ClaimsXten to include additional professional and outpatient facility edits, starting in October

Starting in October 2021, ClaimsXten™ will edit additional services for professional and outpatient facility providers on Blue Cross Blue Shield of Michigan commercial claims. These new edits are part of our ongoing effort to promote correct coding and enhance our claims payment systems.

If you receive one of these edits, submit a corrected claim when appropriate. If you believe the services rendered warrant an exception, submit a clinical editing appeal with medical records.

Here are highlights of what these rules identify and edit:        

• Identifies global obstetric care codes (defined as containing antepartum, delivery and postpartum services) and evaluates history to determine if another global OB care code or a component code, such as antepartum care, postpartum care or delivery‑only services has been submitted (professional claims only)
• Claims containing code pairs found to be unbundled, according to Centers for Medicare & Medicaid Services Integrated Outpatient Code Editor (outpatient facility claims only)
• Procedures that don’t warrant multiple submissions of a procedure or group of procedure codes on a single date of service, or across a date‑of‑service range, when billed by the same or different providers (professional claims only)
• Claim lines where the CMS medically unlikely edits, or MUE, has been exceeded for a CPT or HCPCS code, when reported by the same provider, for the same member, on the same date of service (outpatient facility claims only)
• Claim lines where the CMS MUE has been exceeded for a CPT or HCPCS code, when reported by the same provider, for the same member, on the same date of service (professional claims only)        
• Claim lines with procedure codes that are eligible for the CMS Multiple Procedure Payment Reduction on the Technical Component of Diagnostic Ophthalmology (professional claims only)
• Claim lines that are eligible for pay percent adjustments for multiple quantity. Also applies pay percent adjustments when an eligible procedure code is billed with the modifier 78, FY or FX (professional claims only)
• Multiple endoscopy procedures, reported within the same family, and application of the multiple endoscopy pay percent reduction per CMS guidelines. This applies to surgeon and assistant surgeon (professional claims only).
• Home health care claims that are billed in excess of the allowed number of visits per day (facility claims only).
• Pre‑admission testing when the services are rendered the same day as an inpatient DRG admission or up to seven days prior to an inpatient DRG admission (facility claims only)
• Trauma activation on facility claims if an ambulance transport isn’t paid in history (facility claims only)

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 records.