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:
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.
Comprehensive Code (Column 1) generally represents the major procedure or service when reported with another code.
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).
BlueCross edits are based on NCCI logic.
Example: Effective Jan. 1, 2010, 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 continues to allow providers to bill these consultation codes; therefore, the edits related to these CPT® codes were retained by BlueCross.
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