Additional Commercial Claim Editing Enhancements Coming April 1, 2022

December 29, 2021

Effective April 1, 2022, Blue Cross and Blue Shield of Illinois (BCBSIL) will enhance our claims editing and review process with Cotiviti, INC., for some of our commercial non-HMO members to help ensure that services are accurately coded and properly reimbursed. The April 2022 enhancements are in addition to a previously announced component that will be effective Jan. 10, 2022.

What This Means for You: The enhancements require you to continue to follow generally accepted coding and reimbursement policies. With your help, the enhanced claims review process will help support affordability of health care services for our members.

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

Note: Failure to properly code your claim will result in delayed or denied payment.

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:

  • ICD-10 coding guidelines
  • The Healthcare Common Procedure Coding System (HCPCS)
  • Current Procedural Terminology (CPT®) codes as documented by the American Medical Association (AMA)
  • Correct Coding Initiatives (CCI)
  • Post-Operative Period Guidelines as outlined by the Centers for Medicare & Medicaid Services (CMS)

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

What’s changing?
New components of the editing and review enhancements to be effective April 1, 2022, include:

  • Anatomical Modifiers – This edit validates the area or part of the body on which a procedure is performed. Procedure codes that do not specify right or left require an anatomical modifier. This includes procedures on fingers, toes, eyelids and coronary arteries which have specific CMS-defined modifiers.
  • Diagnosis Code Guidelines – This edit enforces all ICD-10-clinical modification (CM) diagnosis coding guidelines, including reporting of inappropriate code pairs, as well as correct coding of secondary, manifestation, sequelae, chemotherapy administration, external causes and factors influencing health status diagnoses. 

More Information: Continue to watch the News and Updates for future announcements.

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

CPT copyright 2021 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

References to other third party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly.