Claim editing enhancements coming later this year to Medicare Plus Blue claims

To promote correct coding and assist with payment accuracy, Blue Cross Blue Shield of Michigan will enhance its claim editing process for Medicare Plus Blue℠ claims with the following updates later this year. However, we encourage you to follow these guidelines now:

• Primary diagnosis only — Certain diagnosis codes can only be billed in the first-listed or primary diagnosis code field on claims, according to the International Classification of Disease, or ICD. There is an identifier in some ICD‑10‑CM manuals for these codes. We’ll edit the claim line if a primary‑only diagnosis code is billed in a position other than the first‑listed or primary position.
• Surgical procedures requiring anatomical modifiers — CPT codes in the range *10000‑*69999, having a Medicare Physician Fee Schedule, or MPFS, bilateral indicator “1” denote that the surgical code is eligible to be billed on both sides of the body. We’ll edit the surgical code when anatomical modifiers (50, LT, RT, E1, E2, E3, E4, F1, F2, F3, F4, F5, F6, F7, F8, F9, FA, T1, T2, T3, T4, T5, T6, T7, T8, T9, TA, LC, LD, RC, LM, RI) are appropriate, but haven’t been appended to the claim line. For details, refer to the Medicare Claims Processing Manual, Chapter 23, Section 20.9.3.2.
• High‑level E/M codes billed with preventive medicine services — We’ll edit high‑level evaluation and management services (CPT codes *99204, *99205, *99214, *99215) when billed for the same patient on the same date of service as a preventive evaluation and management service (CPT codes *99381 through *99387 and *99391 through *99397). For details, refer to the Medicare Claims Processing Manual, Chapter 12, Section 30.6.

We’ll provide updates on other pertinent information, including when these edits will be effective, in future communications.

Note: The appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form with the necessary supporting documentation. Also, continue to fax one appeal at a time to avoid processing delays.