August 6, 2012
,
Re:
Reimbursement Policies, and McKesson ClaimsXten™ Rules
Dear : Thank you for participating in our network and for the care you provide to your patients who are our members. We are writing to inform you of updates to our Reimbursement Policies and McKesson’s ClaimsXten™ Rules which become effective December 8, 2012. Enclosed are documents which provide the following: TM
●
McKesson ClaimsXten Rules: The enclosed grid includes all claims editing rules in effect for Commercial business as well as those pertaining to Medicaid (including Medi-Cal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families programs). This grid lists all claims editing rules (new, revised and existing).
●
Reimbursement Policies: Copies of all Reimbursement Policies are enclosed, which includes all new, revised and existing reimbursement policies.
You can review complete versions of all of the enclosed Reimbursement Policies and McKesson TM ClaimsXten Rules online via our secure ProviderAccess website. If you are registered for ProviderAccess, go to https://provider2.anthem.com/wps/portal/ebpmybcc and select the link TM entitled: “Reimbursement Policies, and McKesson ClaimsXten Rules” under the “What’s New” section. If your organization is not registered for ProviderAccess, contact your office administrator or click on the “Register for ProviderAccess” link. If you have any questions about these changes, please contact our Provider Care Department at (800) 677-6669. Sincerely,
Aldo De La Torre Vice President, Provider Engagement and Contracting Enclosures
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. ® The Blue Cross name and symbol are registered marks of the Blue Cross Association.
Rules
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Example
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
After Hours 99050 not Reimbursable with Preventive Diagnosis
This rule will deny 99050 (services provided when the office is usually closed) when billed with a preventive diagnosis and/or a preventive service.
Code 99050 will be denied when billed with diagnosis V202
Anthem
After Hours
New
Applied to dates of service on or after 01/01/2013. ICD-10 diagnosis updates to be done at a later date.
Qualitative Drug Screening
This rule will deny codes 80100, 80101, and 80104 Qualitative drug screening will now only be reimbursable using codes G0431 and G0434. Both codes G0431 and G0434 will be eligible for 1 unit of reimbursement per date of service. Use of code G0431 is limited to only high complexity testing, and documentation of FDA approved complexity level for instrumented equipment utilized, and/or CLIA Certificate of Registration, Compliance, or Accreditation as a high complexity lab, may be requested as a condition for reimbursement.
Code 80100 is submitted, this line will be denied
Anthem
Bundled Services and Supplies
New
Edit effective for dates of service on or after 1/1/2013
1
Qualitative Drug Screen Testing
Rules
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Example
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Morton’s Neuroma: 64450, 64640, and 20550 Not Reimbursable with Diagnosis 355.6
This rule will deny 64450, 64640 or 20550 when billed with diagnosis 355.6. This is supported by AMA/CPT which developed specific codes for these services for this diagnosis.
Code 64450 will be denied if billed with diagnosis 355.6
AMA/CPT
Claim Editing Overview
New
Applied to dates of service on or after 01/01/2013. ICD-10 diagnosis updates to be done at a later date.
Durable Medical Equipment billed without DME modifier (NU, UE, RR, RA, RB, or MS) Maintenance and Servicing of Durable Medical Equipment (Modifier MS)
This rule will deny the DME code if the code is billed without the appropriate DME modifier. (NU, UE, RR, RA, RB, or MS)
Code E0250 will be denied when billed without a DME modifier
DME
New
Edit applied to all claims processed on or after December 8, 2012, regardless of date of service.
This rule will deny specific rental DME billed with modifier MS (6 month’s maintenance and service fees parts and labor). . Refer to the DME reimbursement policy
Code E0935 when billed as a rental with modifier MS will be denied.
Industry Standards Centers for Medicare & Medicaid Services (CMS) Anthem
DME
New
Edit applied to dates of service on or after 01/01/2013.
2
Rules
Maintenance and Servicing of DME frequency (modifier MS)
Maximum DME Rental Allowable Has Been Reached (modifier RR)
Purchase of Rental DME previously Rented (modifiers RR, NU, UE, NR)
3
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Example
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
This rule will determine if maintenance and servicing is allowed. When allowed a DME code with modifier MS will be denied if maintenance and servicing has been reported within the previous six months This editing rule will deny DME codes billed as a rental with modifier RR when the item has been rented for more than 10 months.
Code E0574 is eligible for maintenance and servicing but a history line for same item has modifier MS within six months. The current claim line will be denied DME Code K0813 modifier RR has been previously billed for 10 months. When the claim with the 11th occurrence of rental is received the claim will be denied.
Industry Standards CMS
DME
New
Edits applies to dates of service on or after 01/01/2013.
Industry Standards CMS
DME
New
Edit applied to all claims processed on or after December 8, 2012, regardless of date of service.
This rule will pend the line when durable medical equipment is billed with modifier NU UE or NR and prior claims have been billed with modifier RR within prior ten months. The purchase claim will be reviewed to ensure that the allowable for the rental and purchase do not exceed the maximum allowable for the item.
Current line: E0574/NU for date of service 10/01/2010, Paid History line: E0574/RR for date of service 03/01/2010 – 03/31/2010 The will pend for review and pricing.
Industry Standards CMS
DME
New
Edits applies to dates of service for the purchase on or after 01/01/2013.
Rules
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Rental of DME previously purchased (modifiers RR , NU, UE, NR)
This editing rule will deny durable medical equipment when billed with rental modifier (RR) if same item has been previously purchased (modifiers NU UE or NR) in the member's claim history.
Repair and Replacement of Rented Durable Medical Equipment (modifiers RA, RB, KC)
This rule will deny line billed for a rented durable equipment item with modifier (s) RA RB and or KC. Anthem does not reimburse for these services for rented equipment.
Modifier 25: Multiple Evaluation and Management procedures billed with modifier 25
This rule will deny the lower valued evaluation and management procedures when two preventive or two problem oriented E/Ms are billed on the same date of service. Modifier 25 does not override this edit.
4
Example
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless
DME procedure code K0813 modifier RR is billed and the member’s history indicates this same item was previously purchased (modifier NU UE or NR). The Rental line will be denied Code E0935 has been rented and is billed with modifier RA. This charge line will be denied.
Industry Standards
DME
New
Edits applies to dates of service for the rental on or after 01/01/2013.
Anthem
DME
New
Edit applied to dates of service on or after 01/01/2013.
Code 99213 is billed twice for the same date of service and modifier 25 is added to one procedure. Only a single visit will be allowed.
Industry Standard CPT/AMA CMS
Evaluation and Management Services and Related Modifiers 25 & -57 More Than 1 Same Day E/M service section
New
Edit applied to all claims processed on or after December 8, 2012, regardless of date of service.
otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Rules
Screenings with preventive or problem oriented E/Ms
Health and Behavioral Assessments 96150-96155 Not Reimbursable with any Mental Health Diagnosis
5
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
This rule will deny screening services G0101, G0102 and Q0091 and annual exam codes (S0610, S0612, &/or S0613) when reported with a preventive E/M service. When Screening services are performed at the same time as a problem oriented exam, the screening service should be taken into account when determining the correct level of problem-oriented E/M service (99201-99215) to report. Modifiers 25 or 59 will not override the edit. This rule will deny codes 9615096155 when billed with any diagnosis contained within the Mental Disorders chapter of the ICD-9-CM reference book(code range 290-319)
Example
G0101-25 & G0102-25 will deny when billed with 99384 or 99213.
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless
Anthem
Evaluation and Management Services and Related Modifiers 25 & -57
New
New edits, applied to dates of service on or after 01/01/2013.
New
Edit applied to dates of service on or after 01/01/2013. ICD-10 diagnosis updates to be done at a later date.
S0612 will deny when billed with 99384
Codes 96150-96155 will be denied if submitted with diagnosis 295.0.
Effective December 8, 2012
otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Screening Services with Evaluation and Management
Anthem
Health and Behavior Assessment/Intervention
Rules
Lab Service in Facility Place of Service
Multiple Diagnostic Imaging Reductions
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless
Laboratory and Venipuncture Services, Technical/Professional Modifiers TC/26 section.
