Empire BlueCross BlueShield Professional Reimbursement Policy

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Empire BlueCross BlueShieldProfessional Reimbursement Policy• Mutually Exclusive/Redundant: “Mutually exclusive edits consist of combinations ofprocedures that differ in technique or approach but lead to the same outcome. In someinstances, the combination of procedures may be anatomically impossible. Procedures thatrepresent overlapping services or accomplish the same result are considered mutually exclusive.In addition, reporting an initial service and subsequent service is considered mutuallyexclusive.” A procedure determined to be mutually exclusive to another procedure will be deniedreimbursement.• Procedure Rebundling: identifies unbundled procedure codes used to describe a procedure (e.g.a blood panel) when a single more comprehensive code exists. The correct procedure code thatmost accurately represents the service will be added to the claim. The identified unbundledprocedures will be denied, and the appropriate added code will be eligible for reimbursement. Forblood panel rebundling, see our Laboratory and Venipuncture Services reimbursementpolicySame Day Medical Visit: identifies when an E/M visit is billed on the same day as a surgical procedureor substantial diagnostic or therapeutic (such as dialysis, chemotherapy and osteopathic manipulativetreatment) procedure. Our reimbursement policies indicate that an E/M code reported by the sameprovider on the same day as a procedure is rendered by that provider is included within the globalreimbursement for the procedure. See our Global Surgery reimbursement policyTechnical/Professional Component Billing: identifies proper coding of professional, technical, andglobal procedures. Modifier 26 signifies the professional component and Modifier TC signifies thetechnical component.When the CMS NPFSRVF designates that modifier 26 is applicable to a procedure code (PC/TC indicatorof 1 or 6), and the procedure code (e.g. radiology, laboratory, or diagnostic) has been reported by aprofessional provider with a facility place of service, the procedure code must be reported with modifier26 or it will not be eligible for reimbursement.When the NPFSRVF designates that the concept of a separate professional and technical component doesnot apply to a laboratory procedure (PC/TC indicator of 3 or 9), and a professional provider has reportedthe laboratory procedure code with a modifier 26, the laboratory procedure code will not be eligible forreimbursement. When a laboratory procedure with a PC/TC indicator of 3 or 9 is reported by aprofessional provider with a facility place of service, the laboratory procedure code will be deniedsince the facility will bill for performing the laboratory procedure.A global procedure code includes reimbursement for both the professional and technical componentstherefore:NY 0027 Page 8 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.
Empire BlueCross BlueShieldProfessional Reimbursement Policy• If both components are performed by the same provider, the appropriate code must be reportedwithout the 26/TC modifiers.• If a provider has reported a global procedure and also reported the same procedure with aprofessional (26) or technical (TC) component modifier on a different line or claim, the procedurereported with the 26 or TC component modifier will not be eligible for reimbursement.• If a professional provider bills the global code (no modifiers) with a facility place of service, thecode will not be eligible for reimbursement.Clear Claim Connection TM ″′:For informational purposes, a web-based tool called “Clear Claim Connection TM ” developed byMcKesson Health Solutions is available on the Health Plan’s secure Online Provider Services web site.This claims editing tool allows the provider to enter a specific coding scenario and view the editingresults in place on the date of the inquiry (not the actual claim date of service). If a denial is issued forthe coding scenario, the clinical rationale for the denial is usually provided. The results of a codinginquiry may differ from the results of an actual claim payment since a claim may be affected by systemedits outside of ClaimsXten (e.g. member eligibility, or other claim processing and/or pricing logic).IV. Definitions: Customized Claim Edit: A customized claim edit is an edit that is added ormodified for the commercially available claims editing software product in use by the Health Plan.The Health Plan uses ClaimsXten editing software from McKesson as our editing system.Editing: the practice or procedure pursuant to which one or more adjustments are made to CPTcodes or HCPCS codes included in a claim that result in:• payment being made based on some, but not all, of the CPT/HCPCS′ codes included in theclaim• payment being made based on different CPT/HCPCS codes than those included in theclaim• payment for one or more of the CPT/HCPCS codes included in the claim being lowered byapplication of multiple procedure logic• payment for one or more of the CPT/HCPCS codes being denied, or any combination of theabove.History Editing: identifies historical claims that are related to current claim submissions,resulting in adjustments to the previously processed historical claim(s).• History editing capability can auto-adjudicate reimbursement policies including, but notlimited to: global surgery, same day multiple E/M visits, pre/post-operative visits, newpatient visits, frequency rules, incidental, mutually exclusive and rebundle edits andmaternity services.• For example: When reimbursement is made for an E/M visit code submitted on one claim,and then another claim is submitted with a surgical code for the same date of service,NY 0027 Page 9 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.
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Empire BlueCross BlueShield Professional Reimbursement Policy

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