and be valid for the date of service being submitted. All submitted secondary diagnoses will also be validated. Claims or claim lines that include invalid or incomplete diagnoses codes will be denied.

Modifier to Procedure code validation: Most modifiers apply to a specific group of procedure codes and may only be reported in conjunction with those specified procedure codes. Validation of appropriate procedure code/modifier combinations is based on CPT, CMS and Change Healthcare sourcing.

Sourcing: AMA, CMS, the ICD-10-CM Official Guidelines for Coding and Reporting posted on the NCHS Web site, and Change Healthcare Clinical Review.

Application: Professional claims and non-Inpatient Facility claims

CPAP/BiPAP Supply Frequency Rule: This claim editing logic recommends the denial of claim lines containing supply codes associated with the Continuous Positive Airway Pressure or Bi-level Positive Airway Pressure (CPAP/BiPAP) therapy that are submitted at a frequency that exceeds the usual or customary rate. CXT editing will consider supplies billed by all providers for the same member. Details on specific supplies and frequencies are outlined in our reimbursement policy, Supplies associated with Continuous Positive Airway Pressure or Bi-level Positive Airway Pressure (CPAP/BIPAP). This policy is available online.

Sourcing: CMS Local Coverage Determination Policies were used as guidelines in developing Horizon BCBSNJ’s policy.

Application: Professional claims

Diabetic Supply Frequency Rule: The rule recommends the denial of claim lines containing codes for diabetic supply codes submitted at a frequency that exceeds the usual or customary rate. This rule distinguishes the quantity of supplies necessary for patients who are insulin dependent and those who are non-insulin dependent as well as validates that diagnosis of diabetes is included on claims. CXT editing will consider supplies being billed by all providers for the same member. Detail on specific supplies and frequencies are outlined in our Diabetic Supplies reimbursement policy available online.

Sourcing: CMS Local Coverage Determination Policies were used as guidelines in developing Horizon BCBSNJ’s policy

Application: Professional claims

Frequency/Maximum Occurrences Rule: This claim editing logic identifies and addresses situations where a procedure code - the description of which includes terminology (i.e., Bilateral, Unilateral/Bilateral or Single/Multiple) that does not warrant multiple submissions of that procedure for a single date of service – is submitted for multiple units. CXT editing will also identify when a procedure is submitted multiple times, exceeding the maximum allowance that would be clinically appropriate either more than once per date of service or across dates of service. This includes auditing of non-inpatient facility claims against CMS Medically Unlikely Edits (MUE) values.

ClaimsXten will deny the multiple line items, and may replace claim lines in question with the appropriate number of units or a more comprehensive procedure code. If the appropriate number of units has been exhausted, the claim line will be denied, and no additional claim lines will be added.

In the case of procedures that are allowed with more than one unit per DOS, the line item that exceeds the maximum allowed per date of service will be denied and replaced with a new claim line item showing the appropriate number of units.

This rule contains logic to consider the number of times a procedure or service is performed per site when site-specific processing applies.

Sourcing: AMA, CMS, Change Healthcare Clinical Review

Application: Professional claims and non-Inpatient Facility claims

Laboratory Panel/Multi-code Rebundling Rule: This claim editing logic identifies when some or all codes that are part of a comprehensive multiple component blood test (described in the Laboratory section of the CPT manual) are reported separately. Either the individual codes will be denied and the closest code representing the comprehensive procedure will be added to the claim for reimbursement; or the total amount eligible for reimbursement for the separately reported codes will be adjusted so as not to exceed the maximum allowance for the single comprehensive code.

Sourcing: AMA, CMS, Change Healthcare Clinical Review

Application: Professional claims and non-Inpatient Facility claims

Pay Percent Multiple Surgeries Rule: According to the CMS Carrier’s Manual, Chapter XV, Section 15038.A: When more than one surgical service is performed on the same patient, by the same physician, and on the same day:

The fee schedule amount for a second procedure is 50 percent of the fee schedule amount that would have been otherwise applicable for that procedure; and

The fee schedule amount for each additional procedure is 50 percent of the fee schedule amount that would have been otherwise applicable for that procedure.

