BCBSGa to enhance automated claim edits for professional claims

Effective for professional claims (CMS-1500) processed on or after November 18, 2018, BCBSGa will enhance our editing systems to automate edits supported by correct coding guidelines, as documented in industry sources such as CPT, HCPCS Level II, and International Classification of Diseases 10 (ICD-10).  As a result, there will be greater focus on identifying incorrect or inappropriate billing of services by multiple providers within the same tax identification number for the same patient on the same day. This enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines.

 

Below are examples of claim edits that will be automated:

• Accurate reporting of modifiers, including LT, RT, 54, 55, 56, 62,76, 77, 78, 79, 80, 81, 82, and AS, which are often reported for the billing of services rendered by the same provider or multiple providers.
• Ensuring global, professional (modifier 26) and technical components (modifier TC) are billed appropriately by one or more providers in facility and office settings.
• Assessing whether services considered once in a lifetime have been billed more than once.
• Ensuring the reporting of procedures and the associated diagnosis codes are correctly reported together.