CurrentAnthemPolicy N/A

Professional reimbursement policy changes and claims editing updates

Governs updates to Anthem Blue Cross and Blue Shield professional reimbursement policies and ClaimsXten/Claims editing rules affecting claim coding, bundling, frequency limits, and modifier behavior for providers submitting professional claims in Colorado.

Policy Summary

PayerAnthem

PolicyProfessional reimbursement policy changes and claims editing updates

Policy CodePolicy N/A

Change TypeCode-pair edits, bundled denials, frequency limits, modifier policy

Effective DateMarch 1, 2017

Next Review DateN/A

Key ActionProviders should review updated reimbursement policies and ClaimsXten edits via ProviderAccess and Clear Claim Connection and contact their Provider Solutions representative with questions.

SourceLink

POLICY UPDATE CHANGES

New code-pair edits will be implemented for bundled services and supplies and modifiers 59, XE, XP, XS, and XU effective March 1, 2017.

Specific CPT codes (e.g., 63048, 22614, 63081-63088, 82542) will not be eligible for separate reimbursement when reported with specified arthrodesis or related codes; modifiers will not override these edits.

Edit updated to deny 76882 when reported with 76942 based on CPT guidance; modifiers will not override.

Frequency limits effective March 1, 2017: HCPCS H0020 and H0022 limited to one per date of service; CPT 49185 limited to one per date of service; CPT 87491 and 87591 limited to three per date of service.

Modifiers will no longer override specified edits denying separate reimbursement for certain code combinations (examples include 22612 with 22633; 63048 with 22630; 76942 with 76881).

2017-03-01effective date for edits and frequency limits

H0020, H0022, 49185

Policy Summary

PayerAnthem

PolicyProfessional reimbursement policy changes and claims editing updates

Policy CodePolicy N/A

Change TypeCode-pair edits, bundled denials, frequency limits, modifier policy

Effective DateMarch 1, 2017

Next Review DateN/A

Key ActionProviders should review updated reimbursement policies and ClaimsXten edits via ProviderAccess and Clear Claim Connection and contact their Provider Solutions representative with questions.

SourceLink

On This Page

Coverage rules and edits

Anthem denies separate reimbursement for specified code pairs and applies frequency limits; modifiers will not override the listed edits or frequency limits.

ALL of the following

Examples of arthrodesis/laminectomy bundling denials
- CPT 63048 reported with CPT 22633 — bundled; 63048 will not be eligible for separate reimbursement when reported with 22633.
- CPT 22614 reported with any of CPTs 22600, 22610, 22612, 22630, or 22633 — 22614 will not be eligible for separate reimbursement when reported with those codes.
Vertebral corpectomy and anterior interbody bundling
- CPTs 63081, 63082, 63085, 63086, 63087, or 63088 reported with CPT 22558 — the corpectomy codes will not be eligible for separate reimbursement when reported with 22558.
Laboratory and breath test bundling
- CPT 82542 reported with CPT 91065 — 82542 will not be eligible for separate reimbursement when reported with 91065.
Ultrasound guidance/imaging relationship
- CPT 76942 (ultrasonic guidance for needle placement) denied as incidental when reported with CPT 76882 (ultrasound, extremity, nonvascular, limited).
- Updated edit to deny CPT 76882 when reported with CPT 76942 based on CPT guidance; modifiers will not override the edit.
Other incidental/duplicate denials
- Cervical and vaginal cytopathology (CPTs 88141-88155, 88165-88167, 88174-88175 and added HCPCS G0101, G0402, G0438, 60439, S0610, S0612) are considered incidental to E/M services and will be denied when reported by the same provider for the same patient on the same date of service; modifiers will not override these edits.

ALL of the following

Per-date frequency limits
- HCPCS H0020: limited to 1 per date of service.
- HCPCS H0022: limited to 1 per date of service.
- CPT 49185: limited to 1 per date of service.
- CPTs 87491 and 87591: limited to 3 per date of service (CDC-based).

ALL of the following

Modifiers 59, XE, XP, XS, and XU will not override the listed bundled-service edits or the frequency limits effective March 1, 2017.
Illustrative existing edits where modifiers will no longer override
- Denial of CPT 22612 when reported with 22633; modifiers will no longer override the edit.
- Denial of CPT 63048 when reported with 22630; modifiers will no longer override the edit.
- Denial of CPT 76942 as incidental to 76881; modifiers will no longer override the edit.
- Denial of CPT 27275 as incidental to 27093 and 27095; modifiers will not override the edits.

ALL of the following

Full policy details and ClaimsXten edit rationale are available on ProviderAccess; Clear Claim Connection will display the edits and clinical rationale on the effective date.

Code-specific edits and frequency limits

Examples of CPT code pairs denied as bundledCPTNot Covered

63048	Laminectomy, facetectomy and foraminotomy, each additional segment
22633	Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique, single interspace and segment; lumbar
22614	Arthrodesis, posterior or posterolateral technique, each additional vertebral segment
22600	Arthrodesis, posterior or posterolateral technique, single level; cervical below C2

Examples of CPT code pairs denied as bundled (continued)CPTNot Covered

No codes listed

Additional bundled code denialsCPTNot Covered

63081-63088	Vertebral corpectomy codes
22558	Arthrodesis, anterior interbody technique; lumbar
82542	Column chromatography, includes mass spectrometry, non-drug analyte(s)
91065	Breath hydrogen or methane test

Ultrasound guidance and imaging relationshipCPTNot Covered

76942	Ultrasonic guidance for needle placement — incidental when reported with certain ultrasound codes
76882	Ultrasound, extremity, nonvascular, limited

Frequency-limited codesmixedCovered

H0020	Alcohol and/or drug services; methadone administration and/or service
H0022	Alcohol and/or drug intervention service (planned facilitation)
49185	Sclerotherapy of a fluid collection, percutaneous
87491	Chlamydia trachomatis, amplified probe technique
87591	Neisseria gonorrhoeae, amplified probe technique

Frequency per date of service limits (policy)mixed

H0020/H0022	Limited to one per date of service
49185	Limited to one per date of service
87491/87591	Limited to three per date of service

Frequency per date of service limits

HCPCS H0020Limited to 1 per date of service

HCPCS H0022Limited to 1 per date of service

CPT 49185Limited to 1 per date of service

CPT 87491Limited to 3 per date of service

CPT 87591Limited to 3 per date of service

Modifier behavior and tool references

Modifiers will not override listed edits

Modifier 59Will not override listed edits

Modifier XEWill not override listed edits

Modifier XPWill not override listed edits

Modifier XSWill not override listed edits

Modifier XUWill not override listed edits

Clear Claim Connection reference

Tool nameClear Claim Connection (web-based editing tool)

What providers should do

Documentation Required

Review updated edits and policies via ProviderAccess and Clear Claim Connection

Review the updated reimbursement policies on ProviderAccess and examine ClaimsXten edits and rationale in Clear Claim Connection; contact your Provider Solutions representative with questions.

Access updated Reimbursement Policies via ProviderAccess: anthem.com → Provider link → select Colorado → ProviderAccess Login → Medical → Overview tab → Policies and Procedures → View Professional Reimb & Admin Policies.
Use Clear Claim Connection (from the Claims tab in ProviderAccess) to view the ClaimsXten edits and the clinical rationale for edits by entering claim scenarios.
If you have questions, call your Provider Solutions representative.