The Medicare Fee Schedule Data Base (MFSDB) provides indicators to identify those procedures that are subject to the standard rules governing multiple surgeries. A value of 1, 2 or 3 in the Mult Proc column of the fee schedule indicates that the procedure is subject to payment cutback. In addition, CPT provides guidance on those procedures that are exempt from payment reduction in Appendix D and E of the CPT Manual.

This CXT editing rule incorporates both directives. CXT first checks to see if the procedure is deemed eligible for payment cutback according to CMS. If so, this rule then checks to see if the procedure is considered exempt from cutback according to the CPT Manual.

All procedures that are found to be not-exempt and to be deemed eligible for payment cutback will be grouped by date of service and ranked in descending Relative Value Unit (RVU) order. The procedure with the highest RVU will be considered as the primary procedure and a Pay Percent value of 100% will be assigned. All other procedures will be assigned an appropriate Pay Percent value as described above.

CXT editing occurs across all claims from the same provider. If a claim for a primary procedure is received subsequent to claim(s) already processed for procedures determined to be cut-back, the previously processed claims may be adjusted to apply the appropriate payment cutback.

Claims associated with multiple surgeries performed with an Assistant Surgeon or an Assistant at Surgery will be subject to the same payment cutback determination methods.

Sourcing: AMA, CMS

Application: Professional claims

Pay Percent Multiple Cardiology Rule: The editing of multiple cardiology procedures by CXT follows CMS guidelines for Multiple Procedure Payment Reduction (MPPR). According to the CMS National Physician Fee Schedule Relative Value File:

The MPPR on diagnostic cardiovascular procedures applies when multiple services are furnished by the same physician to the same patient in the same session on the same day. The MPPR on these procedures applies to TC-only services, and to the TC of global services. Full payment is made for the TC service with the highest payment under MPFS. Payment is made at 75 percent for subsequent TC services.

The MPPR will apply to multiple services furnished by physicians in the same group practice, as well as to individual physicians.”

CXT editing identifies procedure codes that are eligible for the Multiple Cardiovascular Procedures reduction, as stated above. Such procedures are defined on CMS MPFSDB, with a value of 6 in the Mult Proc column.

When more than one eligible procedure is submitted for the same provider or same group practice and same date of service, the procedures will be grouped together, then sorted and ranked by RVU. For purposes of sorting and ranking, the TC RVU will be assigned to each claim line (regardless of whether the procedure is submitted as the TC-only service or the global service).

Horizon BCBSNJ will follow CMS guidelines for default logic and not allow modifier 59 to override.

Sourcing: CMS

Application: Professional claims

Pay Percent Multiple Ophthalmology Rule: The editing of multiple ophthalmology procedures by CXT follows CMS guidelines for Multiple Procedure Payment Reduction (MPPR). According to the CMS National Physician Fee Schedule Relative Value File:

The MPPR on diagnostic ophthalmology procedures applies when multiple services are furnished by the same physician to the same patient in the same session on the same day. The MPPR on these procedures applies to TC-only services, and to the TC of global services. Full payment is made for the TC service with the highest payment under MPFS. Payment is made at 80 percent for subsequent TC services.

The MPPR will apply to multiple services furnished by physicians in the same group practice, as well as to individual physicians.”

CXT editing identifies procedure codes that are eligible for the Multiple Ophthalmology Procedures reduction, as stated above. Such procedures are defined on CMS MPFSDB, with a value of 7 in the Mult Proc column.”

When more than one eligible procedure is submitted for the same provider or same group practice and same date of service, the procedures will be grouped together, then sorted and ranked by RVU. For purposes of sorting and ranking, the TC RVU will be assigned to each claim line (regardless of whether the procedure is submitted as the TC-only service or the global service).

The reduced RVU will then be divided by the total RVU to receive a Pay Percent value for the second and subsequent procedure codes.

Sourcing: CMS

Application: Professional claims

Pay Percent Multiple Radiology Rule: The editing of multiple radiology procedures by CXT follows CMS guidelines for Multiple Procedure Payment Reduction (MPPR). According to the CMS National Physician Fee Schedule Relative Value File:

“Special rules for the technical component (TC) of diagnostic imaging procedures apply if procedure is billed with another diagnostic imaging procedure in the same family (per the diagnostic imaging family indicator). If procedure is reported in the same session on the same day as another procedure with the same family indicator, rank the procedures by fee schedule amount for the TC. Pay 100% for the highest priced procedure, and 75% for each subsequent procedure.”

