ClaimsXten™ coming to outpatient facilities claims in 2016

Blue Cross Blue Shield of Michigan will begin using McKesson’s clinical coding solution, ClaimsXten, for outpatient facility claims beginning in the first quarter of 2016. This change will apply to services that require Healthcare Common Procedure Coding System reporting.

We will include detailed information in the August 2015 edition of The Record.

Here’s an overview of how ClaimsXten will process claims for outpatient facility services:

Incidental and mutually exclusive services:

• Identifies a HCPCS code performed at the same time as a more complex procedure and that’s clinically tied to the outcome of the primary procedure.
• Identifies procedures that differ in technique and approach but lead to the same outcome.

Same-day medical services:

• Identifies certain HCPCS codes billed by the same facility on the same date of service as a code with a global period.

Clinical daily recommended allowance — all allow once per date of service:

• Identifies claim lines that contain a HCPCS code that allows the service once for a single date of service and the maximum number of times allowed has been exceeded.

Clinical Daily Recommended Allowance — allow multiple times per date of service:

• Identifies claim lines that contain a HCPCS code where the maximum number of times the service may be submitted per date of service has been determined, is more than one and has been exceeded.

Multiple code rebundling:

• Identifies claims containing two or more HCPCS codes used to report a service when a single, more comprehensive procedure code exists that more accurately represents the service performed.

Multiple radiology reduction:

• Identifies certain radiology procedures performed during the same session that are eligible for a reduction when submitted by the same facility.

CMS always bundled:

• Identifies claim lines that contain a Centers for Medicare and Medicaid Services HCPCS code that’s always bundled when billed with another procedure.

Modifiers:
Keep in mind that in certain cases, modifiers may change the payment decision. When appropriate, Blue Cross will support the use of modifiers that indicate unique circumstances for individual patients. The use of modifiers should be documented in the patient’s medical record.

• Modifiers 25, 59, XE, XS, XU and site specific modifiers will identify the claim line as a separate and distinct service or anatomic site to override the incidental and mutually exclusive result.
• Modifiers 25 and 57 will identify the service as a separate service or a decision for surgery to override the same-day medical service result.
• Modifiers 26, TC, 76, 91, LC, LD, LM, RC, RI and site modifiers will identify the claim line as a separate and distinct service or anatomic site to override the Clinical Daily Recommended Allowance - allow once per date of service result.
• Modifiers 76, 91 and site modifiers will identify that a service has been repeated or anatomic site to override the Clinical Daily Recommended Allowance - allow multiple times per date of service result.
• Modifiers 59, XE, XS and XU will identify the claim line as a separate and distinct service to override multiple radiology reduction result.

If you have questions about a ClaimsXten payment decision, you may:

• Request a clinical edit review. We’ll work with our medical consultant to determine if the clinical edit should be changed. Contact Provider Inquiry or your provider consultant.
• Pursue an individual case review. Follow the same process as you would for any claim rejection.

Watch for more information about what ClaimsXten will mean for outpatient facilities in future issues of The Record.