We’re planning to update our clinical edits for Medicare Advantage PPO claims

Blue Cross Blue Shield of Michigan Medicare Advantage PPO will update clinical edits applied to claims starting in June or shortly thereafter. We’re enhancing the edits as part of our efforts to promote correct coding for claims.

These improvements will help ensure that our claim payment policies align with nationally recognized sources of information and are easy to understand. They’ll also help us better meet the needs of a changing health care industry while maintaining alignment with national coding guidelines.

MA PPO medical and payment policies will continue to comply with:

• National coverage determinations
• General coverage guidelines included in original Medicare manuals and instructions
• Written coverage decisions of the local Medicare administrative contractor

Some of the enhancements include, but are not limited to:

• CCI edits
• Evaluation and Management Services
• Global surgery period

As with the application of all our clinical edits, the guidelines and regulations of these sources should be followed:

• Centers for Medicare & Medicaid Services’ medical policies
• American Medical Association CPT coding guidelines
• National bundling edits, including the Correct Coding Initiative
• Modifier usage
• Global surgery period
• Add‑on code usage

As the enhancements draw closer, we’ll provide updates.

The appeal process won’t change with the expanded edits, but new edit codes will be published in the coming months. Continue to submit appeals on the Clinical Editing Appeal Form with the necessary supporting documentation. And remember to continue to fax one appeal at a time to avoid processing delays.