Name of Manual - Blue Cross and Blue Shield of Minnesota

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Chapter 11 Coding Policies and Guidelines (Coding) Table of Contents Coding ....................................................................................................................................... 11-2 Overview..............................................................................................................................11-2 HCPCS Codes...................................................................................................................... 11-2 CPT/Level I..........................................................................................................................11-3 Level II HCPCS ................................................................................................................... 11-5 ICD-9-CM............................................................................................................................11-7 Revenue Codes..................................................................................................................... 11-9 Compatibility .......................................................................................................................11-9 Preventive Care Services ...................................................................................................11-10 Preventive Services Required Under the PPACA .............................................................11-13 General Guides................................................................................................................... 11-22 Zero-billing ........................................................................................................................ 11-22 Coding Edits ........................................................................................................................... 11-23 Overview............................................................................................................................ 11-23 Edit Descriptions................................................................................................................ 11-23 Mutually Exclusive Procedures .........................................................................................11-25 Incidental Procedures.........................................................................................................11-26 Medical Visits on the Same Day as Surgery......................................................................11-27 Global Surgical Package – Pre- and Postoperative Services .............................................11-28 Units of Service Validation and Restriction ......................................................................11-29 General Claims Processing Information ............................................................................ 11-30 Medical and Surgical Supplies...........................................................................................11-30 Multiple Surgery Guidelines..............................................................................................11-30 Patient Billing Impact ........................................................................................................11-30 Coding Appeals.................................................................................................................. 11-31 Helpful Coding Tips ..........................................................................................................11-32 Coding Immunizations and Injections ...............................................................................11-32 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12) 11-1
Coding Policies and Guidelines (Coding) Coding Overview Blue Cross and Blue Shield of Minnesota (Blue Cross) requires submission of valid codes to report medical services and supplies on both professional and institutional claims. This includes Healthcare Common Procedural Coding System (HCPCS) codes, International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis and procedure codes and Revenue codes. 11-2 The Health Insurance Portability and Accountability Act (HIPAA) Transaction and Code Set regulation stipulates submission and acceptance of approved medical code sets. HCPCS and ICD-9-CM codes are among the approved HIPAA medical code sets and must be valid for the actual date of the service. If a HCPCS or ICD-9- CM code is not valid for the date of service, the claim will be returned or denied. Revenue codes are a data element of the institutional claim (837I or UB-04) and must be valid for the date of submission. If a Revenue code is not valid on the date submitted, the claim will be returned or denied. HCPCS Codes The HCPCS coding system was developed by CMS (Centers for Medicare and Medicaid Services) to standardize coding systems used to process claims for all payers, including Medicare and Medicaid. HCPCS is a two level coding system-Level I, a.k.a., CPT, and Level II, alpha-numeric codes. All nationally developed codes are accepted; however, coverage is not guaranteed and other restrictions may apply. Services may deny for various reasons including a subscriber contract exclusion or service limitation, Blue Cross corporate or medical policy, or subject to standardized coding edits. HCPCS codes are updated several times throughout the year. The primary update is January of each year. CMS provides updates to Level II codes on a quarterly basis. In addition to January, code updates are done in April, July, and October. CPT codes are generally updated only in January; however, the AMA can release codes early and make codes slated for the next year’s publication available in the prior July. You will be notified of coding updates by Bulletin or the Provider Press newsletter as to effective date of acceptance by Blue Cross. Reimbursement of new HCPCS/CPT codes billed on professional claims (CMS HICF/837P) will be based on of the then current standard Blue Cross fee schedule allowed amount unless explicitly stated otherwise. Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
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Blue Cross and Blue Shield of Minne
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Recent Chapter changes: Chapter 11
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Chapter 11 - Coding Policies and Gu
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Durable Medical Equipment Date Topi
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Medical Emergency Date Topic Change
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Rehabilitative Services Date Topic
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Table of Contents Chapter 1 At Your
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Introduction Provider Policy and Pr
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How to Contact Us At Your Service P
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At Your Service Claims Address Subm
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Care Management Numbers and Address
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Care Management Numbers and Address
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Company Phone Number Address Public
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At Your Service Provider Identifica
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ID Cards At Your Service Introducti
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Electronic Commerce Overview An imp
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Remote Access Services (continued)
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Provider Communications Provider Co
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Health Plan Members have the Follow
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Provider Agreements Participation a
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Provider Agreements Responsibilitie
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Provider Agreements Provider Number
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Provider Agreements Accounting for
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Provider Agreements Carrier Replace
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Table of Contents Chapter 3 Quality
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Quality Improvement Leadership Rati
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Quality Improvement Telephone Care:
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Quality Improvement Quality of Care
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Quality Improvement Written Policie
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Quality Improvement Written Policie
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Quality Improvement Patient Safety
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Quality Improvement Medical Record
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Quality Improvement Institute for C
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Quality Improvement Quality Improve
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Quality Improvement Physical Facili
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Quality Improvement Treatment Recor
