May 7, 2015

ClaimsXten^TM System Edit Updates, Effective June 2015

Beginning on or after June 15, 2015, Blue Cross Blue and Shield of Oklahoma (BCBSOK) will enhance the ClaimsXten code auditing tool with the following changes to the bundling logic in our claim processing system:

• Surgical pathology-level I procedure codes with gross examination submitted with musculoskeletal, cardiovascular, digestive urinary, nervous, eye and ocular adnexa procedure codes, and HCPCS codes, will be subject to Current Procedural Code Terminology (CPT^®), Centers for Medicare & Medicaid Services National Correct Coding Initiative (CMS NCCI) and industry auditing guidelines.

• Preventive procedure codes submitted with 99201 - 99215 evaluation and management codes without modifier 25 submitted will be subject to CPT, CMS NCCI and industry auditing guidelines.

• Annual gynecological (GYN) exam procedure codes submitted with evaluation and management codes will be subject to CPT, CMS NCCI and industry auditing guidelines.

• Insertion of intrauterine device (IUD) procedure codes submitted with evaluation and management codes will now be subject to CPT, CMS NCCI and industry auditing guidelines.

• Surgical pathology-level IV tissue exam by a pathologist procedure codes will now be subject to CPT, CMS NCCI and industry auditing guidelines. 
  In accordance with CPT/HCPCS guidelines, use of modifiers may impact the outcome of the final adjudication of claims for the changes listed above. Consult your CPT codebook appendix A or HCPCS codebook for guidance in the appropriate use of modifiers.

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™ (C3). C3 is a free, online reference tool that mirrors the logic behind BCBSOK’s code-auditing software. Refer to the Education and Reference Center/Provider Tools/Clear Claim Connection section of our website for additional details on C3 and ClaimsXten. Information also may be published under News and Updates, as well as in upcoming issues of the Blue Review.

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

CPT Copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Checks of eligibility and/or benefit information are not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered.