Here’s more information about professional claim editing enhancements, including DME/P&O services

On Dec. 21, 2018, Blue Cross Blue Shield of Michigan added advanced claim editing for select groups. This is an enhancement to our claim editing processes that encourage correct coding. The goal is to have claim payment policies that are national in scope, simple to understand and come from respectable sources. Given the widespread use of these policies, we believe this will help you and your billing staff to better understand our payment of your claims.

The enhancements are for the correct reporting of:

• Diagnosis codes
• Procedure age
• Modifier guidelines
• Global surgery
• Split surgical care
• Co-surgery
• Team surgery
• Once per lifetime services
• Place of service
• Anesthesia

We’ll administer nationally recognized clinical editing based on guidelines established by American Medical Association CPT guidelines, Centers for Medicare & Medicaid Services standards and general peer accepted standards.

Examples of some edits we’ll adopt:

• Use modifier 79 to report a service performed by the same provider only when the service is unrelated to the original procedure during the 0-day, 10-day or 90-day global period. Documentation must clearly indicate that the procedure is unrelated to the prior surgical procedure.
• Professional services billed by a durable medical equipment supplier, physical therapist or speech-language pathologist during the same time period as institutional hospice care is included in the institutional stay.
• Bill a finger extension or flexion device (procedure code E1825) with the proper finger modifier (FA-F9).
• Manual wheelchair accessories shouldn’t be billed with a power wheelchair.
• Capped rentals should be billed with no more than one capped rental modifier (KH, KI, KJ) on the same claim line.

You can review previous publications on our claim editing process enhancements in the September 2018 Record and the December 2018 Record.

Appeal process for clinical edits

In addition, we’re also streamlining the appeal process for clinical edits. The following changes will begin Jan. 1, 2019:

• Appeals must be submitted with a Clinical Editing Appeal form. All required fields must be completed or the appeal will be returned to you. This form can be found on the Blue Cross provider site. It will also be available in the online provider manual on web-DENIS.
• Submit the appeals form one of the following ways:
• Fax it to 1-866-392-7191
• Mail it to Clinical Editing Appeals
  Mail Code G820
  Blue Cross Blue Shield of Michigan PPO
  611 Cascade West Parkway, SE
  Grand Rapids, MI 49546-2143
• Appeals must be submitted within 180 days of the original clinical editing denial.
• Documentation supporting the appeal must be submitted with the appeal. What is required may vary on the service being appealed. For example, office services that have denied may require office notes, services denied as duplicates will require records for both the denied and paid service to show more than one was performed, surgical denials may require operative reports, and so on. It’s important to look at the denial reason and submit documentation appropriate to the procedure code that was denied and the denial reason.

This process is based on the BCN and Medicare Advantage clinical editing appeals processes. So, if you have submitted an appeal to BCN or MA PPO in the past for a clinical edit, then you have followed the process that will be in place for PPO. The only differences are the explanation (or message) codes and the fax number.

If you have questions about the changes in the appeal process, contact Provider Inquiry at 1-866-344-8525 or contact your provider representative.