Implementation Reminder: Three New Facility Rules for ClaimsXten™, Effective Feb. 22, 2016

Listed below are details regarding three new facility rules that were originally scheduled to be added to our claims processing system effective Oct. 12, 2015, as an enhancement to our ClaimsXten code auditing tool. Please note that the deployment of these rules has been postponed to on or after Feb. 22, 2016. A notice regarding this change in effective date was published in the News and Updates section of the Blue Cross and Blue Shield of Texas (BCBSTX) provider website on Oct. 1, 2015.

We’ve summarized the new rules below:

Medically Unlikely Edits (MUEs) Multiple Lines Facility Rule
This new facility rule identifies claim lines where the MUE has been exceeded for a Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT^®) code, reported by the same provider, for the same member/subscriber, on the same date of service.

An MUE is an edit that reviews claims for units of service for a HCPCS or CPT code for services rendered by a single provider/supplier to a single beneficiary on the same date of service.

The ideal MUE is the maximum units of service that would be reported for a HCPCS or CPT code on the vast majority of appropriately reported claims. The maximum allowed is the total number of times per date of service that a given procedure code may be appropriately submitted by the same provider.

Outpatient Code Editor (OCE) CMS CCI Bundling Rule
This new facility rule identifies claims containing code pairs found to be unbundled according to Centers for Medicare & Medicaid Services (CMS) Integrated Outpatient Code Editor (I/OCE). One of the functions of the I/OCE is to edit claims data to help identify inappropriate coding due to the following reasons: The procedure is a mutually exclusive procedure that is not allowed by the Correct Coding Initiative (CCI) and/or the procedure is a component of a comprehensive procedure that is not allowed by the CCI.

Unbundled Pairs Outpatient Rule
This new facility rule identifies the unbundling of multiple surgical codes when submitted on facility claims. This rule detects surgical code pairs that may be inappropriate for one of the following reasons: one code is a component of the other code, or these codes would not reasonably be performed together on the same date of service.

The ClaimsXten tool offers flexible, rules-based claims management with the capability of creating customized rules, as well as the ability to read historical claims data. ClaimsXten can automate claim review, code auditing and payment administration, which we believe results in improved performance of overall claims management.

To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process, you may continue to utilize Clear Claim Connection^TM (C3). C3 is a free, online reference tool that mirrors the logic behind BCBSTX’s code-auditing software. For more information on C3 and ClaimsXten, including answers to frequently asked questions, refer to the Education & Reference/Provider Tools/Clear Claim Connection page on our provider website. Information also may be published in upcoming issues of Blue Review.

ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for it products and services.

CPT copyright 2015 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.