Tuesday, August 30, 2016

Prepayment Edits to Detect Separate Billing of Services Included in the Global Package

List of EDIT by BCBS insurance to determine the payment

RULE NAME RULE DESCRIPTION

Surgical Inclusive Edit This edit will deny claim lines containing supplies when billed for the same date of service as a surgical procedure for which CMS has assigned a global period.

Incidental Edit : This edit will deny a claim line clinically integral to accomplishing the principal procedure/service or considered a component of the more comprehensive procedure

Multicode Rebundle : This edit will deny a claim line when two or more procedures are used to describe a service when a single, more comprehensive procedure exists that more accurately describes the complete service performed

Mutually Exclusive : This edit will deny a claim line that would not reasonably performed on the same patient on the same day

Same Day Visit : This edit will deny claim lines containing Evaluation and Management codes billed on the same date of service as a procedure code with a global period.

Pre-Op Visit : This edit will deny claim lines containing Evaluation and Management codes billed within the pre-operative period of a procedure code with a global period.

Post Op Visit :This edit will deny claim lines containing Evaluation and Management codes billed within the post-operative period of a procedure code with a global period.

Age Replacement Edit: This edit will deny claim lines containing procedure codes inconsistent with the patient’s age and replaces the line with the age-appropriate code.

Gender Replacement Edit : This edit will deny claim lines containing procedure codes which are inconsistent with the member’s gender and replaces the line with the gender-appropriate code.

Modifier to Procedure Edit :This edit will deny claim lines with invalid modifier to procedure code combinations for those modifiers identified as payment modifiers.

Same Day Laboratory : This rule will deny claim lines with a laboratory procedure submitted without modifier -91 when the same laboratory
procedure was previously submitted by the same provider for the same member and same date of service.

Same Day Laboratory 2 : This rule will deny claim lines with laboratory procedure codes submitted with units of service that exceed the date range on the
line and neither modifier -59 nor -91 were appended to the
procedure code.

Co-Surgeon : This rule will deny claim lines submitted with modifier -62 (Co- Surgeon) when the procedure code typically does not require co- surgeons as determined by the Centers for Medicare & Medicaid Services (CMS), and Current Procedural Terminology (CPT®) co- surgeon guidelines.

Obstetrics Package Rule : This rule will deny potential overpayments for obstetric care. It will evaluate claim lines to determine if any global obstetric care
codes (defined as containing antepartum, delivery and postpartum services, for example code 59400) were submitted with another global OB care delivery code.

Medically Unlikely Edits (MUEs) DME Multiple Lines : This rule will deny claim lines when the units of service for the DME items has been exceeded for a HCPCS code submitted by a provider or multiple providers for the same member and same date of service. The rule is based upon the MUE values from CMS Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS).

Continuous Positive Airway Pressure or Bi-level Positive Airway Pressure (CPAP/ BIPAP) Supply Frequency This rule will deny claim lines submitted with supply codes associated with CPAP/BIPAP therapy when the number of units for those supplies exceeds the recommended replacement schedule as determined by CMS.

CMS Local Coverage Determination L11518, L11528, L171, L27230 may be located using the Medicare Coverage Database on the CMS website at:  http://www.cms.gov/medicare-coverage- database/overview-and-quick-search.aspx
MUEs Multiple Lines : This rule will deny claim lines when the units of service submitted for CPT/HCPCS codes by the same provider, same
member, same date of service, exceeds the MUEs established by CMS for that CPT/HCPCS code.

Frequency Validation – Allowed Multiple Times Per Date of Service Filter : This rule will deny claim lines that contain procedure codes that have been submitted more than once per date of service when the code description is defined as once per date of service.

Frequency Validation – Allowed Once Per Date of Service Filter : This rule will deny claim lines when the quantity billed for the procedure code exceeds maximum allowed per date of service, per site.

CMS National Correct Coding Initiative : The CMS National Correct Coding Initiative (NCCI) policies are based on coding conventions defined in the American Medical
Association (AMA) CPT manual, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice and/or current coding practice. This rule will deny claim lines for which the submitted procedure is not recommended for reimbursement as defined by a code pair found in the NCCI.

Outpatient Facility – MUEs Multiple Lines : This rule will deny outpatient facility claim lines when the units of service submitted for CPT/HCPCS codes by the same provider, same member, same date of service, exceeds the MUEs established by CMS for that CPT/HCPCS code.

Facility Outpatient Code Editor (OCE) CMS CCI Bundling Rule : This rule will deny outpatient facility claim lines containing code pairs found to be unbundled according to CMS Integrated Outpatient Code Editor (I/OCE).

Facility Unbundled Pairs : Outpatient Rule This facility rule identifies the unbundling of multiple surgical codes when submitted on facility claims. The rule detects surgical code pairs that may be inappropriate for one of the following reasons: one code is a component of the other code, or these codes would not be reasonably performed together on the same date of service.


Age Code Replacement Rule : This rule will identify claim lines containing procedure codes or preventive evaluation and management (E/M) codes that are inconsistent with the member’s age for which an alternate code is more appropriate for the age.


In addition to the correct coding edits, A/B MACs (B) must be capable of detecting certain other services included in the payment for a major or minor surgery or for an endoscopy. On a prepayment basis, A/B MACs (B) identify the services that meet the following conditions:

• Preoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure; or

• Same day or postoperative services that are submitted on the same claim or on a subsequent claim as a surgical procedure or endoscopy;
and -

• Services that were furnished within the prescribed global period of the surgical procedure;

• Services that are billed without modifier “-78,” “-79,” “-24,” “25,” or “-57” or are billed with modifier “-24” but without the required documentation; and

• Services that are billed with the same provider or group number as the surgical procedure or endoscopy. Also, edit for any visits billed separately during the postoperative period without modifier “-24” by a physician who billed for the postoperative care only with modifier “-55.”

A/B MACs (B) use the following evaluation and management codes in establishing edits for visits included in the global package. CPT codes 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99271, 99272, 99273, 99274, and 99275 have been transferred from the excluded category and are now included in the global surgery edits.


Evaluation and Management Codes for A/B MAC (B) Edits

92012
92014
99211
99212
99213
99214
99215
99217
99218
99219
99220
99221
99222
99223
99231
99232
99233
99234
99235
99236
99238
99239
99241
99242
99243
99244
99245
99251
99252
99253
99254
99255
99261
99262
99263
99271
99272
99273
99274
99275
99291
99292
99301
99302
99303
99311
99312
99313
99315
99316
99331
99332
99333
99347
99348
99349
99350
99374
99375
99377
99378


NOTE: In order for codes 99291 or 99292 to be paid for services furnished during the preoperative or postoperative period, modifier “-25” or “-24,” respectively, must be used to indicate that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed.

If a surgeon is admitting a patient to a nursing facility for a condition not related to the global surgical procedure, the physician should bill for the nursing facility admission and care with a “-24” modifier and appropriate documentation. If a surgeon is admitting a patient to a nursing facility and the patient’s admission to that facility relates to the global surgical procedure, the nursing facility admission and any services related to the global surgical procedure are included in the global surgery fee.


Services billed with the modifier “-25,” “-57,” “-58,” “-78,” or “-79.”

Exceptions

See §§40.2.A.8, 40.2.A.9, and 40.4.A for instances where prepayment review is required for modifier “-25.” In addition, prepayment review is necessary for CPT codes 90935, 90937, 90945, and 90947 when a visit and modifier “-25” are billed with these services


Exclude the following codes from the prepayment edits required in §40.3.B.
92002
92004
99201
99202
99203
99204
99205
99281
99282
99283
99284
99285
99321
99322
99323
99341
99342
99343
99344
99345

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