CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

ClaimsXten automated claim-edit rules (denial and adjustment criteria)

Describes ClaimsXten automated claim-edit rules used by Blue Cross Blue Shield - New Mexico to identify and recommend denial or adjustment of claim lines based on coding, bundling, units, modifiers, timing, and other payment rules; applies to professional and outpatient facility claims processed by the payer.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyClaimsXten automated claim-edit rules (denial and adjustment criteria)

Policy CodePolicy N/A

Change TypeNo material changes noted

Effective DateN/A

Next Review DateN/A

Key ActionReview and correct coding, modifiers, units, and bundling prior to claim submission to avoid automated denials or adjustments.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

40+distinct named ClaimsXten rules and edits described

professional & facilityrules reference both claim types

Yesincludes retired rules

ClaimsXten Denial / Allowance Criteria

ClaimsXten denial/allowance criteria (summary)

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ALL of the following

Supply lines billed on same date as a surgical procedure with an assigned CMS global period (Surgical Inclusive Edit)same date of service
Denies supply lines considered part of a global surgical package
Claim line clinically integral or incidental to a principal procedure (Incidental Edit)
E/M codes billed on same date as a procedure with a global period (Same Day Visit Edit)
E/M codes billed within pre-operative or post-operative global periods (Pre-Op Visit Edit, Post-Op Visit Edit)

ALL of the following

Two or more procedures used when a single comprehensive procedure exists (Multicode Rebundle Edit)
Procedure combinations where codes are mutually exclusive or would not reasonably be performed same day (Mutually Exclusive Edit)
Code pairs identified by CMS NCCI / CCI as unbundled or not allowed (CMS NCCI / Facility Outpatient Code Editor CMS CCI Bundling Rule)
Facility-specific unbundled surgical code pairs (Facility Unbundled Pairs Outpatient Rule)
Global/component duplication and component billed when global already submitted (Global Component; Component Billed)

ALL of the following

Invalid modifier-to-procedure combinations for payment and non-payment modifiers (Modifier to Procedure Edit; Modifier to Procedure Validation Filter - Non-Payment Modifiers)
Co-surgeon modifier (-62) denied when procedure typically does not require co-surgeons (Co-Surgeon rule)

ALL of the following

Same-day laboratory duplicates previously submitted by same provider for same member/date without modifier -91 (Same Day Laboratory 1)
Lab units exceeding submitted date range without modifier -59 or -91 (Same Day Laboratory 2; retired)
Facility rule: multiple same-day visits with second/subsequent E/M lacking required modifier -27 (Multiple Medical Same Day Visits)

ALL of the following

Units exceed CMS Medically Unlikely Edits (MUEs) for CPT/HCPCS by same provider/member/date (MUEs Multiple Lines; Outpatient Facility - MUEs Multiple Lines)
Quantity or multiple submissions exceed allowed times per date of service (Frequency Validation - Allowed Once/Multiple Times Per Date filters)
Durable Medical Equipment MUEs across providers per member/date (Medically Unlikely Edits - DME Multiple Lines)

ALL of the following

Add-on CPT/HCPCS billed without required base/primary procedure (Add-On Without Base; Add-On Without Base 2; CMS Add-on Without Base Code Facility)
Facility add-on without acceptable supporting base code per CMS (CMS Add-on Without Base Code Facility effective 03/01/2024)
Ancillary procedures billed after a non-covered service are allowed if another covered same-day service supports the ancillary; otherwise recommended denial (Ancillary Procedures effective 03/01/2024)

ALL of the following

Procedures exceeding lifetime event limits (Lifetime Event rule) — procedure submitted more than allowed times in a member's lifetime
New patient E/M recommended denial when any E/M or other face-to-face professional service was billed within prior three years by same provider or same provider group and specialty (New Patient E/M rule)
Bilateral services billed twice when modifier -50 already applied — second submission denied (Bilateral Services for Professional Claims)
Multiple same-day facility E/M or visit codes submitted with same revenue code lacking modifier -27 on second/subsequent visit (Multiple Medical Same Day Visits)
Revenue code lines requiring a HCPCS code when none present — recommended denial (Revenue Codes Requiring HCPCS Codes)

