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New Effective Date: ClaimsXtenTM Adds Three New Outpatient Facility Rules

Posted July 10, 2015  (Updated Sept. 30, 2015)

*In the July 10, 2015 notification, ‘ClaimsXten™ Adds Three New Outpatient Facility Rules, Effective Oct. 12, 2015,’ Blue Cross and Blue Shield of Illinois (BCBSIL) announced the implementation of three new outpatient facility rules for dates of services beginning on or after Oct. 12, 2015. This is to notify you that due to system issues, this implementation will be postponed until Feb. 22, 2016. The date is the only detail that has changed.

Beginning on or after Feb. 22, 2016,* BCBSIL will enhance the ClaimsXten code auditing tool by adding three new outpatient facility rules into our claim processing system. These new rules will apply for claims with dates of service on or after Feb. 22, 2016.* The new rules are summarized below:

Medically Unlikely Edits (MUE) Multiple Lines Facility Rule

This new facility rule identifies claim lines where the MUE has been exceeded for a Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) code, reported by the same provider, for the same member, on the same date of service.

An MUE is an edit that reviews claims for unit of service for a HCPCS or CPT code for services rendered by a single provider/supplier to a single beneficiary on the same date of service. The ideal MUE is the maximum unit of service that would be reported for a HCPCS or CPT code on the vast majority of appropriately reported claims. The maximum allowed is the total number of times per date of service that a given procedure code may be appropriately submitted by the same provider.

Outpatient Code Editor (OCE) CMS CCI Bundling Rule

This new facility rule identifies claims containing code pairs found to be unbundled according to Centers for Medicare & Medicaid Services (CMS) Integrated Outpatient Code Editor (I/OCE). One of the functions of the I/OCE is to edit claims data to help identify inappropriate coding due to the following reasons: The procedure is a mutually exclusive procedure that is not allowed by the Correct Coding Initiative (CCI) and/or the procedure is a component of a comprehensive procedure that is not allowed by the CCI.

Unbundled Pairs Outpatient Rule 

This new facility rule identifies the unbundling of multiple surgical codes when submitted on facility claims. This rule detects surgical code pairs that may be inappropriate for one of the following reasons: one code is a component of the other code, or these codes would not reasonably be performed together on the same date of service.

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 ConnectionTM (C3). C3 is a free, online reference tool that mirrors the logic behind BCBSIL’s code-auditing software.

For more details regarding ClaimsXten, including answers to frequently asked questions, refer to the Clear Claim Connection page. Additional information also may be included in upcoming issues of the Blue Review.

ClaimsXten is a trademark 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.