CurrentBlue Cross Blue Shield - IllinoisPolicy N/A

ClaimsXten rule descriptions for automated claim edits

This document lists and explains the ClaimsXten automated claim-edit rules used by Blue Cross and Blue Shield of Illinois to identify and recommend denial or replacement of claim lines based on coding, frequency, bundling, modifiers, age/gender, global periods, and other payment edits; it affects providers submitting professional and facility claims to BCBSIL.

Policy Summary

PayerBlue Cross Blue Shield - Illinois

PolicyClaimsXten rule descriptions for automated claim edits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMar 21, 2011

Next Review Date

Key ActionDeny claim lines when edits detect billing issues such as MUE breaches, NCCI unbundling, global period conflicts, missing required HCPCS, or other coding/payment rule violations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~40+distinct edit rules and variants described

Multipleedits based on CMS/MUE/NCCI guidance

Severalretired edits noted

Prof & Facilityapplies to claims types

ClaimsXten Edit Decision Criteria

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

ClaimsXten edit decision criteria

Rules that result in recommended denial or replacement of claim lines when conditions are met:

ClaimsXten edits that recommend denial or line replacement when specific coding, frequency, bundling, modifier, MUE, age/gender, global period or lifetime-event conditions are met

Global period / surgical bundling edits

Surgical Inclusive Edit: deny claim lines containing supplies billed on same date of service as a surgical procedure with a CMS-assigned global period.
Same Day Visit Edit: deny E/M codes billed on same date of service as a procedure code with a global period.
Pre-Op Visit Edit: deny E/M codes billed within the pre‑operative period of a procedure code with a global period.
Post-Op Visit Edit: deny E/M codes billed within the post‑operative period of a procedure code with a global period.

Bundling / component edits (NCCI / OCE / I/OCE)

CMS National Correct Coding Initiative: deny claim lines for code pairs defined in NCCI as not recommended for reimbursement.
Facility OCE / I/OCE Bundling: deny outpatient facility claim lines containing code pairs found to be unbundled per CMS OCE/I/OCE (facility unbundled pairs / facility outpatient code editor).
Incidental Edit: deny claim lines clinically integral to or component of a more comprehensive procedure.
Multicode Rebundle Edit: deny claim lines when multiple procedure codes describe a service that is more accurately represented by a single comprehensive code.

Medically Unlikely Edits (MUE) / frequency limits

MUEs Multiple Lines: deny when units of service submitted by same provider for same member/date exceed CMS MUE for the CPT/HCPCS code (professional and facility rules).
Outpatient Facility - MUEs Multiple Lines: deny outpatient facility claim lines when submitted units exceed CMS MUEs for that CPT/HCPCS code.
DME MUEs: deny DME items when units exceed DMEPOS MUE values as defined by CMS.
Allowed Multiple Times / Allowed Once Per Date of Service Filters: deny codes submitted more times per date/site than allowed by code definition.

Add-on and related code presence

Add-On Without Base / Add-On Without Base 2: identify/deny add-on codes billed without presence of related primary/base procedure(s) or billed as sole/only with other add-on codes.
Add-on validation for vaccine/immunoglobulin administration per content in add-on rule modules.

Modifier and non-payment modifier validation

Modifier to Procedure Edit / Modifier to Procedure Validation Filter: deny lines with invalid modifier-to-procedure combinations when modifier is identified as a payment modifier.
Non-Payment Modifiers: recommend denial when a non-payment affecting modifier is submitted that is not appropriate for the procedure; if any submitted modifier is invalid the line is recommended for denial.
Co-Surgeon (-62): deny lines submitted with -62 when the procedure typically does not require co-surgeons per CMS/CPT guidance.

Age / Gender / replacement edits

Age Code Replacement / Age Replacement Edit (retired): identify/deny procedure codes inconsistent with member age and replace with age-appropriate code.
Gender Replacement Edit: deny procedure codes inconsistent with member gender and replace with gender‑appropriate code.

Revenue code / HCPCS and lifetime edits

Revenue Codes Requiring HCPCS Codes: recommend denial of claim lines submitted with a revenue code that requires a HCPCS code when no HCPCS code is present.
Lifetime Event: audit and recommend denial when a procedure has been submitted more times than allowed in a member's lifetime (exceeds lifetime event maximum).

Duplicate / component / bilateral / multiple visit edits

Global Component / Component Billed: identify and prevent overpayment for duplicate global vs component submissions across providers or duplicate professional/technical components.
Bilateral Services for Professional Claims: deny second submission when procedure was already billed with modifier -50 and reimbursement guidelines require single bilateral billing.
Multiple Medical Same Day Visits: recommend denial of multiple E/M/visit codes billed same date, same facility, same revenue code when subsequent E/M lacks required modifier (-27).

New patient / lookback validation

New Patient E/M lookback: recommend denial of new patient E/M when another E/M or face-to-face professional service was billed within prior three years by same provider ID or same provider group and specialty.

Other operational / frequency filters: rules that deny same-day laboratory without required modifiers, CPAP/BIPAP supply frequency exceeding replacement schedule, obstetrics package conflicts, and other specialized filters described in ClaimsXten rule modules.

Coding Tables and Thresholds

CMS-based code groupsmixed

NCCI code pairs	Code pairs defined by CMS NCCI for unbundling/bundling decisions
MUEs (CMS)	Medically Unlikely Edits units limits for CPT/HCPCS

MUE unit thresholds - inv-03: Edits when units exceed CMS MUEs

Policy actionEdits deny claim lines when submitted units for a CPT/HCPCS/DMEPOS code exceed the CMS-established Medically Unlikely Edit (MUE) value.

