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Claims & Billing

This page includes claims and billing guidelines to assist you in submitting claims to BCBSRI.

Important Reimbursement Edits

BCBSRI would like to inform billing providers of certain edits that may affect claims processing.

National Correct Coding Initiative Edits (NCCI): These edits are used by the Centers for Medicare and Medicaid Services (CMS) to promote correct coding. They are edits based upon code pairs. The edits are in place to prevent codes that should not be reported together from being so reported. Usually one of the two members of the pair is a service already included in the other procedure and thus not reported separately when correctly coding. In some cases, the services are mutually exclusive, i.e., the procedures would not be performed concurrently for clinical reasons. NCCI edits are of two types: 1) There are "0" indicator edits, which are never correctly reported together; 2) There are "1" indicator edits, which may be overridden by a modifier (typically modifier 59 or a digit modifier). It is the reporting clinician's responsibility to be sure the modifier is correctly used. NCCI edits are available from the National Technical Information Service. For more information see the CMS website for NCCI: http://www.cms.hhs.gov/NationalCorrectCodInitEd/

Global Periods: BCBSRI uses the surgical global period as designated by CMS.

Assistant Surgeon Payment: We use the CMS table on the Medicare Physician Fee Schedule (PFS) to determine if we will pay for an assistant surgeon. These are not medical necessity determinations and are not reviewed for medical necessity if appealed. The payment determination is a contractual payment policy. Services that have the CMS "assistant-at-surgery restriction" or the "assistant-at-surgery restriction unless medical necessity established with documentation" have no payment for participating physicians. Participating physicians may not require members to pay an assistant fee even if the members accept responsibility to do so, as this is charging outside of the approved amount. The PFS National Payment Amount file lists the status and is found at: http://www.cms.hhs.gov/PhysicianFeeSched/

Preventive Medicine (CPT® 99381-99397) and Office or Other Outpatient Services (CPT 99201-99215), Same Date of Service: BCBSRI pays one of the two services whether or not modifier 25 is applied.

Diagnosis- or Frequency-Related Edits: Some procedures are limited to being considered medically necessary only for certain conditions or at a certain frequency. Medical policy exists for these edits.

Inpatient Concurrent Care and Multiple Visits per Day: Correct coding requires that any physician only report one Inpatient Subsequent Care service (99231-99233) per day. This rule applies to members of the same group in the same specialty, i.e., such members are considered one physician for reporting purposes. Edits will also deny two members of the same specialty from reporting these services on the same day, whether or not they are in the same group. If there is a subspecialty for one of the two physicians that we do not or cannot list in our system, denials will need to be reviewed by the Individual Consideration Unit. We will also review requests for the payment in the unusual case where two physicians of the same specialty in different groups both provided distinct services.

CPT and HCPCSII Codes That Are Not Separately Reimbursed for Physicians or Other Professional Providers: As a general rule, we follow CMS for codes that are "bundled." These are covered services for which there is no payment. Generally, they are part of another service or services concurrently performed or performed in the past or to be performed. In some cases the designation is applied to a code because another code exists to describe the service and we ask that the alternative code be the one used. (For example, if there are G codes and CPT codes for essentially the same service, we typically use the CPT code.) These are contractual payment designations and not medical necessity determinations.

CPT® is a trademark of the American Medical Association.

Denial Codes

Please use the attached listings to obtain details on denial codes found on your Remittance Advices.