Notification: Four New ClaimsXten™ Rules to be Implemented in September 2017

Posted June 20, 2017

Beginning on or after Sept. 18, 2017, Blue Cross and Blue Shield of Illinois (BCBSIL) will implement four new rules into the ClaimsXten software database. These new rules are defined as follows: 

  • Add On Without Base Code – This rule will identify claim lines containing a Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) add-on code billed without the presence of one or more related primary service/base procedure codes. According to the American Medical Association (AMA), “add-on codes are always performed in addition to the primary service/procedure, and must never be reported as a stand-alone code.”
  • Global Component Billing – This rule will identify procedure codes that have components (professional and technical) to help prevent overpayment for either the professional or technical components or the global procedure. The rule will also identify when duplicate submissions occur for the total global procedure or its components across different providers.
  • Duplicate Component Billing – This rule will identify when a professional or technical component of a procedure is submitted and the same global procedure was previously submitted by the same provider ID for the same member for the same date of service.
  • New Patient Code for Established Patient – This rule will identify claim lines containing new patient procedure codes that are submitted for established patients.  According to the AMA, “A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the last three years.”  Similar guidance is provided by Centers for Medicare & Medicaid Services (CMS): According to Pub 100-04, Medicare Claims Processing Manual Ch. 12, Physicians/Non-Physicians Practitioners, Section 30.6.7, Subsection A, "Medicare interprets the phrase ’new patient‘ to mean a patient who has not received any professional services, i.e., E/M service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous three years."

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. Refer to Clear Claim Connection page in the Education and Reference Center/Provider Tools section for answers to answers to frequently asked questions about ClaimsXten and details on how to gain access to C3. Additional information also may be included in upcoming issues of the Blue Review.

ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products and services.

CPT copyright 2016 AMA. All rights reserved. CPT is a registered trademark of the AMA.