New
Edit applied to dates of service on or after 01/01/2013.
New
Edit applied to dates of service on or after 01/01/2013 if not present in provider contract with earlier effective date.
This editing rule will deny the line if the CMS National Physician Fee Schedule Relative Value File (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 the procedure is billed in facility place of service.
A lab code that a PC/TC indicator of 3 or 9 in the NPFSRVF file on the date of service billed (eg. 80050) with place of service outpatient hospital (22). Will be denied
Industry Standards CMS.
Following (CMS) policy, this rule will reduce the technical component of the diagnostic imaging procedures that have a Multiple Procedure Indicator of 4 on the CMS National Physician Fee Schedule (NPFS) by 50% (based on the RVU for the date of service) when multiple diagnostic imaging procedures with a MPI of 4 are billed for the same date of service. Note when
Codes 72146-TC and 72148-TC same day are submitted. Code 72146 has a higher RVU value, 100% of the technical fee schedule amount will be allowed. Code 72148 has a lower RVU than 72146, 50% TC fee schedule amount and 100% of the 26 fee schedule amount will be allowed.
CMS
codes are submitted unmodified an algorithm will be applied to determine the % of the charge for the technical component and the reduction will be applied to this percentage of total charge.
6
Example
Effective December 8, 2012
otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Claim Editing Overview
Multiple Imaging Diagnostic Procedures Subsequent procedure that has an MPI of 4 in the multiple procedure column of the CMS National Physician Fee Schedule (NPFS). .
This rule does not apply to Anthem Blue Cross Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families)
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Rules
Edit logic
Example
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Patient Home Sleep Studies
This editing rule will deny the charge for attended sleep study procedures when billed with place of service home (12).
Code 95808 will be denied when billed with place of service home (12)
Anthem
Place of Service
New
Edit applied to dates of service on or after 01/01/2013.
Prolonged Services 99354, 99355 Not Reimbursable with Diagnosis
This rule will deny code 99354 or 99355 when the diagnosis submitted is not on the Anthem list.
Codes 99354 or 99355 will be denied when billed with diagnosis 077.0.
Anthem
Prolonged Services
New
Edit applied to dates of service on or after 01/01/2013. ICD-10 diagnosis updates to be done at a later date
Anesthesia Complicated by Emergency Situations 99140 Not Reimbursable with Diagnosis
This rule will deny code 99140 (anesthesia complicated by emergency situation) when billed with a routine maternity diagnosis in the Anthem list. CXT 4.4 Revision- Additional diagnoses have been added, refer to the Anesthesia Reimbursement Policy for additional details.
Code 99140 will be denied when billed with diagnosis V22.0, V22.1, 650 etc.
Anthem
Anesthesia
Revised
Revised rule edit applies to all dates of service.
7
ICD-10 diagnosis updates to be done at a later date.
Rules
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4
National Correct Coding Initiative (NCCI) bundling
Diagnosis Invalid for Patient’s Age
8
Edit logic
This rule will deny the charge line for services which are incidental or mutually exclusive to another service. Edits are defined in the National Correct Coding Initiative Coding lists as maintained and posted to the CMS website. 4.4 Revision –Effective with claims processed on or after 12/08/2012, we will be adopting the CMS modifier override that requires the overriding modifier be appended to the denied code. This rule will deny a line when the referenced diagnosis is inappropriate for the patient’s age CXT 4.4 Revisions: The age range appropriate for reproductive services will be changed from 960 to ages 12-55.
Example
Code 38206 will be denied by NCCI when billed with code Q2043
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CMS
Claim Editing Overview
Revised
otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Revised rule edit applies to all dates of service.
Code 77332 will be denied by NCCI when billed with code 77418
Claim line billed with diagnosis 650 will be denied for a patient age 7 or 70.
CXT 4.4 notes – unless
This rule does not apply to Anthem Blue Cross Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families)
Industry Standards
Claim Editing Overview
Revised
This rule is applied to all dates of service. ICD-10 updates to be done at a later date.
