Claim Editing Enhancements Coming Jan. 10, 2022

October 12, 2021

Effective Jan. 10, 2022, Blue Cross and Blue Shield of Illinois (BCBSIL) will enhance our claims editing and review process with Cotiviti for some of our commercial members to help ensure accurate coding of services and that services are properly reimbursed.

What this means for you: The enhancements require you to continue to follow generally accepted claim payment policies. With your help, the improved claims review process will help our members get the right care at the right time and in the right setting. 

These enhancements to the edits do not apply to professional services for our HMO members.

About the guidelines: BCBSIL will continue to follow claim payment policies that are global in scope, simple to understand and come from recognized sources, including the Centers for Medicare & Medicaid Services (CMS).

Using these guidelines will help ensure a more accurate review of all claims.

Note: Inaccurately coded claims will result in denied or delayed payment. 

What’s changing?

Components of the editing and review enhancements include:

Coding for services within the global surgical period – The global surgery package payment policies include all necessary services normally provided by the surgeon before, during and after a surgical procedure, and applies only to primary surgeons and co-surgeons. The global surgery package applies only to surgical procedures that have post-operative periods of 0, 10 and 90 days, as defined by CMS.

More Detail from CMS

The global surgery package includes:

  • Review of preoperative evaluation and management visits after the decision is made to operate, where the visits occur one day prior to major surgery and on the same day a major or minor surgical procedure is performed.
  • When a physician sees a patient within the global follow-up period of a surgical procedure that has a 10-, or a 90-day post-operative period, the physician should report the appropriate modifier(s), relevant to the circumstance, for the procedure performed.
  • The physician should report the appropriate modifier (see below) for any surgical procedure performed within the follow-up period of the original surgical procedure, if applicable. 

The appropriate, applicable modifiers are as follows:

  • 58 – Staged or Related Procedure or Service by the Same Physician during the Postoperative Period
  • 78 – Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period
  • 79 – Unrelated Procedure or Service by the Same Physician during the Postoperative Period

More Information: View our Clinical Payment and Coding Policies for more information on the global surgery package payment policies.

Cotiviti, INC. is an independent company that provides medical claims administration for BCBSIL. References to other third party sources or organizations are not a representation, warranty or endorsement of such organization.