Anthem Blue Cross and Blue Shield (Anthem) CLAIMS XTEN TM RULES Version 4.4 Effective December 8, 2012

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1 Rules Edit logic Example Suppted After Hours not Reimbursable with Preventive Diagnosis This will deny (services provided when the office is usually closed) when billed with a preventive diagnosis and/ a preventive service. Code will be denied when billed with diagnosis V202 Anthem After Hours Applied to dates of service on after ICD 10 diagnosis updates to be done at a later date. Mton s Neuroma: 64450, 64640, and Not Reimbursable with Diagnosis This will deny 64450, when billed with diagnosis This is suppted AMA/CPT which developed specific codes f these services f this diagnosis. Code will be denied if billed with diagnosis AMA/CPT Claim Editing Overview Applied to dates of service on after ICD 10 diagnosis updates to be done at a later date. Durable Medical Equipment billed without DME modifier (NU, UE, RR, RA, RB, MS) Maintenance and Servicing of Durable Medical Equipment (Modifier MS) This will deny the DME code if the code is billed without the appropriate DME modifier. (NU, UE, RR, RA, RB, MS) This will deny specific rental DME billed with modifier MS (6 month s maintenance and service fees parts and lab).. Refer to the DME reimbursement policy Code E0250 will be denied when billed without a DME modifier Code E0935 when billed as a rental with modifier MS will be denied. Centers f Medicare & Medicaid Services () DME Edit applied to all claims processed on after December 8, 2012, regardless of date of service. Anthem DME Edit applied to dates of service on after 1

2 Rules Edit logic Example Suppted Maintenance and Servicing of DME frequency (modifier MS) Maximum DME Rental Allowable Has Been Reached (modifier RR) This will determine if maintenance and servicing is allowed. When allowed a DME code with modifier MS will be denied if maintenance and servicing has been repted within the previous six months This editing will deny DME codes billed as a rental with modifier RR when the item has been rented f me than 10 months. Code E0574 is eligible f maintenance and servicing but a histy line f same item has modifier MS within six months. The current claim line will be denied DME Code K0813 modifier RR has been previously billed f 10 months. When the claim with the 11th occurrence of rental is received the claim will be denied. DME Edits applies to dates of service on after DME Edit applied to all claims processed on after December 8, 2012, regardless of date of service. Purchase of Rental DME previously Rented (modifiers RR, NU, UE, NR) This will pend the line when durable medical equipment is billed with modifier NU UE NR and pri claims have been billed with modifier RR within pri ten months. The purchase claim will be reviewed to ensure that the allowable f the rental and purchase do not exceed the maximum allowable f the item. Current line: E0574/NU f date of service 10/01/2010, Paid Histy line: E0574/RR f date of service 03/01/ /31/2010 The will pend f review and pricing. DME Edits applies to dates of service f the purchase on after 2

3 Rules Edit logic Example Suppted Rental of DME previously purchased (modifiers RR, NU, UE, NR) Repair and Replacement of Rented Durable Medical Equipment (modifiers RA, RB, KC) This editing will deny durable medical equipment when billed with rental modifier (RR) if same item has been previously purchased (modifiers NU UE NR) in the member's claim histy. This will deny line billed f a rented durable equipment item with modifier (s) RA RB and KC. Anthem does not reimburse f these services f rented equipment. DME procedure code K0813 modifier RR is billed and the member s histy indicates this same item was previously purchased (modifier NU UE NR). The Rental line will be denied Code E0935 has been rented and is billed with modifier RA. This charge line will be denied. DME Edits applies to dates of service f the rental on after Anthem DME Edit applied to dates of service on after Modifier 25: Multiple Evaluation and Management procedures billed with modifier 25 This will deny the lower valued evaluation and management procedures when two preventive two problem iented E/Ms are billed on the same date of service. Modifier 25 does not override this edit. Code is billed twice f the same date of service and modifier 25 is added to one procedure. Only a single visit will be allowed. Standard CPT/AMA Evaluation and Management Services and Related Modifiers 25 & 57 Me Than 1 Same Day E/M service section Edit applied to all claims processed on after December 8, 2012, regardless of date of service. 3

