Blue Cross Network – Clinical Editing Updates Coming in June to Outpatient Claims

Starting in June, Blue Care Network and BCN AdvantageSM will be updating clinical edits applied to outpatient claims. We’re expanding the edits to continue promoting correct coding to outpatient claims and maintain alignment with national coding guidelines.

BCN Advantage medical and payment policies will continue to comply with:

• National coverage determinations

• General coverage guidelines included in original Medicare manuals and instructions

• Written coverage decisions of the local Medicare administrative contractor These expanded edits will continue to integrate appropriate local and national coverage determination guidelines. Some of the enhancements include, but are not limited to:

• CCI edits

• Evaluation and management services

Radiology services as with the application of all our clinical edits, the guidelines and regulations of these sources should be followed:

• Centers for Medicare and Medicaid Services’ medical policies

 • American Medical Association CPT coding guidelines

• National bundling edits, including the Correct Coding Initiative

• Modifier usage

• Global surgery period

Add-on code usage the appeal process won’t change. Providers should continue to submit clinical editing appeals on the Clinical Editing Appeal Form with the necessary supporting documentation. Fax one appeal at a time to avoid processing delays.

Source: https://www.bcbsm.com/content/dam/microsites/corpcomm/provider/BCNPN/Assets/archive/2021/02/BCNProviderNews_2021MarApr.pdf