Regence Customized and Significant Clinical Edits

Updates to the Regence Clinical Edits by Code list will be posted on a monthly basis. The following editing rules apply to claims for our commercial products and BlueCard^®. They do not apply to Medicare.

CPT code definitions and rules are followed for:

• Gender,
• Age,
• New Patient,
• Organ or disease-oriented Laboratory Panels and
• Services not intended to be reported by physician in facility setting.

Regence also follows the Centers for Medicare & Medicaid Services (CMS) guidelines for:

• Same Day
• Follow Up Day and
• Pretreatment Day edits.

Same Day edits may be edited in the Correct Code Editor or in a separate Same Day edit depending on the claims processing system.

The following codes will be denied when billed on the same date of service as a surgical code:

99211 99212 99213 99214 99215 99217 99218 99219 99220 99221 99222 99223 99231 99232 99233 99234 99235 99236 99238 99239 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99291 99292 99304 99305 99306 99307 99308 99309 99310 99315 99316 99334 99335 99336 99337 99347 99348 99349 99350 99466 99467 99468 99469 99471 99472 99475 99476 99478 99479 99480

The following Regence Clinical Edits by Code lists are based on Regence Medical and Reimbursement Policy:

• Regence Clinical Edits by Code list (PDF) - updated February 1, 2012. Sorted by code and contains all cosmetic, investigational and Regence invalid codes and supporting documentation requirements for each.  Uniform Medical Plan (UMP) Supplemental Clinical Edits by Code section contains additional edits specific to UMP members.
  • Edit Add List (PDF)
• Previous Lists

Note: Regence will not routinely require submission of clinical information in connection with adjudication of claims except for unlisted codes, codes without allowables, claims to which a modifier 22 is appended, facility claims containing revenue code 0624, or other limited categories of claims included on the Regence Clinical Edits by Code list.

Regence utilizes Medicare’s National Correct Coding Initiative (NCCI) as the basis for clinical edits. NCCI identifies pairs of services that normally should not be billed by the same physician for the same patient on the same day. Regence has identified additional code pair edits to be used as a supplement to Medicare's NCCI. These code pair edits were developed using nationally accepted, logical and predictable coding principles.

• View the Correct Code Editor

Modifier -25

NCCI bypass modifiers, as defined by CMS, will be processed in accordance with the current CMS superscript rules except for the published list of service or procedure code combinations that Regence has determined are not appropriately reported together with Modifier -25.

• View the Regence code pair edits that do not bypass with modifier -25 on the Correct Code Editor

Modifier -59

NCCI bypass modifiers, as defined by CMS, will be processed in accordance with the current CMS superscript rules except for the published list of service or procedure code combinations that Regence has determined are not appropriately reported together with Modifier -59. 

• View the Regence code pair edits that do not bypass with modifier -59 on the Correct Code Editor

Molecular Pathology/Genetic Testing (81200-81408)

Regence has adopted the same approach as CMS regarding reimbursement of the new molecular pathology codes (81200-81408).  We will not reimburse these new codes, however, will continue to reimburse the old "stacking" codes (e.g., 83890-83914, 88363-88366) and HCPCS codes (e.g., G9143, S3800, S3818-S3890), per Regence Medical Policy.  We encourage providers to bill using the same process as requested by CMS; billing both the existing codes and the new codes on the same claim.

Regence has established a maximum allowed units edit for the following qualitative drug screening CPT and HCPCS codes based on CMS coding rules:

80101, G0430, G0431

• View the Regence reimbursement policy.

Services billed using an unlisted procedure code will not be separately reimbursed when considered incidental to a comprehensive procedure billed on the same date of service.

Similarly, if a procedure or service is determined to be incidental to a more comprehensive procedure described by an unlisted code, separate reimbursement will not be allowed.

The following edits apply to claims effective for dates of service on and after September 1, 2011:

• Regence considers CPT Code 82306 to be not medically necessary when billed with diagnosis code ranges 780, V70 – V77.1, V77.3 – V77.8, V77.91, and V78 – V82.9 in the first or second position
• Regence considers CPT 82652 to be medically necessary ONLY when billed with diagnosis codes 135, 252.00 - 252.08, 252.1, 268.0 - 268.2, 270.0, 275.3, 275.40 - 275.42, 275.49, 592.0 - 592.1, 592.9 or 775.4.

The rationale for these edits is detailed in Regence Medical Policy, Laboratory 52, Vitamin D Testing.

Regence has established global periods for certain surgical procedures when the Centers for Medicare & Medicaid Services (CMS) 

• has not established a global period of a specific number of days, and 
• has not indicated that a global period is inappropriate

Services related to the surgical procedure provided within the global period for that surgical procedure, whether the global period is established by CMS or Regence, are considered included in the payment for the surgical procedure.

• View the global periods established by Regence. 
• View the global periods established by CMS (published as part of the RVU file).