Rules
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Example
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Procedure with date span limits
This editing rule will limit the reimbursement for procedures which are reimbursable only for a limited number of occurrences within a specified time frame. CXT 4.4 Revisions: Additional rental DME codes have been added to this rule and will be allowed only once per month. In addition diabetic supplies such as glucometers, lancets and strips will be limited to specific quantities within a specific time frame-appropriate diabetes diagnosis and modifiers KS or KX are required
Procedure code 93294 is billed for date of service 11/15/2011 and also for date of service 12/1/2011. The second submission for this procedure will be denied as this code is per 90 day period by code definition
Industry Standards AMA/CPT
Frequency Editing
Revised
Revised rule. New edits apply to dates of service on and after 1/1/2013.
Multiple Lab Component Rebundling
This rule will deny 2 or more component codes of a multiple component laboratory test and replace them with the more comprehensive lab panel code. Modifier 59 does not override this editing CXT 4.4 Revision: The editing in this rule will be expanded to all blood panels and complete blood count codes.
Laboratory tests 82040, 82247, and 82310 are reported for the same date of service. These are components of the more comprehensive lab panel code 80053. Reimbursement is made on the 80053 Panel test
Industry Standards AMA/CPT
Laboratory and Venipuncture
Revised
Revised rule edit applies to all dates of service.
9
Rules
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Example
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Bilateral procedures (modifier 50)
Bilateral surgery is to be billed on one line with 1 unit and modifier 50. This rule may recode and/or split the total allowed percentage for the bilateral surgical procedure(s) billed on multiple lines to comply with this requirement (eg. 75% on line one and 75% on line 2 to equal 150 %.) 4.4 Revisions: Certain coding scenarios will result in a line being considered bilateral without modifier 50. Refer to the policy for more information.
As an example, When myringotomy procedure code 69420 is billed with modifier 50 on one line and billed again on another line (with or without modifier 50) This rule will recode the two claim lines to a single line with modifier 50, 1 unit and combine the charges.
Industry Standards CMS
Multiple Surgery
Revised
Revised rule edit applies to all dates of service.
Place of Service
This editing rule will deny the charge line for specific procedures and place of service combinations. 4.4 Revisions: DME when rented for use in an facility or office place of service will be denied
Codes, 99050 or 77417 will deny when billed in Place of service 21.
Industry Standards CMS. AMA/CPT
Place of Service DME
Revised
This rule is applied to all dates of service.
Code E0673 will deny when billed with place of service 24. Code E0676 will deny when billed with place of service 11
10
Rules
Pre and post Anesthesia Visits
Assistant Surgeon not allowed (modifiers 80, 81, 82, AS)
Never Reimbursed with Specific Procedures
11
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
This rule will deny evaluation and management codes billed by the anesthesiologist one day prior to or 10 days post anesthesia This rule will deny surgery codes billed with assistant surgeon modifiers 80, 81, 82, or AS if the procedure is on Anthem’s list of codes that do not allow for services of an assistant surgeon. New codes are updated quarterly when necessary per the policy guidelines. This rule will deny services which are listed on the Anthem Bundled Services and Supplies Reimbursement Policy when billed with the specific other services as defined in the policy. These are services or items for which Anthem never provides reimbursement when billed in combination with the codes listed in the policy.
Example
Code 99213 billed within 10 days after anesthesia administration by the anesthesiologist will be denied. Code 14041 billed with modifier 80 will be denied.
All radiological interpretation codes, as well as radiology codes with modifier 26 are denied when billed with procedures 9928199285, and 99221-99223 Code Q0091is denied when billed with Preventive and E/M codes such as 9938199397, G0101, S0610, S0612 and 99201-99215
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless
Industry Standards, Custom
Anesthesia, Global Surgery
Existing
This rule is applied to all dates of service.
American College of Surgeons CMS Industry Standards
Assistant Surgeon and separate list of nonallowed codes
Existing
This rule is applied to all dates of service.
Bundled Service and Supplies
Existing
This rule is applied to all dates of service.
otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Rules
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Anthem Code Bundling
This rule will deny the charge line for services which are incidental or mutually exclusive to another procedure for the same date of service. Please refer to the Modifier 59 and E/M Related Modifiers 25 and 57 for additional details on modifier impacts to this rule.
Diagnosis Code Inappropriate for Patient's Gender
This editing rule will deny the charge line if the diagnosis billed is inappropriate for the patient's gender.
Incomplete Diagnosis
This editing rule will deny the charge line if the diagnosis is incomplete. An incomplete diagnosis is one that has not been coded to the ICD9/10 required length as defined by the National Center for Health Statistics (NCHS) and The Center for Medicare and Medicaid Services (CMS).
12
Example
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless
Procedure codes 72020 and 72072 are billed for the same date of service. 72020 will be denied as incidental to 72072. 99204 and 99219 are billed for the same date of service. 99204 will be denied as mutually exclusive to 99219. Diagnosis 617.0 endometriosis of the uterus denies for a male Diagnosis 600.00 (Benign Prostatic Hypertrophy) denies for a female.
Industry Standards
Claim Editing Overview Modifier Rules, Modifier 59 E/M Related Modifiers 25 and 57
Existing
This rule is applied to all dates of service.
Industry Standards NCHS CMS.
Claim Editing Overview
Existing
This rule is applied to all dates of service.
Claim line billed with diagnosis code 410.2 will be denied as this diagnosis requires a fifth digit for further specificity to be considered complete.
Industry Standards NCHS CMS.
Claim Editing Overview
otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
ICD-10 diagnosis updates to be done at a later date Existing
This rule is applied to all dates of service. ICD-10 diagnosis updates to be done at a later date.
Rules
Diagnosis Code Invalid
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Example
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless
Existing
This rule is applied to all dates of service.
otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
This editing rule will deny a diagnosis code that is not listed as a valid diagnosis for the date of service by the National Center for Health Statistics (NCHS) and The Center for Medicare and Medicaid Services (CMS).
As an example, Claim line billed with 424.00 will be denied as this diagnosis is not a valid diagnosis
Industry Standards NCHS CMS.
Claim Editing Overview
New Patient Visit Code Frequency Limits
This editing rule will deny the charge line for a new patient evaluation and management service if a claim has been previously received within a three year period by the same provider or providers with the same specialty billing under the same Tax Id.
New patient code 99204 or established visit 99213 is billed for date of service 12/31/2010. If the same physician or another physician with the same specialty billing under the same Tax Id submits 99203 within 36 months of 12/31/2010 the additional new visit charge line will be denied.
Industry Standards AMA/CPT
Claim Editing Overview
Existing
This rule is applied to all dates of service.
Procedure Code Deleted (Obsolete)
This editing rule will deny any code which has been end dated by AMA/CPT or CMS/HCPCS.
Code L0100 was end dated in the HCPCS manuals effective 12/31/2006 and would be denied if submitted for a date of service 1/1/2012.
Industry Standards AMA/ CPT
Claim Editing Overview
Existing
This rule is applied to all dates of service.
13
ICD-10 updates to be done at a later date.
Rules
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Procedure and Modifier Combination Invalid Procedure Code Invalid
This editing rule will deny the line if the billed modifier is invalid with the procedure code.
Procedure allowed once per date of service
This rule will limit the number of times the procedure may be billed either on separate lines or units on one line to a single occurrence per date of service.
14
This editing rule will deny line containing a procedure code which has never been a valid CPT/HCPCS code.
Example
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless
Code 99213 is denied when billed with modifier 80 (assistant surgeon) Code 95902 has never been a valid CPT code and would be denied in this editing rule.
Industry Standards AMA/CPT CMS Industry Standards AMA/ CPT
Claim Editing Overview
Existing
This rule is applied to all dates of service.
Claim Editing Overview
Existing
This rule is applied to all dates of service.
Code 27392 (tenotomy open, hamstring, knee to hip; multiple tendons, bilateral) is billed twice for the same date of service will have one unit denied. This procedure, by definition, can only be performed once per date of service.
Industry Standards
Frequency Editing
Existing
This rule is applied to all dates of service.
otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Rules
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Procedure allowed limited times per date of service
This rule will limit the number of times the procedure may be billed either on separate lines or units on one line to a maximum allowable amount per occurrence per date of service.
