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Coding Toolkit

Our health plan's claim adjudication systems utilize customized editing rules and Medicare's National Correct Coding Initiative (NCCI) as the basis for clinical edits. Our health plan's claim adjudication systems are updated on a quarterly basis to recognize the most recent CPT and HCPCS codes, modifier 51 exempt codes, and add-on code changes. Please review your CPT and HCPCS coding publications for codes that have been added, deleted, or changed, and use only valid codes. Please append modifiers to HCPCS and CPT codes when correct coding indicates a modifier is appropriate.

Customized and Significant Clinical Edits

Updates to the 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.

Our health plan 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.

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

92012 92014 92015 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 S0621

The following Clinical Edits by Code lists are based on our health plan's Medical and Reimbursement Policy.

NOTE: This list no longer contains pre-authorization information. Codes for all services and supplies that require pre-authorization can be found on our pre-authorization lists.

Note: Our health plan 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 Clinical Edits by Code list.

Correct Code Editor

Our health plan 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. We have 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.

NCCI bypass modifiers

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 our health plan has determined are not appropriately reported together with Modifier -25.

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 our health plan has determined are not appropriately reported together with Modifier -59. 

Maximum Allowed Units for Procedure Codes

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

80101, 80104, G0431, G0434

Add-on codes
Some services are reported as add-on codes, which describe work done in addition to primary procedures. Add-on codes are not stand-alone codes, and must always be reported with primary procedures. Our health plan will deny reimbursement for an add-on code as a Correct Coding Edit when its primary code is denied as part of an NCCI or Correct Coding Edit code pair. When correct coding indicates the use of a modifier is appropriate for the primary code, that modifier must be appended to both the primary code and add-on code.
Unlisted codes

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.

Codes without allowables
Our health plan may require the submission of clinical information in order to price CPT and HCPCS codes for which an allowed amount has not been established. For questions, please contact your provider relations representative.
Other specific edits

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

  • Our health plan 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
  • Our health plan 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.

Effective on or after May 1, 2014 date of service:

  • Our health plan considers CPT Code 82306 to be medically necessary ONLY when billed with diagnosis code ranges:  252.00 - 252.08; 252.1; 262; 263.0 -263.9; 268.0, 268.1, 268.2, 275.3, 275.40-275.49, 278.4, 571.0 – 571.9, 572, 572.8, 576.2, 579.0  - 579.9, 585.1-585.9,  592.0, 592.1, 733.0-733.09, 751.61, 756.52 and 775.4.
  • Our health plan considers CPT Code 82652 to be medically necessary ONLY when billed with diagnosis code ranges 135, 252.00 - 252.08, 252.1 268.0 -268.2,  270.0, 274.11, 275.3, 275.40 -275.42, 275.49,  592.0- 592.1, 592.9, 588.81 or 775.4.

The rationale for these edits is detailed in our health plan's Medical Policy, Laboratory 52, Vitamin D Testing.

Global Periods

Our health plan 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 our health plan, are considered included in the payment for the surgical procedure.

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