Procedure Terminology-Based Combinations
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Describes Highmark West Virginia's claim-processing edits that combine procedure codes based on terminology or governing guidelines, listing combination (total) procedure codes and their component codes; affects providers submitting claims to Highmark West Virginia.
No material clinical or coverage changes in this revision.
Procedure Combination Rules
Procedure combination listings
Procedure codes listed below have associated component codes; when component codes are reported they may be combined into the listed total procedure code per Highmark's adjudication edits.
ALL of the following
Billing/combinatorial listings
This section provides code-to-component mappings to guide billing; it does not include narrative coverage criteria or prior authorization requirements.
ALL of the following
Providers should submit claims using standard CPT/HCPCS coding and applicable modifiers; Highmark will apply internal combination edits per the listed mappings when adjudicating claims.
Code Lists and Examples
| 0007U | Listed with multiple component codes mapping to various total procedure codes (examples include 80305, 80306, 80307, 80320, 80321, 80322, 80323, 80324, 80325, 80326, 80327, 80328, 80329, 80330, 80332, 80333, 80334, 80335, 80336, 80337, 80338, 80339, 80340, 80341, 80342, 80343, 80344, 80345, 80346, 80347, 80348, 80349, 80350, 80351, 80352, 80353, 80354, 80355, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 80363, 80364, 80365, 80366, 80367, 80368, 80369, 80370) |
| 10030 | Shown with component codes including 75989, 76942, 77002, 77003, 77012, 77021 |
| 0234T | Maps to 75989, 76000, 77001, 77002, 77003 |
Billing Guidance and Adjudication Impact
Claims adjudication via procedure combination edits
Highmark WV adjudicates claims using procedure code combination edits: when component procedure codes are submitted separately, the system may combine them into the listed total (combination) procedure code for payment determination. Providers should report claims recognizing that component codes may be collapsed into a single total procedure code during adjudication, which can affect reimbursement.
Procedure-code component listings (billing implications)
The policy lists procedure codes with their component codes to guide correct claim coding; providers must follow these mappings when submitting claims because component codes shown may be combined into the primary procedure code named in the listing.
Key Terms
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