ANY of the following

Some rules reference CMS policies, MUE values, and CMS coverage databases for determination (e.g., CPAP/BIPAP supply frequency references CMS LCDs)
Certain laboratory and other rules have historical retirements but may be documented for reference (e.g., Same Day Laboratory 2 retired 04/16/2018; Age Replacement retired 03/2016)

Codes, Modifiers, and Limits

Examples of referenced CPT/HCPCS modifier and code conceptsmixed

add-on codes (CPT/HCPCS)	Add-on codes must be billed with an appropriate primary/base procedure; rule flags add-ons billed without base
modifier -62	Co-surgeon modifier denied when not appropriate per CMS/CPT guidance
modifier -91, -59	Same-day lab and unit-range lab edits reference these modifiers for valid multiple submissions

CMS-based coding thresholds and editorsmixed

MUEs (CMS)	Medically Unlikely Edits for CPT/HCPCS units to limit units per date of service
NCCI (CMS CCI)	National Correct Coding Initiative code pair bundling edits

MUE limits (units per CPT/HCPCS code per provider/member/date)

DefinitionUnits per CPT/HCPCS code per provider/member/date of service as established by CMS MUEs

ScopeApplies to multiple-lines and outpatient facility claim edits when submitted units exceed CMS MUE values

Enforcement actionRule will deny claim lines when units submitted by the same provider for the same member and same date of service exceed the MUEs

Related rulesDurable Medical Equipment MUEs, Outpatient Facility - MUEs Multiple Lines, and DME multiple lines rules reference CMS MUE values

Modifiers and exceptionsSome lab/unit rules consider modifiers (e.g., -59, -91) for validity but MUEs are per-code unit limits regardless of modifier

Provider Billing Rules and Actionable Edits

Denial Risk

Core surgical and E/M edits — deny or replace lines for supplies, incidental items, multicode, mutually exclusive, and global-period E/Ms

These edits will deny or replace claim lines for supplies billed the same date as a surgical procedure with a CMS-assigned global period; deny items clinically integral or incidental to a principal procedure; deny multicode submissions when a single, more comprehensive procedure exists; deny mutually exclusive procedures billed the same day; and deny E/M codes billed on the same day, pre-op, or post-op during a procedure's global period. Age- and gender-inconsistent procedure codes are also replaced with appropriate codes where specified.

Surgical Inclusive Edit: denies supply lines billed same date as a surgical procedure with a CMS global period.
Incidental Edit: denies claim lines clinically integral to or components of a more comprehensive procedure.
Multicode Rebundle Edit: denies when multiple codes describe a service best represented by one comprehensive code.
Mutually Exclusive Edit: denies procedures not reasonably performed on the same patient same day.
Same Day / Pre-Op / Post-Op Visit Edits: deny E/M codes billed during a procedure's global period.
Age/Gender Replacement Edits: deny and replace codes inconsistent with patient age or gender (where specified).

Denial Risk

Modifier, co-surgeon, lab, and MUE edits — validate modifiers, -62 use, -91 for same-day labs, and MUE/frequency limits

These rules identify and recommend denial for invalid modifier-to-procedure combinations (including non-payment modifier validation), inappropriate use of co-surgeon modifier -62, same-day laboratory duplicates missing modifier -91 or -59 as applicable, and for units that exceed CMS MUEs or violate frequency-per-date rules.

Modifier to Procedure Edit: denies claim lines with invalid modifier-to-procedure combinations for payment modifiers.
Co-Surgeon: denies lines with modifier -62 when the procedure typically does not require a co-surgeon per CMS/CPT guidance.
Same Day Laboratory 1: denies lab lines submitted without modifier -91 when same procedure was previously submitted by same provider/same member/same date.
Medically Unlikely Edits (Multiple Lines): denies when units by same provider/member/date exceed CMS MUEs.
Frequency Validation filters: deny when codes are submitted more than allowed per date of service or exceed per-date quantity limits.