ScopeApplies to CPT, HCPCS and DMEPOS codes submitted by the same provider for the same member and date of service (includes outpatient facility MUEs).

Trigger examplesExcessive quantity/units billed for supply or durable medical equipment codes (e.g., CPAP/BIPAP supplies replacement schedule referenced to CMS).

Related rulesOutpatient Facility - MUEs Multiple Lines; DME MUEs; MUEs Multiple Lines.

Effective guidance sourceMUE values as established by CMS (CMS DMEPOS MUEs and CMS MUE tables).

New patient E/M lookback - inv-04: Denial when prior E/M exists

Policy actionRecommend denial of a New Patient E/M claim when any E/M or other face-to-face professional service was billed within the prior three years by the same provider (same provider ID) or same provider group and specialty.

Lookback period3 years prior to the date of service.

Provider matchingSame provider ID, or same provider group and same specialty triggers the edit.

Triggering service typesAny E/M code or other face-to-face professional service on a previously billed claim within the lookback period.

Effective ruleNew Patient E/M (Effective: 09/18/2017).

Provider Billing Rules and Denial Risks

Denial Risk

Surgical Inclusive Edit

Deny claim lines containing supplies billed on the same date of service as a surgical procedure for which CMS has assigned a global period.

Denial Risk

Incidental Edit

Deny a claim line that is clinically integral to accomplishing the principal procedure/service or is considered a component of the more comprehensive procedure.

Denial Risk

Multicode Rebundle Edit

Deny a claim line when two or more procedure codes are used to describe a service when a single, more comprehensive procedure exists that more accurately describes the complete service performed.

Denial Risk

Mutually Exclusive Edit

Deny a claim line that would not reasonably be performed on the same patient on the same day (mutually exclusive procedure combinations).

Denial Risk

Same Day Visit Edit

Deny claim lines containing Evaluation and Management (E/M) codes billed on the same date of service as a procedure code with a CMS-assigned global period.

Denial Risk

Co‑Surgeon (-62) Restrictions

Deny claim lines submitted with modifier -62 (Co‑Surgeon) when the procedure code typically does not require co‑surgeons as determined by CMS and CPT co‑surgeon guidelines.

Denial Risk

MUEs — Multiple Lines

Deny claim lines when the units of service submitted for CPT and/or HCPCS codes by the same provider for the same member and same date of service exceed the MUEs established by CMS for that code.

Denial Risk

CMS National Correct Coding Initiative (NCCI)

Deny claim lines for which the submitted procedure is not recommended for reimbursement as defined by a code pair found in the CMS National Correct Coding Initiative (NCCI).

Denial Risk

Outpatient Facility — MUEs Multiple Lines

Deny outpatient facility claim lines when the units of service submitted for CPT/HCPCS codes by the same provider, same member, same date of service, exceed the MUEs established by CMS for that code.

Denial Risk

Revenue Codes Requiring HCPCS

Recommend denial of claim lines submitted with a revenue code that requires a HCPCS code when no HCPCS code is present; if a claim is missing a HCPCS code, the claim line will be denied.

Denial Risk

Lifetime Event — Lifetime-Limited Procedures

Audit procedure codes that have lifetime limits and recommend denial when the lifetime event maximum has been reached; additional submissions beyond the lifetime total are not recommended for reimbursement.

Key Terms

ClaimsXten - inv-16: Term reference (definition)

DefinitionClaimsXten is third-party coding software (Change Healthcare) used by BCBSIL to apply automated claim edits; Change Healthcare is solely responsible for the software and content.

FunctionImplements automated edit rules that identify and recommend denial or replacement of claim lines based on coding, frequency, bundling, modifiers, age/gender, global periods and other payment edits.

Vendor noteClaimsXten is a trademark of Change Health Care, Inc.; contact the vendor for product questions.

DocumentationRule descriptions include effective dates and reference CMS, AMA CPT, NCCI, MUE and I/OCE guidance where applicable.

Medically Unlikely Edits (MUEs) - inv-17: Term reference (definition)

DefinitionMedically Unlikely Edits (MUEs) are CMS-established unit limits for CPT/HCPCS/DMEPOS codes used to detect and deny claim lines when submitted units exceed those values.

ApplicationUsed to deny multiple lines or excessive units submitted by the same provider for the same member and date of service (includes DME and outpatient facility MUE rules).

Source guidanceMUE values and replacement schedules referenced to CMS (specified in rule descriptions).

Example rulesMUEs Durable Medical Equipment (DME) Multiple Lines; Outpatient Facility - MUEs Multiple Lines; MUEs Multiple Lines.

National Correct Coding Initiative - inv-18: Term reference (definition)

DefinitionThe National Correct Coding Initiative (NCCI) is a CMS policy set of code pair edits and coding conventions used to identify unbundling and coding combinations not recommended for reimbursement.

BasisNCCI policies are based on AMA CPT coding conventions, national/local Medicare policies, coding guidelines from national societies, and standard medical/surgical practice.

Policy actionClaimsXten will deny claim lines for procedure pairs deemed inappropriate under NCCI code pair edits.

Effective ruleCMS National Correct Coding Initiative (Effective: 03/23/2015).