Empire BlueCross BlueShield Professional Reimbursement Policy

Empire BlueCross BlueShieldProfessional Reimbursement PolicyI. Documentation and ReportingAll claims submitted by a provider must be in accordance with the reporting guidelines and instructionscontained in the American Medical Association (AMA) CPT Manual, “cpt Assistant,” HCPCS, andICD-9-CM publications.” Providers are responsible for accurately reporting the medical, surgical,diagnostic, and therapeutic services rendered to a member with the correct CPT and/or HCPCS codes, andfor appending the applicable modifiers, when appropriate. The code(s) and modifier(s) must be active forthe date of service reported, and describe the services provided during the patient encounter.• The member’s medical records must legibly and accurately describe the services that warrantedthe use of a specific CPT /HCPCS code.• The Health Plan reserves the right to perform audits or investigations to confirm appropriatereporting of services provided to our members and initiate recovery for inappropriatereimbursement.• Based on audit findings and/or published reporting guidelines (for example, CPT guidelines),we may update our reimbursement policies and claims editing system.• If a ClaimsXten denial related to one of the rules listed below is received on a remit, pleasereview the billing for the submitted claim prior to initiating an appeal. If an error in coding isdetected, please correct the information and resubmit as needed.II. ClaimsXten ChangesThe Health Plan implements ClaimsXten changes (e.g., customization, updates, upgrades, andreimbursement policy changes) on a periodic basis.• These changes will reflect the addition of new/revised CPT/HCPCS codes and the HealthPlan’s associated edits, Correct Coding Initiative (CCI) updates and/or revisions, and changesidentified through the Health Plan’s regular review or due to inquiry. Additionally, thesechanges will include edits associated with the Health Plan’s reimbursement policies.• The Health Plan reserves the right to change our reimbursement policies and claim editingsystem without prior notice.III. ClaimsXten RulesMany ClaimsXten rules incorporate “same provider” editing which results in the denial ofseparate reimbursement for services rendered on the same day (or across dates of service for Pre-Op/Post Op days and Frequency Validation) by the same provider. This editing identifies “sameprovider” as any provider with the same tax identification number (TIN) or individual provideridentification number. Some rules that incorporate the “same provider” identification are:• Always Bundled Services and Supplies and Supplies for Same Day Surgery• Pre-Op/Post-Op Days• Base Code Validation and Base Code Quantity• Technical/Professional Component Billing• Frequency ValidationNY 0027 Page 2 of [10]Empire HealthChoice HMO, Inc.,and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association,an association ofBlue Cross and Blue Shield Plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue ShieldAssociation.