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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.

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

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

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