Note: On May 7, 2010, CMS published Pub 100-20, Transmittal: 694, Change Request: 6965 which states that effective July 1, 2010, “For services furnished on or after dates of service July 1, 2010, contractors shall pay 50 percent of the fee schedule amount for the TC of each additional procedure in the SAME family when performed during the same session on the same day.”

Note: Effective January 1, 2011, the Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2011 applies. The MPPR now applies to CT and CTA, MRI and MRA, and ultrasound procedures furnished to the same patient in the same session, regardless of imaging modality, and not limited to contiguous body areas. This change is reflected in the National Physician Fee Schedule Relative Value File Calendar Year 2011.

CXT editing occurs across claims and will follow applicable guidelines based on the date of service. If a claim for a primary procedure is received subsequent to claim(s) already processed for procedures determined to be cut-back, the previously processed claims may be adjusted to apply appropriate payment cutbacks.

This CXT editing may occur in addition to any editing performed by Horizon BCBSNJ’s radiology utilization management delegated vendor, however, a procedure will only have payment cutback applied once by EITHER the radiology utilization management delegated vendor or CXT.

Sourcing: CMS

Application: Professional claims

Pay Percent Multiple Therapy Rule: The editing of multiple therapy procedures by CXT follows CMS guidelines for Multiple Procedure Payment Reduction (MPPR). According to the CMS National Physician Fee Schedule Relative Value File:

According the Centers for Medicare and Medicaid Services (CMS), when multiple therapy procedures are performed, the primary procedure should receive reimbursement at 100%. All secondary and subsequent procedures should have the non-facility Practice Expense RVU reduced by 50%.”

CXT editing identifies procedure codes that are eligible for the Multiple Therapy Procedures reduction, as stated above. Such procedures are defined on CMS MPFSDB with a Multiple Procedure (Mult Proc) indicator of “5” and are submitted on the same date of service for the same member and the same provider.

Eligible therapy procedures will be “grouped” based on the same member and same date of service. Within a “group”, claim lines will be sorted and ranked according to the highest non-facility Practice Expense RVU. This RVU component, along with the Work RVU and the Malpractice RVU components will be used in this rule.

Once all of the lines within the group have been sorted and ranked, a Pay Percent value will be assigned. For the procedure code that is ranked first and submitted with a quantity of one, no reduction will be applied. Any other procedures that are submitted secondarily will have the reduction of 0.50 applied to the non-facility Practice Expense RVU for services furnished in both office and institutional settings. The rule logic will then add together the other components of the RVU, which include the Work RVU and the Malpractice RVU.

For therapy services furnished by a group practice or “incident to” a physician’s service, the MPPR applies to all services furnished to a patient on the same day, regardless of whether the services are provided in one therapy discipline or multiple disciplines, e.g., Physical Therapy (PT), Occupational Therapy (OT), or Speech-Language Pathology (SLP).

The reduction applies to the Healthcare Common Procedure Coding System (HCPCS) codes contained on the list of “always therapy” services that are paid under the physician fee schedule, regardless of the type of provider or supplier that furnishes the services.

Sourcing: CMS

Application: Professional claims from providers who do not have a participating contractual agreement with Horizon on the date services were rendered.

New Patient Evaluation and Management (E&M) Rule: This claim editing logic identifies any new-patient E&M procedure codes submitted for established patients. A new patient is defined as one who has not received any professional services from the rendering physician or another physician of the same specialty who belongs to the same group practice, within the previous three years. If our editing system identifies a new or established E&M code reported within the last three years, the new patient E&M code will be denied. In such instances, a new claim must be submitted with the appropriate established E&M code.

Sourcing: AMA

Application: Professional claims

Obstetrical Services Rule: This claim editing logic identifies when a physician or other provider has reported a routine maternity E&M antepartum or postpartum care service within 270 days of a global maternity delivery code. If detected, the claim line for the E&M, antepartum or postpartum care services may be denied based on CPT coding guidelines on the services included in a total obstetric package.

