November 30, 2023
On or after March 1, 2024, Blue Cross and Blue Shield of Illinois will update the ClaimsXten software database to better align coding with the reimbursement of claim submissions.
These are the changes:
This rule identifies claim lines containing procedure codes indicated by the Centers for Medicare & Medicaid Services to be always bundled when billed with any other procedure. According to the CMS National Physician Fee Schedule Relative Value File, this procedure has a status code indicator of “B,” which is defined as: “Payment for covered services is always bundled into payment for other services not specified.” This rule is appropriate for professional claims only.
CMS Add-on Without Base Code Facility
This rule identifies claim lines containing a Current Procedural Terminology or Healthcare Common Procedure Coding System assigned add-on code when billed without acceptable supporting primary procedure/base code by the same practitioner for the same patient on the same date of service, per CMS. According to CMS, add-on codes are always performed in addition to the primary service or procedure and must never be reported as a stand-alone code. An add-on code is eligible for payment if its related primary procedure/base code is also eligible for payment to the same practitioner for the same patient on the same date of service. This rule is appropriate for outpatient facility claims only.
This rule identifies claim lines billed by the same or a different provider either on the same day or different day (depending on the procedure code) after a non-covered service. This rule can consider both facility and non-facility claims.
Before denying an ancillary service, the rule check for other covered services that may have been performed on the same day as the non-covered procedure. If found, the rule will allow the ancillary service. This rule is appropriate for professional claims and outpatient facility claims only.
To determine how coding combinations may be evaluated during claim adjudication, use Clear Claim ConnectionTM. Refer to the Clear Claim Connection page for answers to frequently asked questions about ClaimsXten and details on how to gain access to C3.
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.
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