Additional Information about Enhanced Clinical Editing Process Implementation

As communicated on March 29, 2022,  Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will implement an enhancement to our claims processing system that supports correct coding effective June 1, 2022. The goals of this endeavor are to implement, to the extent possible, claim payment policies that are national in scope, simple to understand and that align and are referenced from industry standard sources. Blue Cross NC believes that this will enable you and your billing staff to more readily understand our payment of claims given the widespread use of these policies.    

After implementation, you may receive claims denials or payment changes based on these enhanced claim editing concepts on your explanation of payment or electronic remittances. For additional information on the specifics of your claim submission payment decisions, or to file a grievance or appeal, please contact the Provider Blueline at 800-214-4844.  

Please see below for examples of some of the additional coding and payment policies being implemented. For a complete listing of all new and updated reimbursement policies related to this implementation, please visit the commercial and medical policy updates pages.

ICD-10-CM Diagnosis Coding 

In addition to ensuring ICD-10 diagnosis codes are coded to the highest level of specificity, and that appropriate diagnosis to age and diagnosis are being submitted, there are unique coding attributes of the ICD-10 CM code set and coding conventions that also need to be observed. 

Excludes 1 notes are used to indicate when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Services reported with one or more diagnosis code pairs that are subject to the Excludes 1 note policy will be denied as inappropriate coding.   

Laterality has been built into the code descriptions in many cases. Some ICD-10 codes specify whether the condition occurs on the left, right, or is bilateral. If no bilateral code is provided and the condition is bilateral, then according to ICD guidelines, codes for both the left and the right should be assigned. Only when the side is not identified in the medical record should the unspecified code be assigned. Care should be taken to submit the appropriate laterality designated code(s) based on the medical record or services may be denied for inappropriate coding. 

Principal, primary or the only diagnosis submitted on a claim should never be one of the following, based on coding guidelines: 

• External causes 
• Manifestation codes 
• Sequela codes 

Diagnosis to diagnosis pointer and diagnosis to modifier edits are also new to the editing rules for ICD-10. If a diagnosis code for the left side is used in the header, the line pointer and/or line modifier must match to the left side or service lines may be denied for inappropriate coding. 

Modifiers 

Anatomic Modifiers

Anatomic modifiers are included for fingers, toes, eyelids, coronary arteries, as well as modifiers for right, left, or bilateral procedures. Usage of these modifiers is important so distinct anatomical sites can be identified during processing of a claim. Inappropriate usage, or failure to report these modifiers, may lead to unnecessary denials or payment reductions. 

Physical Medicine/Rehabilitation Services Modifiers  

For the Medicare line of business, we follow CMS guidelines that require certain physical, occupational, and speech/language services to be billed with the therapy service modifiers GN, GO, or GP to indicate that the member is under a plan of care. Failure to report these modifiers may result in a denial of services. 

Inappropriate Modifiers  

Services billed with anatomical modifiers that do not require them, or with modifiers 78 or 79 when no prior surgery is present in history, are examples of modifiers that may lead to denial of services. Use care when submitting modifiers in that they are  supported by the medical record. Due to system limitations in the past, we’ve advised and allowed the use of modifier 59 with the more descript X modifiers (XE, XS, XP, XU).  Beginning June 1, 2022, claim lines with duplicative modifiers of 59 and an X modifier will be denied and must be corrected. 

Procedure Coding  

In addition to rules for procedure to age validation, additional editing will be applied based on procedure code definition, procedure coding guidelines, separate procedures, add-on codes, and “Incident To” services. 

National Coverage Determinations 

According to CMS policy, certain lab services are payable when billed with specific diagnoses. These services will be denied in the absence of one of the designated covered diagnoses identified in the NCD coding manual which can be found on the CMS website, Chapter 1, Part 3, Section 190, at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS014961.html. 

These diagnosis requirements will apply to both Commercial and Medicare lines of business. 

HCC – Risk Adjusted Coding 

The Centers for Medicare and Medicaid Services (CMS) funds Medicare Advantage health plans using a risk-adjusted methodology which includes the severity of reported illness for each Medicare beneficiary enrolled with the health plan. Each health plan, in turn, passes on this risk-adjusted reimbursement to the IPA. This CMS reimbursement model, known as Hierarchical Condition Categories (HCCs), determines each Medicare beneficiary’s clinical severity using ICD-10 diagnosis codes submitted to health plans during the course of normal claims adjudication. The HCCs correspond to enhanced reimbursement for chronically ill members. The net effect of this model is that more premium funding may be available to the health plans, and subsequently the IPA and its primary care physicians, when all diagnosis codes are documented in the medical record, captured on claims, and transmitted to CMS.  

CMS now uses the HCC model to risk adjust beneficiaries across multiple programs, including Medicare Fee for Service Next Generation ACO (NGACO) and other shared savings models. 

Each diagnosis listed determines the overall health of the patient, which determines the reimbursement amount. The most common diagnoses are 

• Diabetes with or without complications 
• Congestive Heart Failure 
• Chronic Obstructive Pulmonary Disease 
• End Stage Liver Disease/Renal Failure 
• Cancer 
• Drug/Alcohol Dependence 
• Major Depressive, Bipolar, and Paranoid Disorders 

Primary care physicians, as well as specialists, are provided with an opportunity to have a positive influence on premium rates received from contracted Medicare Advantage plans, as well as on individual practice revenue. 

Providers are expected to:

• Include all documented chronic conditions on the visit claim (can include up to 12 diagnosis codes / CMS 1500 form). 
• Fully assess and document all patients’ chronic conditions at least once a year. 
• Use ICD-10 codes to the highest level of specificity and submit codes for chronic conditions annually. 
• Allow Blue Cross NC’s HCC coding staff (on-site or electronic) access to their charts for concurrent, prospective and retrospective HCC medical record review. 
• Be available for follow-up meetings to discuss HCC documentation improvement opportunities based on findings during medical record review. 
• Interact with health plans for gap closure analysis. 
• Participate in Medicare Advantage analytic programs sponsored by the health plans. 

Revenue Codes  

Similar to CMS, Blue Cross NC will require some revenue codes to be reported with corresponding CPT/HCPCS codes. This will allow for a greater understanding of what services are being submitted and enable Blue Cross NC to more accurately adjudicate claims.