4 Rules Edit logic Example Suppted Screenings with preventive problem iented E/Ms This will deny screening services G0101, G0102 and Q0091and annual exam codes (S0610, S0612, &/ S0613) when repted with a preventive E/M service. When Screening services are perfmed at the same time as a problem iented exam, the screening service should be taken into account when determining the crect level of problem iented E/M service ( ) to rept. Modifiers will not override the edit. G & G will deny when billed with S0612 will deny when billed with Anthem Evaluation and Management Services and Related Modifiers 25 & 57 Screening Services with Evaluation and Management edits applied to dates of service on after Lab Service in Facility Place of Service This editing will deny the line if the National Physician Fee Schedule Relative Value File (NPFSRVF) designates that the concept of a separate professional and technical component does not apply to a labaty procedure (PC/TC indicat of 3 9), and the procedure is billed in facility place of service. A lab code that a PC/TC indicat of 3 9 in the NPFSRVF file on the date of service billed (eg ) with place of service outpatient hospital (22). Will be denied. Labaty and Venipuncture Services, Technical/Professional Modifiers TC/26 section. Claim Editing Overview Edit applied to dates of service on after 4

5 Rules Edit logic Example Suppted Multiple Diagnostic Imaging Reductions Patient Home Sleep Studies Following () policy, this will reduce the technical component of the diagnostic imaging procedures that have a Multiple Procedure Indicat of 4 on the National Physician Fee Schedule (NPFS) 50% (based on the RVU f the date of service) when multiple diagnostic imaging procedures with a MPI of 4 are billed f the same date of service. Note when codes are submitted unmodified an algithm will be applied to determine the % of the charge f the technical component and the reduction will be applied to this percentage of total charge. This editing will deny the charge f attended sleep study procedures when billed with place of service home (12). Codes TC and TC same day are submitted. Code has a higher RVU value, 100% of the technical fee schedule amount will be allowed. Code has a lower RVU than 72146, 50% TC fee schedule amount and 100% of the 26 fee schedule amount will be allowed. Code will be denied when billed with place of service home (12) Multiple Diagnostic Procedures Subsequent procedure that has an MPI of 4 in the multiple procedure column of the National Physician Fee Schedule (NPFS).. Edit applied to dates of service on after 01/01/2013 if not present in provider contract with earlier effective date. Anthem Place of Service Edit applied to dates of service on after Prolonged Services 99354, Not Reimbursable with Diagnosis This will deny code when the diagnosis submitted is not on the Anthem list. Codes will be denied when billed with diagnosis Anthem Prolonged Services Edit applied to dates of service on after ICD 10 diagnosis updates to be done at a later date 5

6 Rules Edit logic Example Suppted Anesthesia Complicated Emergency Situations Not Reimbursable with Diagnosis Diagnosis Invalid f Patient s Age This will deny code (anesthesia complicated emergency situation) when billed with a routine maternity diagnosis in the Anthem list. CXT 4.4 Revision Additional diagnoses have been added, refer to the Anesthesia f additional details. This will deny a line when the referenced diagnosis is inappropriate f the patient s age CXT 4.4 Revisions: The age range appropriate f reproductive services will be changed from 9 60 to ages Code will be denied when billed with diagnosis V22.0, V22.1, 650 etc. Claim line billed with diagnosis 650 will be denied f a patient age Anthem Anesthesia edit applies to all dates of service. ICD 10 diagnosis updates to be done at a later date. Claim Editing Overview This is applied to ICD 10 updates to be done at a later date. 6

7 Rules Edit logic Example Suppted Procedure with date span limits This editing will limit the reimbursement f procedures which are reimbursable only f a limited number of occurrences within a specified time frame. CXT 4.4 Revisions: Additional rental DME codes have been added to this and will be allowed only once per month. In addition diabetic supplies such as glucometers, lancets and strips will be limited to specific quantities within a specific time frame Procedure code is billed f date of service 11/15/2011 and also f date of service 12/1/2011. The second submission f this procedure will be denied as this code is per 90 day period code definition AMA/CPT Frequency Editing. edits apply to dates of service on and after 1/1/2013. Multiple Lab Component Rebundling This will deny 2 me component codes of a multiple component labaty test and replace them with the me comprehensive lab panel code. Modifier 59 does not override this editing CXT 4.4 Revision: The editing in this will be expanded to all blood panels and complete blood count codes. Labaty tests 82040, 82247, and are repted f the same date of service. These are components of the me comprehensive lab panel code Reimbursement is made on the Panel test AMA/CPT Labaty and Venipuncture edit applies to all dates of service. 7

