BCBS- ClaimsXten to include additional professional and outpatient facility edits, starting in October

Starting in October 2021, ClaimsXten™ will edit additional services for professional and outpatient facility providers on Blue Cross Blue Shield of Michigan commercial claims. These new edits are part of our ongoing effort to promote correct coding and enhance our claims payment systems.

If you receive one of these edits, submit a corrected claim when appropriate. If you believe the services rendered warrant an exception, submit a clinical editing appeal with medical records.

Here are some highlights of what these rules identify and edit:        

• Claims containing code pairs found to be unbundled, according to Centers for Medicare & Medicaid Services Integrated Outpatient Code Editor (outpatient facility claims only)
• Procedures that don’t warrant multiple submissions of a procedure or group of procedure codes on a single date of service, or across a date‑of‑service range, when billed by the same or different providers (professional claims only)
• Claim lines where the CMS medically unlikely edits, or MUE, has been exceeded for a CPT or HCPCS code, when reported by the same provider, for the same member, on the same date of service (outpatient facility claims only)
• Claim lines where the CMS MUE has been exceeded for a CPT or HCPCS code, when reported by the same provider, for the same member, on the same date of service (professional claims only)        

When appropriate, Blue Cross will support the use of modifiers that indicate unique circumstances for individual patients. The use of modifiers should be documented in the patient’s medical records.

Source: https://www.bcbsm.com/content/dam/microsites/corpcomm/provider/the_record/2021/jul/Record_all_articles.shtml