ClaimsXtenTM Facility Rules: Implementation Update and Notification of Postponement for FEP and BlueCard® Host

February 5, 2016

(Updated Feb. 18, 2016)

On Oct. 2, 2015, Blue Cross and Blue Shield of Oklahoma (BCBSOK) announced the upcoming implementation of three new Outpatient Facility Rules for dates of service beginning on or after Feb. 22, 2016. This notification is to confirm that implementation will occur as scheduled, except for Federal Employee Program (FEP) groups and BlueCard Host claims.

As provided in our previous disclosure notice, the new rules are summarized below. This implementation will be postponed for FEP groups and BlueCard Host claims only, until further notice. 

Medically Unlikely Edits (MUEs) Multiple Lines Rule

This new facility rule identifies claim lines where the MUE has been exceeded for a Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT®) code, reported by the same provider, for the same member, on the same date of service. 

An MUE is an edit that reviews claims for units of service for a HCPCS or CPT code for services rendered by a single provider/supplier to a single beneficiary on the same date of service.

The ideal MUE is the maximum units of service that would be reported for a HCPCS or CPT code on the vast majority of appropriately reported claims. The maximum allowed is the total number of times per date of service that a given procedure code may be appropriately submitted by the same provider. 

Outpatient Code Editor Bundling Rule

This new facility rule identifies claims containing code pairs found to be unbundled according to the Centers for Medicare & Medicaid Services (CMS) Integrated Outpatient Code Editor (I/OCE). One of the functions of the I/OCE is to edit claims data to help identify inappropriate coding due to the following reasons: The procedure is a mutually exclusive procedure that is not allowed by the Correct Coding Initiative (CCI) and/or the procedure is a component of a comprehensive procedure that is not allowed by the CCI. 

Unbundled Pairs Outpatient Rule 

This new facility rule identifies the unbundling of multiple surgical codes when submitted on facility claims. This rule detects surgical code pairs that may be inappropriate for one of the following reasons: One code is a component of the other code, or these codes would not reasonably be performed together on the same date of service. 

The ClaimsXten tool offers flexible, rules-based claims management with the capability of creating customized rules, as well as the ability to read historical claims data. ClaimsXten can automate claim review, code auditing and payment administration, which we believe results in improved performance of overall claims management. 

To help determine how coding combinations on a particular claim may be evaluated during the claim adjudication process, you may continue to utilize Clear Claim ConnectionTM (C3). C3 is a free, online reference tool that mirrors the logic behind BCBSOK’s code-auditing software. For more information on C3 and ClaimsXten, including answers to frequently asked questions, refer to the Clear Claim Connection page in the Education and Reference Center/Provider Tools section of our Provider website. Information also may be published in upcoming issues of the Blue Review.

ClaimsXten and Clear Claim Connection are trademarks of McKesson Information Solutions, Inc., an independent third party vendor that is solely responsible for its products and services.

CPT copyright 2015 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA