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Commercial Code Bundling

Overview

Note: For Professional Claims Only

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 from sources such as but not limited to:
National Correct Coding Initiative (NCCI)
American Medical Association (AMA)
Centers for Medicare and Medicaid Services (CMS)
Medical Societies and Associations
BlueCross BlueShield of Tennessee Reimbursement Policies
BlueCross BlueShield of Tennessee clinical expertise

Reimbursement Rule Indicators and RBRVS

Please refer to the appropriate billing and reimbursement sections of the BlueCross BlueShield of Tennessee Provider Administration Manual for additional information. Additionally, the Centers for Medicare & Medicaid Services website offers Commercial Reimbursement Rule Indicators and RBRVS Relative Value Units (RVUs) guidance that may be helpful.

More about 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 Orthopedic 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

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.

Definitions

Comprehensive Code (Column 1) Generally represents the major procedure or service when reported with another code.

More about 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).

Reversed NCCI
The order of the Comprehensive and Component Codes have been reversed based on the Medicare's Physician Work RVU's when clinically indicated so the code with the higher RVU will be considered the Comprehensive code.

Retained NCCI
The BlueCross BlueShield of Tennessee edits are based on NCCI logic.
Example: Effective 01/01/10, 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 BlueShield of Tennessee continues to allow providers to bill these consultation codes; therefore, the edits related to these CPT® codes were retained by BlueCross BlueShield of Tennessee.

Bundling Rationale (Claims filed before Aug. 25, 2017)

BlueCross BlueShield of Tennessee uses a clinical editing database. The clinical editing rationale supporting this database is provided here to assist you in understanding the rationale behind certain code pairs in the database.

Code pairs reported here are updated quarterly based on the following schedule.

Date Data Effective for Source

Date Change Is Applied by BCBST

January 1

April 1

April 1

July 1

July 1

October 1

October 1

January 1

 

These updates will be published on BCBST.com at least 30 days prior to the effective date of any additions, deletions or changes.

2017

Summary of Changes 2017

Code Bundling Rationale 2017 Q3

CPT® Codes

Code Bundling Rationale 2017 Q2

CPT® Codes

Code Bundling Rationale 2017 Q1

CPT® Codes

2016

Summary of Changes 2016

Code Bundling Rationale 2016 Q4

CPT® Codes

Code Bundling Rationale 2016 Q3

CPT® Codes

Code Bundling Rationale 2016 Q2

CPT® Codes

Code Bundling Rationale 2016 Q1

CPT® Codes

2015

Summary of Changes 2015

Code Bundling Rationale 2015 Q4

CPT® Codes

Code Bundling Rationale 2015 Q3

CPT® Codes

Code Bundling Rationale 2015 Q2

CPT® Codes

Code Bundling Rationale 2015 Q1

CPT® Codes

2014

Summary of Changes 2014

Code Bundling Rationale 2014 Q4

CPT® Codes

Code Bundling Rationale 2014 Q3

CPT® Codes

Code Bundling Rationale 2014 Q2

CPT® Codes

Code Bundling Rationale 2014 Q1

CPT® Codes

2013

Summary of Changes 2013

Code Bundling Rationale 2013 Q4

Code Bundling Rationale 2013 Q3

Code Bundling Rationale 2013 Q2

Code Bundling Rationale 2013 Q1

2012

Summary of Changes 2012

Code Bundling Rationale 2012 Q4

Code Bundling Rationale 2012 Q3

Code Bundling Rationale 2012 Q2

Code Bundling Rationale 2012 Q1

2011

Summary of Changes 2011

Code Bundling Rationale 2011 Q4

Code Bundling Rationale 2011 Q3

Code Bundling Rationale 2011 Q2

April1, 2011 - June 31, 2011

Code Bundling Rationale 2011 Q1

January 1, 2011 - March 31, 2011

CPT® Codes

2010

Summary of Changes 2010

Code Bundling Rationale 2010 Q4

October 1, 2010 - December 31, 2010

CPT® Codes

Code Bundling Rationale 2010 Q3

July 1, 2010 - September 30, 2010

CPT® Codes

Code Bundling Rationale 2010 Q2

April 1, 2010 - June 30, 2010

CPT® Codes

Code Bundling Rationale 2010 Q1

January 1, 2010 - March 31, 2010

CPT® Codes

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