Unilateral Procedures billed Multiple Times when bilateral Code exists
This rule will replace unilateral procedure codes when billed more than once per date of service if a bilateral procedure code exists for the service.
Pre-Operative Visits
This editing rule will deny the line for an evaluation and management code billed within the pre-operative period.
Post-Operative Visits
This editing rule will deny the line for an evaluation and management code billed within the post-operative period.
15
Example
29125 (application of a short arm splint) is billed three times with right and left modifiers. The second submission of 29125 –RT is denied. 29125 -RT 29125 -LT 29125 –RT (Deny) Code 70328 (Radiologic examination, unilateral) is billed twice for the same service date. Both units or lines will be denied and replaced with the corresponding bilateral procedure 70330 1 unit. Code 99213 billed one day prior to surgery code 49000 with the same diagnosis will be denied as a preoperative visit Code 99213 billed within 90 days post operative period for code 49000 will be denied as a post operative visit.
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless
Industry Standards
Frequency Editing
Existing
This rule is applied to all dates of service.
Industry Standards AMA/CPT
Frequency Editing
Existing
This rule is applied to all dates of service.
Industry Standards AMA/CPT
Global Surgery
Existing
This rule is applied to all dates of service.
Industry Standards AMA/CPT
Global Surgery
Existing
This rule is applied to all dates of service.
otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Rules
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Supplies Same Day as Procedure
This editing rule will deny the line for supply codes when billed on the same day as a procedure.
Duplicate Component Modifier Billing (26, TC)
This editing rule will deny lines billed with a professional (26) or technical modifier (TC) when the procedure code was previously submitted as a global procedure for the same provider ID, patient, & date of service.
Missing Professional Component in Facility Place of Service
This editing rule will deny the line when the CMS National Physician Fee Schedule Relative Value File indicates modifier 26 is applicable (PC/TC indicator of 1 or 6), and the procedure is billed without modifier 26 with a facility place of service. Modifier 26 is required..
16
Example
A4206 will be denied when billed with chemo administration codes such as 96405 A7041 will be denied when billed with surgery codes such as 11005 If procedure code 70010 is submitted as global with no component modifier and claim lines are received which contain procedure code 70010 and modifier 26 and/or modifier TC these claim lines will be denied. Code 78805 is billed without the professional component modifier (26) with a place of service inpatient (21). This line will be denied.
Supported by
Effective December 8, 2012
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless
Injection-Infusion Administration Bundled Supplies, Always Bundle, and Global Surgery
Existing
This rule is applied to all dates of service.
Industry Standards
Laboratory and Venipuncture Services Technical/Professional Modifiers Section
Existing
This rule is applied to all dates of service.
Industry Standards CMS.
Laboratory and Venipuncture Services, Technical/Professional Modifiers TC/26 section. Claim Editing Overview
Existing
This rule is applied to all dates of service.
Industry Standard AMA/CPT CMS
otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Rules
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Example
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Modifier 22: Procedure with Modifier 22
This rule will pend the claim for additional review for increase of allowance when the procedure code is billed with modifier 22 to identify unusual procedural services AND the claim is submitted with medical records.
Procedure code 58661 is billed with modifier 22 and medical records the claim will be pended for medical review for possible additional allowance
Industry Standards
Modifier Rules Modifier 22
Existing
This rule is applied to all dates of service.
Modifier Increase or Decreases
Anthem has identified modifiers which will increase or decrease the reimbursement. Please refer to the policy for details
Procedure code 6472652 (reduced Services) will be reimbursed at 50%. Procedure Code 6472650 (bilateral) will be reimbursed at 150%.
Industry Standards
Modifier Rules
Existing
This rule is applied to all dates of service.
