| Regence claim adjudication systems utilize customized editing rules and Medicare's National Correct Coding Initiative (NCCI) as the basis for clinical edits. Regence claim adjudication systems are updated on a quarterly basis to recognize the most recent CPT and HCPCS codes, modifier 51 exempt codes, and add-on code changes. Please review your CPT and HCPCS coding publications for codes that have been added, deleted, or changed, and use only valid codes. Please append modifiers to HCPCS and CPT codes when correct coding indicates a modifier is appropriate.
| Regence Customized and Significant Clinical
Edits |
Updates to the Regence
Clinical Edits by Code list will be
posted on a monthly basis. The following editing
rules apply to claims for our commercial products
and BlueCard®:
CPT code definitions and rules are followed for:
- Gender,
- Age,
- New Patient and
- organ or disease-oriented Laboratory Panels.
Regence also follows the Centers for Medicare & Medicaid Services (CMS) guidelines for:
- Same Day and
- Follow Up Day edits.
The following Regence Clinical Edits by Code lists
are based on Regence Medical and Reimbursement
Policy:
Note: Regence will not routinely
require submission of clinical information in connection
with adjudication of claims except for unlisted
codes, codes without allowables, claims to which
a modifier 22 is appended, or other limited categories
of claims included on the Regence
Clinical Edits by Code list. |
| Correct Code Editor |
Regence utilizes Medicare’s National Correct Coding Initiative (NCCI) as the basis for clinical edits. NCCI identifies pairs of services that normally should not be billed by the same physician for the same patient on the same day. Regence has identified additional code pair edits to be used as a supplement to Medicare's NCCI. These code pair edits were developed using nationally accepted, logical and predictable coding principles.
|
| NCCI bypass modifiers |
NCCI bypass modifiers, as defined by CMS, will be processed in accordance with the current CMS superscript rules on the new claims system. Over the next year, our current claims system will be modified to align with the new system and these rules.
Relative to modifiers -25 and -59, Regence has not determined service or procedure code combinations that are not appropriately reported together with those modifiers, beyond those identified by Centers for Medicare and Medicaid Services (CMS) in the National Correct Coding Initiative (NCCI). |
| Add-on codes |
| Some services are reported as add-on codes, which describe work done in addition to primary procedures. Add-on codes are not stand-alone codes, and must always be reported with primary procedures. Regence will deny reimbursement for an add-on code as a Regence Correct Coding Edit when its primary code is denied as part of an NCCI or Correct Coding Edit code pair. When correct coding indicates the use of a modifier is appropriate for the primary code, that modifier must be appended to both the primary code and add-on code. |
| Codes without allowables |
Regence may require the submission of clinical information in order to price CPT and HCPCS codes for which an allowed amount has not been established. For questions, please contact your provider services consultant. |
| Regence Global Periods |
| Regence has established global
periods for certain procedures. Services
provided within this global period are considered
included in the payment for the initial procedure. |
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