8 Rules Edit logic Example Suppted Bilateral procedures (modifier 50) Pre and post Anesthesia Visits Assistant Surgeon not allowed (modifiers 80, 81, 82, AS) Bilateral surgery is to be billed on one line with 1 unit and modifier 50.This may recode bilateral surgical procedures billed on multiple lines to comply with this requirement and the total allowed percentage may be split between lines on the claim. 4.4 Revisions: Certain coding scenarios will result in a line being considered bilateral without out modifier 50. Refer to the policy f me infmation This will deny evaluation and management codes billed the anesthesiologist one day pri to 10 days post anesthesia This will deny surgery codes billed with assistant surgeon modifiers 80, 81, 82, AS if the procedure is on Anthem s list of codes that do not allow f services of an assistant surgeon. As an example, When myringotomy procedure code is billed with modifier 50 on one line and billed again on another line (with without modifier 50) This will recode the two claim lines to a single line with modifier 50, 1 unit and combine the charges. Code billed within 10 days after anesthesia administration the anesthesiologist will be denied. Code billed with modifier 80 will be denied., Custom American College of Surgeons Multiple Surgery edit applies to all dates of service. Anesthesia, Global Surgery Assistant Surgeon and separate list of nonallowed codes This is applied to This is applied to 8

9 Rules Edit logic Example Suppted Never Reimbursed with Specific Procedures This will deny services which are listed on the Anthem Bundled Services and Supplies when billed with the specific other services as defined in the policy. These are services items f which Anthem never provides reimbursement when billed in combination with the codes listed in the policy. All radiological interpretation codes, as well as radiology codes with modifier 26 are denied when billed with procedures , and Code Q0091is denied when billed with Preventive and E/M codes such as , G0101, S0610, S0612 and Bundled Service and Supplies This is applied to Anthem Code Bundling This will deny the charge line f services which are incidental mutually exclusive to another procedure f the same date of service. Please refer to the Modifier 59 and E/M Related Modifiers 25 and 57 f additional details on modifier impacts to this. Procedure codes and are billed f the same date of service will be denied as incidental to and are billed f the same date of service will be denied as mutually exclusive to Claim Editing Overview Modifier Rules, Modifier 59 E/M Related Modifiers 25 and 57 This is applied to 9

10 Rules Edit logic Example Suppted Diagnosis Code Inappropriate f Patient's Gender This editing will deny the charge line if the diagnosis billed is inappropriate f the patient's gender. Diagnosis endometriosis of the uterus denies f a male Diagnosis (Benign Prostatic Hypertrophy) denies f a female. NCHS. Claim Editing Overview This is applied to ICD 10 diagnosis updates to be done at a later date Incomplete Diagnosis This editing will deny the charge line if the diagnosis is incomplete. An incomplete diagnosis is one that has not been coded to the ICD9/10 required length as defined the National Center f Health Statistics (NCHS) and The Center f Medicare and Medicaid Services (). Claim line billed with diagnosis code will be denied as this diagnosis requires a fifth digit f further specificity to be considered complete. NCHS. Claim Editing Overview This is applied to ICD 10 diagnosis updates to be done at a later date. Diagnosis Code Invalid This editing will deny a diagnosis code that is not listed as a valid diagnosis f the date of service the National Center f Health Statistics (NCHS) and The Center f Medicare and Medicaid Services (). As an example, Claim line billed with will be denied as this diagnosis is not a valid diagnosis NCHS. Claim Editing Overview This is applied to ICD 10 updates to be done at a later date. 10

11 Rules Edit logic Example Suppted Patient Visit Code Frequency Limits This editing will deny the charge line f a new patient evaluation and management service if a claim has been previously received within a three year period the same provider providers with the same specialty billing under the same Tax Id. patient code established visit is billed f date of service 12/31/2010. If the same physician another physician with the same specialty billing under the same Tax Id submits within 36 months of 12/31/2010 the additional new visit charge line will be denied. AMA/CPT Claim Editing Overview This is applied to Procedure Code Deleted (Obsolete) This editing will deny any code which has been end dated AMA/CPT /HCPCS. Code L0100 was end dated in the HCPCS manuals effective 12/31/2006 and would be denied if submitted f a date of service 1/1/2012. AMA/ CPT Claim Editing Overview This is applied to Procedure and Modifier Combination Invalid Procedure Code Invalid This editing will deny the line if the billed modifier is invalid with the procedure code. This editing will deny line containing a procedure code which has never been a valid CPT/HCPCS code. Code is denied when billed with modifier 80 (assistant surgeon) Code has never been a valid CPT code and would be denied in this editing. AMA/CPT AMA/ CPT Claim Editing Overview This is applied to Claim Editing Overview This is applied to 11