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Integrated Health Management Progra
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Integrated Health Management Provid
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Integrated Health Management Utiliz
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Integrated Health Management Medica
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Integrated Health Management Overvi
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Integrated Health Management Pre-Ce
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Integrated Health Management Decisi
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Integrated Health Management Defini
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Integrated Health Management For Lo
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Integrated Health Management Appeal
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Integrated Health Management Case &
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Integrated Health Management Diseas
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Integrated Health Management Focuse
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Integrated Health Management Specia
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Integrated Health Management Overvi
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Integrated Health Management Sample
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Health Care Options Prepaid Medical
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Health Care Options Member ID Cards
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Health Care Options Blue Cross and
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Health Care Options Double Gold Dou
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Health Care Options Medicare Basic
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Health Care Options Platinum Blue S
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Health Care Options MedicareBlue PP
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Health Care Options Inquiries and C
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Health Care Options Additional info
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Health Care Options Minnesota Senio
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Health Care Options MinnesotaCare P
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Health Care Options BlueLinkTPA Blu
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Health Care Options Delta Dental Hi
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Health Care Options Prime Therapeut
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Health Care Options Workers' Compen
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Health Care Options HICF 1500 Form
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Health Care Options Networks Blue C
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Blue Plus Member Information Introd
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Blue Plus Member Rights and Respons
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Blue Plus Member Rights and Respons
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Blue Plus Member Benefits Members
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Blue Plus Quality of Care Complaint
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Blue Plus Referral Points Remember
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Blue Plus Referral Not Required We
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Blue Plus Standing Referral Minneso
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Blue Plus Clarifications of Terms (
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Blue Plus [Date] [Name of patient]
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Blue Plus Special Member Benefits O
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Blue Plus OB/GYN Open Access Diagno
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Blue Plus OB/GYN Open Access Diagno
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BlueCard® Claim Status Inquiry ...
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BlueCard® Identifying BlueCard ®
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BlueCard® Identifying BlueCard ®
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BlueCard® BlueCard Service Claims
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BlueCard® Prior Authorization and
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BlueCard® Electronic Data Intercha
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BlueCard® Claims Processed by the
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BlueCard® Overview (continued) 3.
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BlueCard® Claim Payment Guidelines
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BlueCard® Calls from Members and O
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BlueCard® Guidelines (continued) W
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BlueCard® Types of Medicare Advant
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BlueCard® Medicare Advantage Claim
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BlueCard® Reimbursement for Medica
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Claims Filing HCPCS/ Accommodation
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Claims Filing Administrative Simpli
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Claims Filing Claims with Attachmen
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Claims Filing Claims with Coordinat
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Claims Filing Claims with Coordinat
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Claims Filing 1500 HICF Form Profes
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Claims Filing Ordering Forms and Ma
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Claims Filing Site of Service (cont
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Coding Policies and Guidelines (Mod
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Chapter 11 Coding Policies and Guid
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Part-time (Medically Directed) Anes
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Electroconvulsive Treatments Blue C
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Moderate (Conscious) Sedation Monit
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Coding Policies and Guidelines (Beh
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Coding Restrictions Code Restrictio
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CTSS Skills Training and Developmen
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Intensive Residential Treatment Ser
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IRTS Member Eligibility IRTS Access
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Adult Non-Residential Crisis Servic
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MH-TCM Services to Minnesota Health
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Dialectical Behavioral Therapy/DBT
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Autism Spectrum Disorder/EIBI (cont
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Autism Spectrum Disorder/EIBI (cont
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Psychiatric Consultation to Primary
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Psychiatry and Chemical Dependency
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Medication Management M0064 and 908
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Nutritional Counseling/Medical Nutr
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Practitioner Key MD = Psychiatrist
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Clinical Supervision Under Minnesot
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Missed Appointments (continued) Cou
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Guidelines for Court Ordered Evalua
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Guidelines for Court Ordered Evalua
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Behavioral Health Quality Improveme
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Prior Authorization Requirements Co
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Waivers and Upgraded/Deluxe DME Wai
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Hearing Aids (continued) Website Co
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Portable Oxygen Billing (continued)
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Elderly Waiver Program (continued)
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Referrals and Prior Authorization (
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Adult Day Care Bath Services Coding
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Home Infusion (continued) Coding Po
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Hot and Cold Pack Exclusion TMJ Ort
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Massage and Manual Therapy Exclusio
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MHCP PT, OT, ST Authorization Proce
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Bilateral Services (continued) Codi
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Assistant Surgeons (continued) Assi
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