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Effective March 31, 2020, New Payment Policy for BCCHP and MMAI Members

Posted March 2, 2020

Effective with claims that have a processing date of March 31, 2020, Blue Cross and Blue Shield of Illinois (BCBSIL) will not allow for reimbursement when mutually exclusive diagnosis codes are submitted for Blue Cross Community Health PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members.

Our goal is to process claims consistently and in accordance with industry best practice standards. Therefore, BCBSIL will be instituting additional payment policies that are aligned with correct-coding initiatives, Centers for Medicare & Medicaid Services (CMS) guidelines and national benchmarks and industry standards.

One of the unique attributes of the ICD-10-CM code set is the concept of Excludes1 notes. An Excludes1 note indicates that the excluded code identified in the note should never be used at the same time as the code or code range listed above the Excludes1 note. An Excludes1 note is used to indicate when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. These conditions are mutually exclusive code combinations. 

These Excludes1 notes are located under the applicable section heading or specific ICD-10-CM code to which the note is applicable. When the note is located following a section heading, then the note is applicable to all codes in the section. For more information on the appropriate reporting of diagnosis codes, refer to the 2020 release of the ICD-10-CM Official Guidelines for Coding and Reporting.