2 de marzo de 2020
 

On or after June 15, 2020, we will update the ClaimsXten software database to better align coding with the reimbursement of claim submissions.

  • On or after June 15, 2020 we will update three rules: Revenue Codes Requiring healthcare Coding System (HCPCS) Codes, Lifetime Event, Multiple Medical Same Day Visits.

Revenue Codes Requiring (HCPCS) Code

This rule recommends the denial of claim lines if they are:

  • Submitted with a revenue code that requires a HCPCS code, and
  • No HCPCS code is present.

If a claim is missing a HCPCS code, the claim line will be denied.

Lifetime Event

This rule audits claims to determine if a procedure code has been submitted more than once or twice on the same date of service or across dates of service when it can only be performed once or twice in a lifetime for the same member.

The Lifetime Event is the total number of times that a procedure may be submitted in a lifetime.

This is the total number of times it is clinically possible or reasonable to perform a procedure on a single member. After reaching the maximum number of times, additional submissions of the procedure are not recommended for reimbursement.

Multiple Medical Same Day Visits

This outpatient facility rule identifies and recommends the denial of claims with multiple Evaluation & Management (E&M) codes and other visit codes that are:

  • Submitted on the same date of service,
  • Performed at the same facility,
  • Submitted with the same revenue code, and
  • Where the second and subsequent E&M code submitted lacks the required modifier –27.

 

To determine how coding combinations may be evaluated during claim adjudication, use Clear Claim ConnectionTM (C3). Refer to the Clear Claim Connection page for answers to preguntas about ClaimsXten and details on how to gain access to C3.

ClaimsXten and Clear Claim Connection are trademarks of Change Healthcare, an independent company providing coding software to BCBSNM. Change Healthcare is solely responsible for the software and all the contents. BCBSNM makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Change Healthcare. Si tiene alguna pregunta acerca de los productos o servicios ofrecidos por estos proveedores, debe comunicarse con el proveedor directamente.