ClaimsXtenTM March 2015 Update

December 23, 2014

Beginning on or after March 23, 2015, Blue Cross and Blue Shield of Texas (BCBSTX) will enhance the ClaimsXten code auditing tool by adding Centers for Medicare and Medicaid Services (CMS) Correct Coding Initiative Rule into our claim processing system. The purpose of this new rule is to identify claims containing code pairs found to be unbundled according to the CMS National Correct Coding Initiative (NCCI). The CMS NCCI coding policies are based on coding conventions defined in the AMA’s Current Procedural Terminology (CPT) manual, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice and/or current coding practice.

The ClaimsXten tool offers flexible, rules-based claims management with the capability of creating customized rules, as well as the ability to read historical claims data. ClaimsXten can automate claim review, code auditing and payment administration, which we believe results in improved performance of overall claims management.

BCBSTX will continue with the modifier 59 exempt program through ClaimsXten. This program is based on the CMS NCCI.

NCCI guidelines state, "Each NCCI edit has an assigned modifier indicator. A modifier indicator of ’0‘ indicates that NCCI associated modifiers cannot be used to bypass the edit." BCBSTX will continue to use ClaimsXten as the code pair default. NCCI edits (either Incidental or Mutually Exclusive) that are currently not part of the ClaimsXten database will NOT be added.

To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process, you may continue to utilize Clear Claim ConnectionTM (C3). C3 is a free, online reference tool that mirrors the logic behind BCBSTX’s code-auditing software. Refer to our website for additional information on gaining access to C3.

For updates on ClaimsXten, watch the News and Updates on our Provider website, as well as upcoming issues of the Blue Review.

Checks of eligibility and/or benefit information are not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered.

ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for it products and services.

CPT copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.