CXT editing occurs across claims and across multiple providers. It is suggested that the billing provider review our Billing Guidelines for Maternity Services, available online, for additional information.

Sourcing: AMA (CPT)

Application: Professional claims

Pre-Op/Post-Op Rule: This claim editing logic identifies E&M services billed by the same provider within a procedure's pre- and/or post-operative period as defined by CMS. If the date of the E&M code falls within the procedure’s global surgery period, then no additional reimbursement will be considered. In such cases, the billed E&M service will be denied as part of the global surgical reimbursement. If multiple procedures are performed on the same day with different global periods, the pre and post-operative period will be defined by the procedure with the greater global period. Global surgery indicators may be found in the MPFS look-up tool available on the CMS website.

Sourcing: CMS and Change Healthcare Clinical Review

Application: Professional claims

Procedure Unbundling Rule: Unbundling occurs when two or more procedure codes are used to describe a service when a single, more comprehensive procedure code exists that more accurately describes the complete service performed. In some instances, submitted procedure codes may be replaced with a more appropriate procedure code by our CXT editing system. Additional details regarding unbundling rules are listed below.

Incidental: An incidental procedure is one that is performed at the same time as a more complex, primary procedure and is clinically integral to the successful outcome of that primary procedure. A separately billed procedure determined to be incidental to another procedure will not be considered for reimbursement.

Mutually Exclusive: Mutually Exclusive procedures consist of combinations of procedures that differ in technique or approach but lead to the same outcome and in some instances, the combination of procedures may be anatomically impossible. Procedures that represent overlapping services or accomplish the same result are considered mutually exclusive.
Reporting an initial service and subsequent service is also considered mutually exclusive. A procedure determined to be mutually exclusive to another procedure will not be considered for reimbursement.

Procedure Rebundling: Procedure rebundling is a process by which the denial of certain claim lines is recommended when another, more comprehensive, procedure is more appropriate. If the more comprehensive procedure code is also submitted for the same date of service, the component procedure codes will be denied and the comprehensive procedure code will be considered for reimbursement. If the more comprehensive procedure code is not submitted for the same date of service, the component procedure codes will be denied and the more comprehensive procedure code will be added as a new claim line.

Sourcing: Change Healthcare Clinical Review, AMA

Application: Professional claims and non-Inpatient Facility claims

Quantity Date Span Rule: This claim editing logic identifies when multiple services/components of a single procedure are submitted across multiple dates of service on the same claim line and the Units of Service billed per claim line are not equal to the number of days in the From/To date span on the claim line. If a service spans multiple days, then the service must only occur once on every day within the span.

If there is a gap, or if the service occurs multiple times on one or more days within the span, the services cannot be billed on the same claim line, and that claim line will be denied.

Sourcing: Horizon BCBSNJ CXT functionality

Application: Professional Claims

Related Services Rule: This claim editing logic identifies services related to a non-covered surgery that was denied due to Horizon Medical Policy. E&M services performed by the same provider who performed a non-covered surgery will not be reimbursed from 1 day prior, the same day or through 5 days after the date of the non-covered surgery.

Sourcing: Horizon BCBSNJ CXT functionality

Application: Professional Claims

Site Modifiers with Multiple Units of Service Rule: The number of anatomic site modifiers on a claim line must be equal to the Units of Service (UOS) on that claim line. Additionally, the same anatomic site modifier cannot be billed more than once on a single claim line.

If the number of anatomic site modifiers does not equal the UOS on the claim line, the services cannot be billed on the same claim line and the line will be denied.

Sourcing: Horizon BCBSNJ CXT functionality

Application: Professional Claims

Same Day Medical Visit Rule: This claim editing logic identifies when an E&M service is billed on the same day as a surgical procedure or substantial diagnostic or therapeutic (such as dialysis, chemotherapy and osteopathic manipulative treatment) procedure.

An E&M code reported for the same date of service as a procedure rendered by that same provider is considered included within the global reimbursement for that procedure. In such circumstances, CXT editing will not consider the E&M service for reimbursement.

