Claim Editing Enhancements Coming April 1, 2022

Dec. 28, 2021

Effective April 1, 2022, 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 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.

About the guidelines: BCBSTX will continue to follow claim payment policies that are global in scope, simple to understand and come from recognized sources, including:

  • ICD-10 coding guidelines
  • The Healthcare Common Procedure Coding System (HCPCS)
  • Current Procedural Terminology (CPT®) codes as documented by the American Medical Association (AMA)
  • Correct Coding Initiatives (CCI)
  • Post-Operative Period Guidelines as outlined by the Centers for Medicare and Medicaid Services (CMS)

Using these guidelines will help ensure a more accurate review of all claims.

What’s changing: 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. Use of 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: these new enhancements follow a previous announcement for an edit that will go live Jan. 10, 2022. See the previous announcement.

More Information: View the Cotiviti, Inc Edit Descriptions for additional guidance. 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. Watch News and Updates for future updates.


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