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Rules
Multiple Endoscopy Reductions
Multiple Surgery Reductions
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ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Multiple endoscopic procedures in the same base family per CMS for the same date of service have special multiple surgery reduction calculations. The 2ndary procedures are reimbursed at a rate less than 50%. Please refer to the Anthem Multiple Surgery Reimbursement Policy for details When eligible multiple surgeries (having a Multiple procedure indicator of 2 or 3 on the CMS National Physician Fee Schedule Relative value file) are billed for the same date of service a multiple surgery reduction is applied to the code with the lower valued RVU based on the date of service. Please refer to the policy for additional details
Example
29887 (RVU 21.95) 29873 (RVU 15.34) 29887 has the highest RVU & will be reimbursed at 100% of the allowed amount. 29873 has the lower RVU & will be reimbursed at 35% of the allowed amount Codes 26433 and 26455 are billed for 7/1/2012. Code 26455 has a lower RVU per the CMS RVU file for date of service 7/1/2012 and will be reimbursed at 50%
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless
Anthem
Multiple Surgery
Existing
This rule is applied to all dates of service.
otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
This rule does not apply to Anthem Blue Cross Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families)
Industry Standards CMS
Multiple Surgery
Existing
This rule is applied to all dates of service.
Rules
Maternity Visits
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ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
This rule pends the obstetrical delivery codes for a review of claim history. If E/M codes have been billed by the same physician or group within the prenatal period for routine maternity diagnosis the E/Ms after the initial visit will be denied and overpayments will be recouped.
Example
Code 99213 with date of service after the initial visit diagnosing pregnancy and prior to the delivery will be denied as included in the global obstetrical procedure allowance.
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or Existing rule
CXT 4.4 notes – unless
Industry Standards
Routine Obstetric Services
Existing
This rule is applied to all dates of service.
otherwise noted the rules apply to both Anthem Blue Cross Commercial and Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4
Effective December 8, 2012
Section 2 The editing rules described on following pages (22-25) are only applicable to claims when the services are being provided for a member in one of the Anthem Blue Cross Medicaid Programs: • • • • • •
20
MediCal L.A. Care MRMIP CMSP AIM Healthy Families
Rule
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Co-Surgeon
Identifies claim lines containing procedure codes billed with a cosurgery modifier that typically do not require co-surgeons according to the Centers for Medicare and Medicaid Services (CMS).
Global Component
Identifies claim lines with procedure codes which have components (professional and technical) to prevent overpayment for either the professional or technical components or the global procedure. The rule also detects when duplicate submissions occurred for the total global procedure or its components across different providers. Edits are applied: Global vs. Global Global vs. Professional Global vs. Technical Professional vs. Global Technical vs. Global Professional vs. Professional Technical vs. Technical
21
Example
This rule recommends the denial of claim lines containing procedure codes, submitted with cosurgery modifier 62 in any of the four modifier positions, where there is a payment restriction for co-surgery according to the CMS Medicare Physician Fee Schedule. If a global procedure is billed on a current line or support line without a “26” or “TC” present in any modifier fields, and the claim facility flag = Y, the technical component (–TC) will be assumed. If a global procedure is billed on the current line without a –26 or – TC present in any modifier fields, and the claim facility flag = N, and the POS is Inpatient or Outpatient, the professional component (–26) will be assumed on the current line.
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or existing rule
CXT 4.4 notes –The
CMS
N/A
New
Edit applied to dates of service on or after 01/01/2013.
CMS National Physician Fee Schedule Relative Value
N/A
New
Edit applied to dates of service on or after 01/01/2013.
following rules apply only to Anthem Blue Cross Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Rule
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Example
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or existing rule
CXT 4.4 notes –The following rules apply only to Anthem Blue Cross Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Inpatient Only Procedures Billed as an Outpatient Multiple Medical Same Day visits
Identifies claim lines containing Outpatient Prospective Payment System (OPPS) C status procedure codes that are not payable when billed in an outpatient setting.
C status procedure code 19306 will be denied when submitted without modifier –CA.
CMS OPPS
N/A
New
Edit applied to dates of service on or after 01/01/2013.
Identifies multiple evaluation and management codes and other visit codes submitted on the same date of service, the same facility and the same revenue code where the second and subsequent E&M code submitted lacks modifier -27.
CMS
N/A
New
Edit applied to dates of service on or after 01/01/2013.
MUE Multiple Lines Facility Rule
This rule will audit Facility claims submitted on a UB04 only. Identifies claim lines where the MUE has been exceeded for a CPT/HCPCS code, reported by the same provider, for the same member, on the same date of service.
