| Q: |
What coding manual does BCBSTX use? |
| A: |
BCBSTX utilizes CPT and HCPCS manuals for coding and ClaimCheck as our code auditing software.
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| Q: |
Our office recently received clinical information from the AMA that would help in an argument to change claim check (bundling) edits. Can we expect BCBSTX to make those changes? |
| A: |
BCBSTX does take AMA information into consideration when reviewing our bundling logic. In addition, BCBSTX requests the recommendation of Physicians/Professional Providers within a specific specialty to provide details regarding multiple procedures and how they should be considered.
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| Q: |
Does BCBSTX use McKesson software? |
| A: |
Yes, BCBSTX currently utilizes a version of McKesson Information Solutions’ ClaimCheck for code editing.
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| Q: |
BCBSTX does not recognize CCI rules. Does BCBSTX recognize all modifiers established in the Medicare guidelines? |
| A: |
Our code auditing software, ClaimCheck is consistent with many CCI edits. Although BCBSTX accepts all standard modifiers, not all modifiers impact reimbursement.
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| Q: |
We have codes that are bundling together even though we submit a separate diagnosis for each code. Is this correct? |
| A: |
Bundling edits are primarily determined from CPT or other procedure codes submitted with a claim. They are only secondarily affected by diagnosis codes and also take into account the most likely clinical scenario and/or the most comprehensive procedure performed.
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| Q: |
We have a physician who is billing two different procedures; however, we commonly receive a denial for one of the procedures billed. Our appeals are also denied for bundling. The office is following CCI, why are these not being reimbursed separately? |
| A: |
BCBSTX utilizes a version of McKesson Information Systems’ ClaimCheck, not CCI. Although ClaimCheck often follows CCI, it does not always mirror CCI. For an appeal or additional consideration, BCBSTX recommends you include details, including medical records where appropriate, to substantiate each procedure being considered independently for reimbursement.
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| Q: |
Where can you obtain a copy of the bundling edits? |
| A: |
The vendor licensing agreement prohibits us producing spreadsheets, tables or mass lists of all bundling edits in the software. However, information about our code edits may be referenced at http://www.bcbstx.com/provider/clear_claim_
connection.htm. This tool, Clear Claim ConnectionTM (CCC), the web-based code auditing reference tool, is now available to all contracted Blue Cross Blue Shield of Texas (BCBSTX) providers. CCC mirrors the ClaimCheck® auditing rules that BCBSTX has adopted as part of its claim adjudication process. It provides easy access to ClaimCheck payment policies and rules along with clinical rationales, clarification and source information for ClaimCheck edits.
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| Q: |
When I bill a vaccine with an office visit or a preventive care visit, why does my visit deny? |
| A: |
Verify usage of the correct administrative code of a vaccine for the specific age range. Please refer to the CPT manual section entitled "Immunization Administration for Vaccines/Toxoids."
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