Coverage & Claims

Overview

BlueCross applies code editing rules to evaluate the accuracy and adherence of medical claims to accepted national standards. These rules are based on code editing guidelines such as:

• National Correct Coding Initiative (NCCI)
• Centers for Medicare and Medicaid Services (CMS) guidelines
• American Medical Association (AMA) coding guidelines
• Guidelines published by medical societies/associations such as:
• American Academy of Orthopedic Surgeons (AAOS)
• American College of Obstetricians and Gynecologists (ACOG)
• BlueCross BlueShield of Tennessee clinical expertise
• BlueCross code rules are also based on reimbursement policies such as but not limited to the following:
• Bundled Services Regardless of the Location of Service
• Bundled Services when the Location of Service is the Physician’s Office
• Corneal Topography
• Durable Medical Equipment (Purchase and Rentals)
• Home Pulse Oximetry
• Screening Test for Visual Acuity
• Visual Function Screening
• Quarterly Reimbursement Changes – These reimbursement policies may be viewed in the Commercial Provider Administration Manual and the BlueCare Tennessee Provider Administration Manual.

BlueCross code editing rules will be applied during the claim payment process. Retrospective audits may still be necessary when all associated claims are available for review.

Code editing can occur on multiple levels depending on the combination of codes reported.

BlueCross reserves the right to request supplemental information (e.g. anesthesia record, operative report, medical records, etc.) to determine appropriate application of code bundling rules.

Final reimbursement determinations are based on several factors, including but not limited to, member eligibility on the date of service, medical appropriateness, code edits, applicable member co-payments, coinsurance, deductibles, benefit plan exclusions/limitations, authorization/referral requirements and medical policy/coverage decisions.

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

Definitions

Comprehensive Code (Column 1)

Generally represents the major procedure or service when reported with another code

Component Code (Column 2)

Generally represents the lesser procedure or service. Reimbursement for a component code is considered included in the reimbursement for the comprehensive code when the service is billed by the same provider for the same patient on the same date of service (i.e., reimbursement for the component code will not be made separately from the comprehensive code).

Retained NCCI

BlueCross edits are based on NCCI logic.

Example: Effective Jan. 1, 2010, the Centers for Medicare and Medicaid Services (CMS) no longer recognize CPT® codes 99241-99245 (office or outpatient consultations) and 99251-99255 (inpatient consultations) under the Medicare Physician’s Fee Schedule.

As a result, CMS termed the edits for these CPT® codes. BlueCross continues to allow providers to bill these consultation codes; therefore, the edits related to these CPT® codes were retained by BlueCross.

Upcoming Code Edits

• Code Editing for Facility High Level Emergency Room Services (July 1, 2024)
• Office and Outpatient Evaluation and Management Visit Complexity Add-on Payment Code G2211 (Effective Jan. 1, 2024)
• Code Editing for Facility High Level Emergency Room Services (Effective March 3, 2023)
• Ophthalmology Policies (Effective June 15, 2022)
• Gynecologic Screening Services with Preventive Medicine Visits (Effective Nov. 1, 2021)
• Durable Medical Equipment and Supplies Policies (Effective June 1, 2021)
• Ophthalmology Policies (Effective June 1, 2021)
• Maximum Units (MUE) Edits Policy (Effective June 1, 2021)
• High-Level Emergency Room Evaluation and Management Services (Effective July 1, 2021)
• Insertion of Intrauterine Devices (Effective 9/17/20)
• Notice to Facilities Billing Outpatient Services (Effective 7/13/20)
• Correct Modifier Reporting and Editing (Effective 4/30/20)
• Editing for Procedure/ Revenue Code conflict (Effective 2/1/20)
• Diagnosis Code Guideline Policy - ICD-10-CM Sequela (7th character "S") Codes (Effective 2/1/20)
• Place of Service Policy - Mutually Exclusive Places of Service (Effective 2/1/20)
• Radiation Oncology Policy (Effective 2/1/20)
• Diagnosis-Age Policy - Diagnosis-Age Consistency (Effective 12/17/19)
• Place of Service Policy - Evaluation and Management Place of Service Restrictions - Part 2 (Effective 12/17/19)
• Evaluation and Management Services Policy - Consultation with Annual Exam or Screening Diagnoses (Effective 12/17/19)
• Bundled Services Policy - Bundled Services Billed on the Same Day as Other Payable Services (Effective 12/17/19)
• Evaluation and Management Services - Outpatient Consultations (Effective 12/1/19)
• Genetic Testing - Molecular Pathology Testing for Lynch Syndrome (Effective 12/1/19)
• Evaluation and Management - Transitional Care Management (TCM) Services (Effective 12/1/19)
• Inappropriate Age for Procedure (Effective 10/1/19)
• Pneumococcal Vaccine Frequency (Effective 10/1/19)
• Diagnosis Code Guideline Policies (Effective 10/1/19)
• Professional Services Billed on CMS 1500 Form (Effective 7/1/19)
• Evaluation and Management Services (Effective 7/1/19)
• Secondary Diagnosis Coding (Effective 7/1/19)
• Appropriate Use of Manifestation Codes Overview (Effective 5/1/19)

Other Updates

• Revised E&M Codes for Commercial Claims (Jan. 1, 2021)

Upcoming Code Edits

• Avalon Healthcare Solution - Laboratory Procedures Reimbursement Policy
• Current Lab Testing Policies

We’ll pay for emergency screening examination services conducted to determine if an emergency physical/behavioral health condition exists and for all emergency services that are medically necessary until the member is stable.

Our prospective review process allows providers to submit claims and medical records for review of a medical emergency before screening fee payment when the diagnosis code filed isn’t on the Medical Emergency Diagnosis code list. Providers may attach the complete emergency room medical record to the claim upon initial submission. The claim and record will be suspended for clinical review.

For complete information about these policies, please see the Emergency Services section of the Provider Administration Manual.

Emergency Medical Services for Undocumented and Ineligible Aliens

For information about emergency medical services coverage for undocumented and ineligible aliens, please visit the State of Tennessee website.