12 Rules Edit logic Example Suppted Procedure allowed once per date of service This will limit the number of times the procedure may be billed either on separate lines units on one line to a single occurrence per date of service. Code (tenotomy open, hamstring, knee to hip; multiple tendons, bilateral) is billed twice f the same date of service will have one unit denied. This procedure, definition, can only be perfmed once per date of service. Frequency Editing This is applied to Procedure allowed limited times per date of service Unilateral Procedures billed Multiple Times when bilateral Code exists This will limit the number of times the procedure may be billed either on separate lines units on one line to a maximum allowable amount per occurrence per date of service. This will replace unilateral procedure codes when billed me than once per date of service if a bilateral procedure code exists f the service (application of a sht arm splint) is billed three times with right and left modifiers. The second submission of RT is denied RT LT RT (Deny) Code (Radiologic examination, unilateral) is billed twice f the same service date. Both units lines will be denied and replaced with the cresponding bilateral procedure unit. AMA/CPT Frequency Editing This is applied to Frequency Editing This is applied to 12

13 Rules Edit logic Example Suppted Pre Operative Visits Post Operative Visits This editing will deny the line f an evaluation and management code billed within the pre operative period. This editing will deny the line f an evaluation and management code billed within the post operative period. Code billed one day pri to surgery code with the same diagnosis will be denied as a preoperative visit Code billed within 90 days post operative period f code will be denied as a post operative visit. AMA/CPT AMA/CPT Global Surgery This is applied to Global Surgery This is applied to Supplies Same Day as Procedure Duplicate Component Modifier Billing (26, TC) This editing will deny the line f supply codes when billed on the same day as a procedure. This editing will deny lines billed with a professional (26) technical modifier (TC) when the procedure code was previously submitted as a global procedure f the same provider ID, patient, & date of service. A4206 will be denied when billed with chemo administration codes such as A7041 will be denied when billed with surgery codes such as If procedure code is submitted as global with no component modifier and claim lines are received which contain procedure code and modifier 26 and/ modifier TC these claim lines will be denied. Standard AMA/CPT Injection Infusion Administration Bundled Supplies, Always Bundle, and Global Surgery Labaty and Venipuncture Services Technical/Professional Modifiers Section This is applied to This is applied to 13

14 Rules Edit logic Example Suppted Missing Professional Component in Facility Place of Service This editing will deny the line when the National Physician Fee Schedule Relative Value File indicates modifier 26 is applicable (PC/TC indicat of 1 6), and the procedure is billed without modifier 26 with a facility place of service. Modifier 26 is required.. Code is billed without the professional component modifier (26) with a place of service inpatient (21). This line will be denied.. Labaty and Venipuncture Services, Technical/Professional Modifiers TC/26 section. Claim Editing Overview This is applied to Modifier 22: Procedure with Modifier 22 This will pend the claim f additional review f increase of allowance when the procedure code is billed with modifier 22 to identify unusual procedural services AND the claim is submitted with medical recds. Procedure code is billed with modifier 22 and medical recds the claim will be pended f medical review f possible additional allowance Modifier Rules This is applied to Place of Service This editing will deny the charge line f specific procedures and place of service combinations. Codes, will deny when billed in Place of service 21.. AMA/CPT Place of Service This is applied to 14

15 Rules Edit logic Example Suppted Co Surgeon Global Component 15 Identifies claim lines containing procedure codes billed with a cosurgery modifier that typically do not require co surgeons accding to the Centers f Medicare and Medicaid Services (). Identifies claim lines with procedure codes which have components (professional and technical) to prevent overpayment f either the professional technical components the global procedure. The also detects when duplicate submissions occurred f the total global procedure its components across different providers. Edits are applied: Global vs. Global Global vs. Professional Global vs. Technical Professional vs. Global Technical vs. Global Professional vs. Professional Technical vs. Technical This recommends the denial of claim lines containing procedure codes, submitted with co surgery modifier 62 in any of the four modifier positions, where there is a payment restriction f co surgery accding to the Medicare Physician Fee Schedule. If a global procedure is billed on a current line suppt line without a 26 TC present in any modifier fields, and the claim facility flag = Y, the technical component ( TC) will be assumed. If a global procedure is billed on the current line without a 26 TC present in any modifier fields, and the claim facility flag = N, and the POS is Inpatient Outpatient, the professional component ( 26) will be assumed on the current line. N/A Edit applied to dates of service on after National Physician Fee Schedule Relative Value N/A Edit applied to dates of service on after

