Code and Clinical Editing Guidelines (Professional and Facility)
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Governs the use of code and clinical editing software and rules applied to claims adjudication for professional and facility claims for Blue Cross Blue Shield - Nevada; affects providers submitting claims and adjudication processes for members' benefits.
No material clinical or coverage changes in this revision.
Nonreimbursable Coding and Relationships
Nonreimbursable and Related Coding
CCEG determines non-reimbursable situations and relationship between reported codes and diagnosis/service.
Denial applies at the claim line level for units exceeding the MUE.
Referenced Edit Sets, Tools, and Limits
| NCCI | National Correct Coding Initiative edits (procedure-to-procedure) |
| MUE | Medically Unlikely Edits |
| PTP | Procedure-to-procedure edits |
| OCE | Outpatient Code Edits |
| Standard correct coding | Standard correct coding applies |
Authorization, Medical Necessity, and Provider Requirements
Authorization and Medical Necessity Requirements
Providers must follow authorization and medical necessity guidelines appropriate to the procedure and diagnosis; services must meet the member's benefit plan limits and be supported in the medical record. Failure to follow authorization, medical necessity, or billing/submission guidelines may result in claim denial, rejection, or recovery/recoupment of payment.
- Obtain any required prior authorization before rendering services when the member’s benefit plan requires it.
- Document medical necessity and support all billed CPT/HCPCS/revenue codes in the medical record or office notes.
- Follow applicable billing and submission guidelines; noncompliance may lead to denial, rejection, or repayment.
Key Definitions and Editing
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