Three New ClaimsXten^TM Rules to be Implemented March 2024

Bundled Service

This rule identifies claim lines containing procedure codes indicated by the Centers for Medicare & Medicaid Services to be always bundled when billed with any other procedure. According to the CMS National Physician Fee Schedule Relative Value File, this procedure has a status code indicator of “B,” which is defined as: “Payment for covered services is always bundled into payment for other services not specified.” This rule is appropriate for professional claims only. 

CMS Add-on Without Base Code Facility

This rule identifies claim lines containing a Current Procedural Terminology or Healthcare Common Procedure Coding System assigned add-on code when billed without acceptable supporting primary procedure/base code by the same practitioner for the same patient on the same date of service, per CMS. According to CMS, add-on codes are always performed in addition to the primary service or procedure and must never be reported as a stand-alone code. An add-on code is eligible for payment if its related primary procedure/base code is also eligible for payment to the same practitioner for the same patient on the same date of service. This rule is appropriate for outpatient facility claims only.

Ancillary Procedures

This rule identifies claim lines billed by the same or a different provider either on the same day or different day (depending on the procedure code) after a non-covered service. This rule can consider both facility and non-facility claims.

Before denying an ancillary service, the rule checks for other covered services that may have been performed on the same day as the non-covered procedure. If found, the rule will allow the ancillary service. This rule is appropriate for professional claims and outpatient facility claims only.