CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Coding and claim edits for surgical global period, anatomical modifiers, diagnosis coding guidelines, and laterality

Describes Cotiviti claim-edit logic and coding requirements used by Blue Cross Blue Shield of Oklahoma for validating procedure modifiers, diagnosis code positions, laterality, and global surgical period modifier use; applies to professional and facility claims processed by Cotiviti on behalf of BCBSOK.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyCoding and claim edits for surgical global period, anatomical modifiers, diagnosis coding guidelines, and laterality

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date01/10/2022 / 04/01/2022

Next Review DateN/A

Key ActionAppend the appropriate global period or anatomical/laterality modifiers in the first modifier position and ensure diagnosis sequencing and laterality match to avoid claim denials.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 global + lateralitykey required modifiers called out

Anatomical enforcementprocedures denied if required anatomical modifier missing or incorrect

Diagnosis validationedits for disallowed primary/principal diagnoses (e.g., external causes, manifestations, secondary, sequela)

Laterality editsedits comparing modifier laterality to diagnosis and diagnosis-to-diagnosis conflicts

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Modifier and Diagnosis Edit Rules

When to report global-surgery-period modifiers

If a physician performs services during the global follow-up period of another surgical procedure, report the appropriate modifier relevant to the circumstance.

ANY of the following

Modifier 58 — Staged or Related Procedure or Service by the Same Physician during the postoperative period
Modifier 78 — Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period
Modifier 79 — Unrelated Procedure or Service by the Same Physician during the postoperative period

Anatomical modifier requirement

Claims will deny if a procedure requires an anatomical (laterality/site) modifier and it is missing or if the modifier does not match the procedure's required anatomical site.

ALL of the following

If a procedure has a required anatomical modifier, that modifier must be appended (first modifier position); otherwise the claim line will deny.
If an anatomical modifier is appended but does not match the appropriate anatomical site for the procedure code, the claim line will deny.

Diagnosis code position and acceptability rules

Edits identify when diagnosis codes are not submitted according to ICD-10 and CMS rules for primary/principal or only-diagnosis positions.

ALL of the following

External cause codes (ICD-10 V-Y) cannot be the only diagnosis or primary/principal diagnosis; claims received with only V-Y codes will be denied.
Manifestation codes cannot be the primary/principal or the only diagnosis; such placements will result in denial.
Secondary-only diagnosis codes cannot be used as the primary/principal or the only diagnosis; such placements will be denied.
Sequela (7th character 'S') codes cannot be primary/principal or the only diagnosis; the underlying condition must be sequenced first.

Laterality edits

Validates correspondence between laterality modifiers and diagnosis laterality and detects conflicting lateral diagnoses on a line.

ALL of the following

Laterality Modifier to Diagnosis Mismatch: edits identify when modifiers RT, LT or 50 do not correlate with the submitted diagnosis on the line.
Laterality Diagnosis to Diagnosis Mismatch: edits deny procedures when two diagnoses on the same line conflict in laterality (e.g., left and unspecified for the same anatomic site).

Code Groups and Modifier Guidance

Global period modifiersModifier

58	Staged or Related Procedure or Service by the Same Physician during the Postoperative Period
78	Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period
79	Unrelated Procedure or Service by the Same Physician during the Postoperative Period

Laterality modifiers and bilateralityModifier

RT	Right side modifier (validated against diagnosis)
LT	Left side modifier (validated against diagnosis)
50	Bilateral procedure modifier
TA,T1-T9	Toes (examples of anatomical modifiers referenced in document)

Diagnosis requirements for chemotherapy administrationICD-10

Z51.11	Encounter for antineoplastic chemotherapy
Z51.12	Encounter for antineoplastic immunotherapy

What Providers Must Do

Billing Rule

Append correct modifiers

Append the appropriate global period or anatomical/laterality modifier in the first modifier position (box 24D or SV101-3 electronically). If a procedure requires an anatomical modifier, failure to append one or appending an incorrect modifier will result in denial.

Documentation Required

Sequence diagnoses per ICD-10 guidelines

Policy Scope and Administrative Notes

This policy describes the Cotiviti claim-edit logic and coding requirements used by Blue Cross Blue Shield of Oklahoma (BCBSOK) to validate use of global surgical period modifiers, required anatomical/laterality modifiers, diagnosis code sequencing and position, and laterality edits. The edits apply to both professional and facility claims processed by Cotiviti on behalf of BCBSOK. Cotiviti performs claims administration for BCBSOK; verification of eligibility/benefit information is not a guarantee of payment.

Key Terms

Excludes1

Excludes1An ICD-10-CM note indicating two conditions that cannot be reported together; an Excludes1 Note means the excluded code should never be used at the same time as the code to which the note applies.

ApplicabilityExcludes1 notes may appear under a specific code or following a section heading; when following a section heading the note applies to all codes in that section.

Denial rationaleWhen codes with an Excludes1 relationship are billed together on professional claims, edits will deny the combination as mutually exclusive.

Effective Dates and Reviews

Effective dates for sections of this policy are: 01/10/2022 for the global surgical period edits and 04/01/2022 for the anatomical modifier, diagnosis guideline, and laterality sections. Last review and next review dates are not provided.