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December 2015
ClaimsXten™ coming to outpatient facilities next year: Let us help you make the transition
As you’ve read in The Record previously, McKesson ClaimsXten is coming to outpatient facility claims in early 2016. Below we’ve outlined how ClaimsXten will further align Blue Cross Blue Shield of Michigan’s outpatient and professional payment policy as it relates to quantity, bundling and same-day medical services. Also included is additional detail regarding appropriate reimbursement for multiple surgical and multiple radiology services.
Coding category |
What you need to know |
Incidental and Mutually Exclusive |
An incidental procedure is one that is performed at the same time as a more complex procedure and is integral to the successful outcome of the primary procedure.
A mutually exclusive edit consists of combinations of procedures that differ in technique or approach but lead to the same outcome. In some instances, the combination of procedures may be anatomically impossible. Procedures that represent overlapping services are considered mutually exclusive. In addition, reporting an initial service and subsequent service is considered mutually exclusive.
This rule will occur before the consolidation of surgical services that occurs today. |
Same Day
Medical Services |
Identifies evaluation and management services reported on the same day as certain medical, diagnostic and therapeutic services where a global period is assigned and should not reimburse separately. |
Clinically Recommended Daily Allowance —
allowed once per date of service |
Quantity limits will continue as it does today for outpatient facility services, but will be administered and maintained by ClaimsXten. Identifies claim lines that contain a procedure code that allows the service once for a single date of service when the maximum number of times allowed has been exceeded. |
Clinically Recommended Daily Allowance —
allowed more than once per date of service |
Quantity limits will continue as it does today for outpatient facility services, but will be administered and maintained by ClaimsXten. Identifies claim lines that contain a procedure code where the maximum number of times the service may be submitted per date of service has been determined, is more than one, and the maximum number of times allowed has been exceeded. |
Multiple Code Rebundling |
Identifies claims containing two or more procedure 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 is eligible for a reduction when performed at the same time. ClaimsXten will follow CMS guidelines.
When a procedure code is eligible for the multiple radiology reduction, Blue Cross will pay the code with the highest allowed amount in full for the technical component. Subsequent procedure codes eligible for multiple radiology reduction will be paid at 50 percent of the allowed amount. |
CMS Always Bundled Procedures |
Identifies claim lines that contain a procedure code indicated by the Centers for Medicare & Medicaid Services to always be bundled when billed with another procedure. ClaimsXten will follow CMS guidelines. |
Modifiers may be used as appropriate
Modifiers are used to indicate that a service or procedure has been altered by some specific circumstance, or to provide more information regarding the service performed. Most modifiers apply to a group of procedure codes and may only be reported with those specified codes.
Per billing guidelines, outpatient facilities should report, as required, modifiers for the appropriate procedure code. Modifiers can affect the payment policy recommendation given by ClaimsXten, but doesn’t guarantee payment. Use of the following modifiers where appropriate will ensure payment accuracy and coding consistency.
Coding category |
Modifier(s) |
What the modifier does |
Incidental and Mutually Exclusive |
-25, -59, -XE,- XS, -XU and site specific modifiers |
Identifies the claim line as a separate and distinct service or anatomic site to override the incidental and mutually exclusive result |
Same Day
Visit |
Modifier -25 |
Identifies the service as separate and distinct from other reported services
Note: According to national reporting guidelines, modifier 57 is not applicable to outpatient facility reporting. |
Clinically Recommended Daily Allowance — allowed once per date of service |
-76, -91, -LC, -LD,
-LM, -RC, -RI and site specific modifiers |
Identifies 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. The clinical record should indicate the repeat service.
Blue Cross payment policy recognizes modifier 76 when reported with surgical pathology procedure codes.
Note: According to national reporting guidelines, modifiers TC and 26 are not applicable to outpatient facility reporting. |
Clinically Recommended Daily Allowance — allow multiple times per date of service |
-76, -91 and site specific modifiers |
Identifies that a service has been repeated to allow multiple times per date of service. The clinical record should indicate the repeat service. |
Multiple Code Rebundling |
-59, -XE, -XS and -XU and site specific modifiers |
Modifiers indicate a distinct and separate service to allow component codes. The clinical record should indicate the separate and distinct services performed. |
Multiple Radiology Reduction |
-59, -XE, -XS and -XU |
Identifies the claim line as a separate and distinct service to prevent a reduction of radiology procedures that were preformed in separate times. |
Billing identical procedures multiple times
The clinically recommended daily allowance determines the number of times identical procedures can be billed on a single date of service for the same patient. The total number of times that a specific procedure code may be allowed reflects the number of times that it is clinically appropriate to perform the service on a single date of service across all anatomic sites.
ClaimsXten quantity editing determines when the use of multiple units is appropriate. Factors included in this determination are derived from the nomenclature for a particular procedure code or the ability to clinically perform a particular service more than one time on a single date of service.
All or any of the following factors below will determine the number of times a code is eligible for reimbursement on a single date of service:
- The nomenclature of a procedure code includes the word “bilateral.”
- The nomenclature of a procedure code includes the phrase “unilateral/bilateral.”
- A procedure code description specifies “unilateral” and there is another code for the bilateral service or another add-on code for additional services. (The unilateral procure code cannot be submitted more than once on a single date of service.)
- The total number of times it is clinically possible to perform a given procedure on a single date of service might be limited. In some circumstances, a site specific modifier will allow a code to process when used more than once. These modifiers will identify the specific side or finger digit when more than one site is being treated or evaluated.
- When a procedure code is submitted with multiple units — and only a single unit is allowed — reimbursement will be based on only one unit unless an appropriate modifier is appended.
- Surgical services are not subject to quantity reimbursement; they are subject to multiple surgical bundling logic.
New reporting and payment policy guidelines
New reporting and payment policy guidelines |
CPT codes *94760, *94761, *94762 |
When reported with another service, pulse oximetry will be considered part of the other reported service and not separately reimbursed. |
Blue Cross continues to demonstrate its commitment to the development of a fair and consistent payment policy by working collaboratively with its participating outpatient facility providers. If you have questions about a Blue Cross payment decision, contact your provider consultant or continue to follow the same appeals process that you do today. |