16 Rules Edit logic Example Suppted Inpatient Only Procedures Billed as an Outpatient Multiple Medical Same Day visits MUE Multiple Lines Facility Rule Identifies claim lines containing Outpatient Prospective Payment System (OPPS) C status procedure codes that are not payable when billed in an outpatient setting. Identifies multiple evaluation and management codes and other visit codes submitted on the same date of service, the same facility and the same revenue code where the second and subsequent E&M code submitted lacks modifier 27. This will audit Facility claims submitted on a UB04 only. Identifies claim lines where the MUE has been exceeded f a CPT/HCPCS code, repted the same provider, f the same member, on the same date of service. C status procedure code will be denied when submitted without modifier CA. This recommends the denial of claims containing multiple E&M codes f which the second and/ subsequent visit codes lack the presence of modifier (application of a sht arm splint) is billed three times with right and left modifiers. The second submission of RT is denied RT LT RT (Deny) OPPS N/A Edit applied to dates of service on after N/A Edit applied to dates of service on after N/A Edit applied to dates of service on after 16

17 Rules Edit logic Example Suppted Medicaid Medically Unlikely Edit Durable Medical Equipment Medicaid Medically Unlikely Edit Outpatient Hospital This applies the medically unlikely edits (MUE) to durable medical equipment (DME) providers when the quantity f a single date date range exceeds the medically unlikely edit (MUE) limit f the HCPCS/CPT code. This edits f durable medical equipment claims billed on a professional claim fm. This applies the medically unlikely edits (MUE) to outpatient facility claim lines when the quantity f a single date date range exceeds the medically unlikely edit (MUE) limit f the HCPCS/CPT code. This edits facility claims. DME code E0111 is billed on a professional claim with three units f single date of service. The line will be denied as the quantity exceeds the MUE limit f this service. A facility bills code with three units f a single date of service. The line will be denied as the quantity exceeds the MUE limit f this service Medicaid Medicaid N/A Federal Mandate Edit applied to dates of service on after October 1, 2010, and processed on after December 8, N/A Federal Mandate Edit applied to dates of service on after October 1, 2010, and processed on after December 8,

18 Rules Edit logic Example Suppted Medicaid Medically Unlikely Edit Practitioner Medicaid NCCI Outpatient Hospital This applies the medically unlikely edits (MUE) to professional claims when the quantity f a single date date range exceeds the medically unlikely edit (MUE) limit f the HCPCS/CPT code. This edits professional provider claims (non DME Facility providers). This denies facility claim lines if the line procedure is the denied procedure in the code pairs as identified the Centers f Medicare and Medicaid () National Crect Coding Initiative (NCCI) f Facility (hospital) emergency department, observation, hospital labaty services, all facility therapy services and outpatient hospital claims. A physician bills code with three units f a single date of service. The line will be denied as the quantity exceeds the MUE limit f this service A facility submits a claim with procedure code 52277(column one) with procedure code (column two) f the same member, same date of service and the same provider. Procedure code is paid and procedure code is denied. Medicaid Medicaid N/A Federal Mandate Edit applied to dates of service on after October 1, 2010, and processed on after December 8, N/A Federal Mandate Edit applied to dates of service on after October 1, 2010, and processed on after December 8, The will apply the NCCI associated modifier. The override modifiers can be on the deny line, the suppt line both the deny line and suppt lines. 18

19 Rules Edit logic Example Suppted Medicaid NCCI Practitioner This denies procedures when the code is the denied procedure in the code pairs in the Centers f Medicare and Medicaid () National Crect Coding Initiative (NCCI) f practitioner claims ambulaty surgery center claims. The will apply the NCCI associated modifier overrides. The override modifiers can be on the deny line, the suppt line both. A professional provider submits code (column one) with procedure code (column two) f the same member, same date of service and the same provider. Procedure code is paid and procedure code is denied. Medicaid N/A Federal Mandate Edit applied to dates of service on after October 1, 2010, and processed on after December 8,

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