Reminder: Claim Editing Enhancements Coming April 1

Reminder: Claim Editing Enhancements Coming April 1

February 23, 2022

As of April 1, Blue Cross and Blue Shield of Texas (BCBSTX) will enhance our claims editing and review process with Cotiviti, Inc., for some of our commercial members to help ensure accurate coding of services and that services are properly reimbursed.

What’s changing effective April 1 2022: Components of the editing and review enhancements include:

  • Anatomical Modifiers - CMS-defined anatomical modifiers validate the area or part of the body on which a procedure is performed. Procedure codes that do not specify right or left require an anatomical modifier. This includes procedures on fingers, toes, eyelids and coronary arteries which have specific CMS-defined modifiers.
  • Diagnosis Code Guidelines - Use of correct ICD_10 codes will be verified. ICD-10-clinical modification (CM) diagnosis coding guidelines, including reporting of inappropriate code pairs, as well as correct coding of secondary, manifestation, sequelae, chemotherapy administration, external causes and factors influencing health status diagnoses. These guidelines are contained in the ICD-10-CM Diagnosis Codes Manual.

Reminder: Effective Jan. 10, 2022, the following edit was implemented:

  • Coding for services within the global surgical period - The global surgery package payment policies include all necessary services normally provided by the surgeon before, during and after a surgical procedure, and applies only to primary surgeons and co-surgeons. The global surgery package applies only to surgical procedures that have post-operative periods of 0, 10 and 90 days, as defined by CMS.

What this means for you: The enhancements require you to continue to follow generally accepted claim payment policies. With your help, the enhanced claims review process will help our members get the right care at the right time and in the right setting.

Note: Inaccurately coded claims will result in denied or delayed payment.  To edit or correct a denied claim, refer to the Claim Forms, Submissions, Responses and Adjustments section under Claims Filing Tips on our provider website.

More Information: View edits that will take effect on April 1, 2022 in Cotiviti, Inc. Edit Descriptions for additional guidance. Watch News and Updates for future updates

Cotiviti, Inc. is an independent company that provides medical claims administration for BCBSTX.