Three New ClaimsXten™ Rules to be Implemented in June 2020

March 12, 2020

We will soon update the ClaimsXten software database to better align coding with the reimbursement of claim submissions.

Implementation Schedule

On or after June 15, 2020, we will implement three new rules, as follows:

  • Revenue Codes Requiring Healthcare Coding System (HCPCS) Codes
  • Lifetime Event
  • Multiple Medical Same Day Visits

Rule Details

Revenue Codes Requiring (HCPCS) Codes

This rule recommends the denial of claim lines if they are:

  • Submitted with a revenue code that requires a HCPCS code; and
  • No HCPCS code is present.

If a claim is missing a HCPCS code, the claim line will be denied.

Lifetime Event

This rule audits claims to determine if a procedure code has been submitted more than once or twice on the same date of service or across dates of service when it can only be performed once or twice in a lifetime for the same member.

The Lifetime Event is the total number of times that a procedure may be submitted in a lifetime.

This is the total number of times it is clinically possible or reasonable to perform a procedure on a single member. After reaching the maximum number of times, additional submissions of the procedure are not recommended for reimbursement.

Multiple Medical Same Day Visits

This outpatient facility rule identifies and recommends the denial of claims with multiple Evaluation & Management (E&M) codes and other visit codes that are:

  • Submitted on the same date of service;
  • Performed at the same facility;
  • Submitted with the same revenue code; and
  • Submitted with a second and subsequent E&M code that lacks the required modifier –27.

 

For More Information

To determine how coding combinations may be evaluated during claim adjudication, use Clear Claim ConnectionTM (C3). Refer to the Clear Claim Connection page for answers to frequently asked questions about ClaimsXten and details on how to gain access to C3.

Important note: C3 does not contain all claim edits and processes used by Blue Cross and Blue Shield of Illinois (BCBSIL) in adjudicating claims; and the results from the use of the C3 tool are not a guarantee of the final claim determination.

This material is for educational purposes only and is not intended to be a definitive source for coding claims. Health care providers are instructed to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials.

ClaimsXten and Clear Claim Connection are trademarks of Change Healthcare, an independent company providing coding software to BCBSIL. Change Healthcare is solely responsible for the software and all the contents. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Change Healthcare. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.