We’re enhancing our claim editing for Medicare Plus Blue

In 2023, Blue Cross Blue Shield of Michigan will enhance its Medicare Plus Blue℠ claim editing process for multiple type of bill 0131 claims, submitted for the same member and date of service.

All outpatient services performed on the same date of service, by the same health care provider, should be reported on the same claim. Any necessary correction or addition to the claim should be reported using a different type of bill. We’ll immediately begin retrospective claim adjustments to promote correct coding and assist with payment accuracy.

Subsequent claims submitted after an initial outpatient claim with TOB 0131 will be denied.

There should be only one claim with TOB 0131 per patient, per facility, per day. If a claim is submitted with TOB 0131 and additional charges or changes need to be submitted, a corrected claim should be submitted with either a 0137 or 0138 bill type. If a TOB 0137 claim is submitted, this indicates that the previous claim was incomplete and the current claim has all the information that should have been included from the first claim. 

According to Uniform Billing Editor:

• Hospitals are required to report all outpatient prospective payment system services that are provided on the same day of surgery, on the same claim, except claims containing condition codes 20, 21, or G0.
• Hospitals and community mental health centers can’t submit a late charge bill for TOB code 012X, 013X, 014X or 076X.  Instead, they must submit an adjustment claim using TOB code 0XX7 for any services required to be billed with a HCPCS code, units and line-item dates of service. A separate claim containing only late charges isn’t allowed by Medicare.

Exclusions

Claims with condition code 20, 21, G0 reported in any position and repetitive billing type of service revenue codes:

• DME rental 0290 to 0299
• Respiratory therapy 0410, 0412, 0419
• Physical therapy 0420 to 0429
• Occupational therapy 0430 to 0439
• Speech-language pathology 0440 to 0449
• Skilled nursing 0550 to 0559
• Kidney dialysis treatments 0820 to 0859
• Cardiac rehabilitation services 0482, 0943
• Pulmonary rehabilitation services 0948

Note: The best way to receive payment for these services is to submit a corrected claim. If necessary, you can use the appeal process, which won’t change. Continue to submit appeals on the Clinical Editing Appeal Form with the necessary documentation. Fax one appeal at a time, to avoid processing delays. If appealing a retrospective recovery, refer to your provider manual for appeal options or call 1-866-309-1719.