Name of Manual - Blue Cross and Blue Shield of Minnesota

Mutually Exclusive
Procedures
Blue Cross Blue and Shield of Minnesota Provider Policy and Procedure Manual (07/12/12)
Coding Policies and Guidelines (Coding)
Mutually exclusive procedures exist when a claim is submitted for
two or more procedures that are not usually performed on the same
patient, on the same date of service. In mutually exclusive
relationships, the most clinically intense code is recognized for
payment. Clinical intensity is generally based on the total RVU for
the procedures submitted.
An example would be billing the following procedure codes
together:
58260......Vaginal Hysterectomy
58150......Total Abdominal Hysterectomy
Since a hysterectomy would not be performed using two different
approaches, the vaginal hysterectomy would be denied as mutually
exclusive to the abdominal hysterectomy. This edit would result in
the line item denial of procedure 58260 and would be the
participating network provider’s liability.
Another example would be billing the following procedures
together:
27550......Closed treatment of a knee dislocation
27556......Open treatment of a knee dislocation
The knee would not be reduced by doing both procedures. The
open procedure would survive as the one that was more clinically
intense. This would result in the line item denial of procedure
27550 and would be the participating network provider’s liability.
When this edit is applicable, the following message(s) will appear
on your current remittance advice:
Payment is included in the allowance of the other procedure.
Service is not payable with other service rendered on the same
date.
These charges are not covered. Less complex procedures with
the same outcome and date of service as another procedure are
not eligible.
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