Sourcing: CMS and Change Healthcare Clinical Review

Application: Professional Rules

Global/Technical/Professional Component Billing Rules: This claim editing logic validates the appropriate coding of professional component, technical component and global procedures. Modifier 26 signifies the professional component and Modifier TC signifies the technical component.

When the CMS’ National Physician Fee Schedule Relative Value File (NPFSRVF) designates that modifier 26 is applicable to a procedure code (PC/TC indicator of 1 or 6), and the procedure (e.g. radiology, laboratory, or diagnostic) has been reported by a professional provider with a facility-based place of service, the procedure code must be reported with modifier 26. If modifier 26 is not submitted the line will be denied and a new claim line will be added along with the missing modifier 26 and processed accordingly.

If CMS NPFSRVF designates that the concept of a separate professional and technical component does not apply to a laboratory procedure (PC/TC indicator of 3 or 9), and a professional provider has reported the laboratory procedure code with a modifier 26 or TC, the laboratory procedure code will be denied. If a laboratory procedure with a PC/TC indicator of 3 or 9 is reported by a professional provider with a facility place of service, the laboratory procedure code will be denied; in this case, the facility will bill for performing the laboratory procedure.

A global procedure code includes reimbursement for both the professional and technical components. If both of these components are performed by the same provider, the appropriate code must be reported without the 26/TC modifiers. If a provider has reported a global procedure and also reported the same procedure with a professional (26) or technical (TC) component modifier on a different line or claim, the procedure reported with the 26 or TC component modifier will be denied. CXT editing will occur across the same or different providers, including facility charges.

Sourcing: CMS NPFSRVF for modifier -26 and -TC validity

Application: Professional claims and non-Inpatient Facility claims

CMS Correct Coding Initiatives Rule: The claim editing logic within this rule denies claim lines for submitted procedures that are not recommended for reimbursement when submitted with another procedure according to CMS NCCI code pair guidelines. NCCI code pair edits may be reviewed online at www.cms.gov. Billing providers should note that:

NCCI incidental edits consist of those edits referenced as the CMS column1/column 2 edits, (formerly the comprehensive/component edits).

NCCI mutually exclusive edits consist of those edits located in the NCCI mutually exclusive tables. For mutually exclusive NCCI edits, ClaimsXten may reverse the denied code to allow the code with the highest RVU to be paid.

NCCI edits will be applied to code pairs which might, under our other reimbursement rules (such as procedure unbundling), be eligible for separate reimbursement but that under NCCI edits are considered incorrect coding; therefore, procedures within such code pairs are not eligible for separate reimbursement.

Sourcing: CMS

Application: Professional claims

Outpatient Code Editor (OCE) CMS Correct Coding Initiative (CCI) Bundling Rule:This claim editing logic identifies claims containing hospital outpatient services/procedure code pairs found to be unbundled according to CMS I/OCE. CXT will deny claim lines for which the submitted procedure is not recommended for reimbursement when submitted with another procedure as defined by a code pair found in the CMS OCE for one of the following reasons:

Procedure is a mutually exclusive procedure that is not allowed by the CCI.

Procedure is a component of a comprehensive procedure that is not allowed by the CCI.

OCE edits for hospitals maybe reviewed by visiting:

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html

Sourcing: CMS

Application: Non-Inpatient Facility claims

D. Use of Reimbursement Policy

State and federal law, as well as member contract language, including definitions and specific inclusions/exclusions, take precedence over Reimbursement Policies and must be considered first in determining eligibility for coverage for a given claim.

The member’s contract benefits in effect on the date that services are rendered must be applied.

Reimbursement Policy is constantly evolving and subject to change. Horizon BCBSNJ reserves the right to review and update its claims reimbursement policies.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit.
  • Provider Participation Agreement.
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity.
  • Mandated or legislative required criteria will always supersede.

History:
04/22/2016: Policy Approved

07/13/2016: Committee approved addition to Section C. ClaimsXten Rules, Add-on code without Base Code Rule: Add-on codes will deny when corresponding base code is denied.

8/22/2016: Add to Section C. ClaimsXten Rules: Pay Percent Multiple Cardiology, Ophthalmology and Therapy Rules; Effective 2/2018

8/30/2017: Replaced McKesson with Change Healthcare (formerly McKesson)

Policy 080_v5.0_08302017