December 2016

CVP Implementation Notice

Blue Cross and Blue Shield of New Mexico (BCBSNM) will be implementing a secondary code auditing software starting March 2017.  This software will audit professional and outpatient facility claims for correct coding as outlined by AMA CPT coding guidelines and CMS.  Auditing will be done on professional claims within the following categories:

Add-on Codes:  An add-on procedure code will not be allowed in the absence of a primary procedure code

Age/Gender:  Will edit codes based on the age/gender identified in the CPT code book.

Correct Coding Initiative (CCI):  The National CCI is a compilation of CMS bundling edits that apply to Physician and Outpatient Hospital claims

Data Validation:  Identifying whether the CPT code is valid. 

Duplicates and Multiple Units:  For codes that cannot be billed more than once on the same date of service, within a defined date range, or over the lifetime of the patient.  Also identifies excessive number of units submitted. 

Evaluation and Management (E/M): Identifies multiple E/M services billed by the same provider on the same date of service,

Global Surgery: CMS defines specific time periods during which certain services related to a surgical procedure are to be included in the payment of the surgical procedure.

Procedure to Modifier Validation: Validates a claim line’s procedure and modifier codes against a set of allowed modifiers by procedure code sourced by the AMA and/or CMS. 

Lab:  Identifies if a procedure or service is part of a lab panel or if all component codes are submitted for a panel instead of the comprehensive code. 

Medically Unlikely:  An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. 

Multiple Surgeons:  Evaluates the appropriateness for an assistant surgeon, co-surgeon or team surgeon for all surgical procedures. 

New Visit:  AMA defines a new patient as a patient “who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within 3 years.”  Analysis will be done to determine if a New Visit E/M has been billed within a three-year period. 

Obstetric Care:  Applies acceptable methods for billing obstetric services and identifies duplicate or conflicting methods of billing obstetric services and/or their components. 

Incidental: CMS-sourced list of services and procedures that are considered incidental to other services or procedures provided on the same date of service.