Home Administrative Billing & Reimbursement BlueCard® Health and Wellness Medical PEAR portal Pharmacy Products Quality Management

Enhanced claim edits to support correct coding principles and important information about Medicare Advantage

November 20, 2019

As a reminder, claims received by Independence on or after June 10, 2018, are subject to a claim editing process during prepayment review to ensure compliance with current industry standards and support the automated application of correct national coding principles.* By applying these principles, we will be consistent with other payers in the region and will apply claim payment principles that are national in scope, simple to understand, and continue to comply with industry standard sources, including:

  • Centers for Medicare & Medicaid Services (CMS) standards such as the National Correct Coding Initiative (NCCI), modifier usage, and global surgery guidelines
  • American Medical Association (AMA) Current Procedural Terminology (CPT®) coding guidelines
  • CMS HCPCS LEVEL II Manual coding guidelines
  • ICD-10 Instruction Manual coding guidelines

Please be advised that as guidelines from these sources are updated, our claim edits will be reviewed and additional claim edits will be implemented as applicable. In addition to the above, Medicare Advantage plans comply with the National Coverage Determinations (NCD).

*Self-funded groups have the option to not participate in the enhanced claim edits; therefore, prepayment review may vary by health plan.

Areas of focus

The enhanced claim editing process for our Medicare Advantage lines of business will continue to focus on ensuring compliance with CMS coverage policies and reporting guidelines. Medicare Advantage plans are subject to edits that comply with clinical and correct coding criteria as defined in CMS publications including but not limited to, the following:

  • Medicare NCD Manual
  • Medicare Claims Processing Manual
  • Medicare NCD Coding Policy Manual and Change Report (ICD-10-CM): Clinical Diagnostic Laboratory Services

In addition to the above, Independence enforces CMS rules on appropriate modifier usage including, but not limited to the following:

  • KX
  • AT
  • Q0

With the implementation of these claim edits, claims submitted with inappropriate coding will be returned or denied. Providers will be notified via the Provider Explanation of Benefits (EOB) (professional) or Provider Remittance (facility), which will include a reason code for the claim return or denial. Any returned claims must be corrected prior to resubmission. These changes should have little or no impact to billing practices for submission of claims that are in accordance with the guidelines listed above and national industry-accepted coding standards.

Claim review requests

We recognize there may be times when you have questions regarding the outcome of a claim edit. As with all claim review requests, these questions should be submitted using the Claim Investigation transaction on the NaviNet® web portal (NaviNet Open). Claim lines that have gone through the editor can be identified by the alpha-numeric codes and messages beginning with E8 on your Provider EOB or Provider Remittance. Refer to the box below for more information.

Identifying claims that went through the new claim editor process

If your claim was affected by one of the new claim edits, the edit explanation will be displayed on your electronic remittance report (835) and/or paper Provider EOB or Provider Remittance. Unique alpha-numeric codes and messages have been created that begin with E8. Should your claim line contain an E8XXX code/message, it means it was affected by the enhanced claim editor. You can also find the E8XXX codes/messages on the Claim Status Inquiry Detail screen in NaviNet Open. To view, hover your mouse over the service line and select View Additional Detail. If you see an E8XXX code/message, the line went through an edit. Only E8XXX codes/messages are part of the enhanced claim editor. All other codes/messages are unrelated to the enhanced claim editor. Many of these rejections can be resolved by sending a corrected claim submission. Please ensure it follows the procedures outlined in the Partners in Health UpdateSM article, Claim investigation and corrected claim submission procedures.


Automated claim edits

Here are some examples of the higher volume enhanced claim edits we continue to see:

ICD-10 coding

  • Excludes 1 Notes: Claim lines reported with mutually exclusive code combinations according to the ICD-10-CM Excludes 1 Notes will be denied.
    • When a code from range H73.0 – H73.099 (Acute myringitis) is associated to the same claim line as a code in either the range H65 – H65.93 (Nonsuppurative otitis media) or the range H66 – H66.93 (Suppurative and unspecified otitis media), then the claim line will be denied.
  • Laterality: The Diagnosis-to-Modifier comparison assesses the lateral diagnosis associated to the claim line to determine if the procedure modifier matches the lateral diagnosis. If it does not match, the claim line will be denied.
    • DIAG1: H60.332 (Swimmer's ear, left ear)
    • CPT: 69000 (Drainage external ear, abscess, or hematoma; simple)
    • MOD: RT
  • Primary diagnosis code reporting: Certain diagnosis codes cannot be reported as the only or primary diagnosis code on a claim. If one of the following codes is reported as the only or primary diagnosis, then the claim line will be denied:
    • Manifestation codes
    • External causes (i.e., "V – Y" codes)
    • Secondary codes (e.g., Z33.1)

Evaluation and Management services

  • Only one new patient visit will be allowed to the same group practice and specialty within three years.
  • Only one initial inpatient hospital visit and inpatient hospital discharge will be allowed per hospital stay.
  • Accurate reporting of initial, subsequent, and observation discharge care. Only the admitting physician is eligible to bill the observation care.

Surgical services

  • Accurate reporting of modifiers for the billing of surgical services rendered by one or more providers.

 

Learn more

For questions about the claim editing process, please review our Claim edit enhancements: Frequently asked questions (FAQ), which can also be found in the Frequently Asked Questions archive on Independence NaviNet Open Plan Central or in the Quick Links section on the right-hand side of this page. The FAQ will be updated as more information becomes available.

If you still have questions after reviewing the FAQ, please send an email to claimeditquestions@ibx.com.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

NaviNet® is a registered trademark of NantHealth, an independent company.


This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of Independence Blue Cross. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
Connect with us     Facebook     Twitter     Flickr     YouTube     Walk the Talk    Independence Pinterest    Independence LinkedIn    Independence Instagram Site Map        Anti-Fraud        Privacy Policy        Legal        Disclaimer
© 2023 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.