This rule recommends the denial of claims containing multiple E&M codes for which the second and/or subsequent visit codes lack the presence of modifier -27. 29125 (application of a short arm splint) is billed three times with right and left modifiers. The second submission of 29125 –RT is denied. 29125 -RT 29125 -LT 29125 –RT (Deny)
CMS
N/A
New
Edit applied to dates of service on or after 01/01/2013.
22
Rule
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
Example
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or existing rule
CXT 4.4 notes –The following rules apply only to Anthem Blue Cross Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
Medicaid Medically Unlikely Edit Durable Medical Equipment
This rule applies the CMS medically unlikely edits (MUE) to durable medical equipment (DME) providers when the quantity for a single date or date range exceeds the CMS medically unlikely edit (MUE) limit for the HCPCS/CPT code. This rule edits for durable medical equipment claims billed on a professional claim form.
DME code E0111 is billed on a professional claim with three units for single date of service. The line will be denied as the quantity exceeds the CMS MUE limit for this service.
CMS Medicaid
N/A-Federal Mandate
New
Edit applied to dates of service on or after October 1, 2010, and processed on or after December 8, 2012.
Medicaid Medically Unlikely Edit Outpatient Hospital
This rule applies the CMS medically unlikely edits (MUE) to outpatient facility claim lines when the quantity for a single date or date range exceeds the CMS medically unlikely edit (MUE) limit for the HCPCS/CPT code. This rule edits facility claims.
A facility bills code 11450 with three units for a single date of service. The line will be denied as the quantity exceeds the CMS MUE limit for this service
CMS Medicaid
N/A-Federal Mandate
New
Edit applied to dates of service on or after October 1, 2010, and processed on or after December 8, 2012.
Medicaid Medically Unlikely Edit Practitioner
This rule applies the CMS medically unlikely edits (MUE) to professional claims when the quantity for a single date or date range exceeds the CMS medically unlikely edit (MUE) limit for the HCPCS/CPT code. This rule edits professional provider claims (non DME or Facility providers).
A physician bills code 11450 with three units for a single date of service. The line will be denied as the quantity exceeds the CMS MUE limit for this service
CMS Medicaid
N/A-Federal Mandate
New
Edit applied to dates of service on or after October 1, 2010, and processed on or after December 8, 2012.
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Rule
Medicaid NCCI Outpatient Hospital
ANTHEM BLUE CROSS CLAIMS XTENTM RULES Version 4.4 Edit logic
This rule denies facility claim lines if the line procedure is the denied procedure in the code pairs as identified by the Centers for Medicare and Medicaid (CMS) National Correct Coding Initiative (NCCI) for Facility (hospital) emergency department, observation, hospital laboratory services, all facility therapy services and outpatient hospital claims.
Example
Effective December 8, 2012
Supported by
Related Anthem Reimbursement Policy
New Revised or existing rule
CXT 4.4 notes –The
A facility submits a claim with procedure code 52277(column one) with procedure code 53600 (column two) for the same member, same date of service and the same provider. Procedure code 52277 is paid and procedure code 53600 is denied.
CMS Medicaid
N/A-Federal Mandate
New
Edit applied to dates of service on or after October 1, 2010, and processed on or after December 8, 2012.
A professional provider submits code 23585 (column one) with procedure code 99149 (column two) for the same member, same date of service and the same provider. Procedure code 23585 is paid and procedure code 99149 is denied.
CMS Medicaid
N/A-Federal Mandate
New
Edit applied to dates of service on or after October 1, 2010, and processed on or after December 82012.
following rules apply only to Anthem Blue Cross Medicaid (MediCal, L.A. Care, MRMIP, CMSP, AIM and Healthy Families).
The rule will apply the NCCI associated modifier. The override modifiers can be on the deny line, the support line or both the deny line and support lines. Medicaid NCCI Practitioner
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This rule denies procedures when the code is the denied procedure in the code pairs in the Centers for Medicare and Medicaid (CMS) National Correct Coding Initiative (NCCI) for practitioner claims or ambulatory surgery center claims. The rule will apply the NCCI associated modifier overrides. The override modifiers can be on the deny line, the support line or both.
