Overview

Overview

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

  • National Correct Coding Initiative (NCCI)
  • American Medical Association (AMA) coding guidelines such as:
    • CPT® Manual
    • CPT® Clinical Examples
    • CPT® Assistant
    • CPT® Changes
    • CPT® Companion
    • CPT® Information Services
    • Principles of CPT®
  • Centers for Medicare and Medicaid Services (CMS) guidelines such as:
    • HCPCS Manual
    • CMS Program Memorandums and Transmittals
    • Federal Register
    • Medicare Part B Medicare Bulletins
    • Medicare Durable Medical Equipment Regional Carrier (DMERC) DMEPOS Supplier Manual and Revisions
    • DMERC Advisories
    • Statistical Analysis DMERC (SADMERC) Product Classification Lists
    • Statistical Analysis DMERC (SADMERC) Coding Bulletins
  • Guidelines published by medical societies/associations such as:
    • American Academy of Orthopaedic Surgeons (AAOS)
    • American College of Obstetricians and Gynecologists (ACOG)
  • BlueCross BlueShield of Tennessee code bundling 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 BlueShield of Tennessee clinical expertise
  • Review criteria for modifiers that bypass code bundling edits pdf file

BlueCross BlueShield of Tennessee code bundling rules will be applied during the claim payment process, when feasible. Some edits can only be applied when all associated claims are processed. In those cases, the edit will be applied during the retrospective audit process when all associated claims are available for review.

Code bundling can occur on multiple levels depending on the combination of codes reported. For example, when multiple codes are billed for one date of service, two codes could bundle into one code. That one code could then bundle into another code.

BlueCross BlueShield of Tennessee 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.

Code bundling edits for BlueCare® and TennCareSelect were implemented March 1, 2014.  Further information on these edits may be found on bluecare.bcbst.com, the BlueCare Tennessee website.

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

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Page Modified:May 21, 2012