Denial Risk

Facility coding and bundling edits — outpatient MUEs, CMS CCI bundling, unbundled pairs, global/component duplication, add-on without base

Facility-oriented edits will deny outpatient facility claim lines that exceed CMS MUEs, identify CMS CCI/NCCI bundling/unbundling per the Outpatient Code Editor, detect facility unbundled surgical pairs and global/component duplication, and flag add-on codes billed without the required base procedure (including the 2024 CMS add-on without base facility rule).

Outpatient Facility MUEs: deny when facility CPT/HCPCS units by same provider/member/date exceed CMS MUEs.
Facility Outpatient Code Editor / CMS CCI Bundling: deny code pairs found to be unbundled per CMS IOC Editor.
Facility Unbundled Pairs: detect surgical code pairs inappropriate for facility claims (component relationships or not reasonable together).
Global / Component and Component Billed rules: identify duplicate global vs professional/technical component submissions across providers.
Add-On Without Base (facility): identify add-on CPT/HCPCS billed without acceptable supporting primary/base procedure (including CMS Add-on Without Base Code Facility effective 03/1/2024).

Denial Risk

Visit, modifier, lifetime/ancillary and revenue code edits — new patient E/M, bilateral detection, lifetime limits, revenue-HCPCS, add-on/ancillary checks

These edits recommend denial for new patient E/M codes when another E/M or face-to-face professional service by the same provider/group and specialty occurred within three years; detect bilateral services billed twice when modifier -50 was already applied; require modifier -27 for second/subsequent same-day facility E/M visits; enforce lifetime event limits; flag revenue codes that require HCPCS when none present; and identify bundled or ancillary procedures per CMS add-on and ancillary checks.

New Patient E/M: recommends denial when any E/M or professional face-to-face service billed within prior three years by same provider/provider group and specialty.
Bilateral Services (Professional): denies a second submission when code was already billed with modifier -50.
Multiple Medical Same Day Visits: recommends denial for multiple E/M or visit codes on same date/facility/revenue code when second/subsequent E/M lacks modifier -27.
Lifetime Event: audits and recommends denial when a procedure has been submitted more times than allowed in a lifetime.
Revenue Codes Requiring HCPCS: recommends denial when a revenue code requires a HCPCS code and none is present.
CMS Add-on and Ancillary Procedure Checks (2024): identifies add-ons without base and ancillary services after non-covered procedures, allowing ancillary if another covered service on same day supports it.

Key Terms and Abbreviations

MUE — Medically Unlikely Edit (definition)

TermMedically Unlikely Edit (MUE)

Basic definitionAn edit that limits the units of service submitted for a CPT or HCPCS code by the same provider for the same member on the same date of service to the maximum units established by CMS

Operational effectWhen submitted units exceed the CMS-established MUE, the rule will deny the claim line

VariantsApplies to multiple-lines, DME items, and outpatient facility claim lines as separate MUE rule implementations

Add-on code — definition and usage notes

TermAdd-on code

CMS definitionA CPT or HCPCS code that is always performed in addition to a primary service or procedure and must never be reported as a stand-alone code

Billing requirementAdd-on codes must be billed with an appropriate primary/base procedure; rule identifies add-ons billed without base

Policy implementationsAdd-On Without Base (professional and facility variants) and CMS Add-on Without Base Code Facility rules detect add-ons billed without required supporting primary codes

NCCI / CMS CCI — National Correct Coding Initiative

AcronymNCCI / CMS CCI

DefinitionNational Correct Coding Initiative (CMS Correct Coding Initiative) — coding policies and code-pair edits based on CPT conventions, Medicare policies, national guidance and coding practice to identify inappropriate code pairs

Operational effectRule will deny claim lines when a submitted procedure is not recommended for reimbursement as defined by an NCCI code pair

ImplementationsCMS National Correct Coding Initiative and Facility Outpatient Code Editor CMS CCI Bundling Rule enforce NCCI/CCI bundling and unbundling on professional and facility claims