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Payment Policies - UB-04 ClaimsiCAP to Apply to Outpatient Facility ServicesTo view these documents you will need Adobe Reader. Choose the icon to
download for free. Effective for dates of service on and after September 29, 2006, Wellmark Blue Cross and Blue Shield will improve the Claim Adjudication Process (iCAP). iCAP aligns Wellmark policy with national coding and billing guidelines. This section contains the major Wellmark Payment/Coding Policies for UB-04 billers.
iCAP (Improve the Claims Adjudication Process)i CAP aligns Wellmark policy with national coding and billing guidelines established by the AMA’s Current Procedural Terminology (CPT), the Centers for Medicare and Medicaid Services (CMS) and specialty societies. In addition to the general policies outlined below, we have also implemented special payment policies. Download the iCAP
Specialty Policies (pdf) - Updated 09/2007 Correct Coding Initiative (CCI)The National Correct Coding Initiative (CCI) is a collection of bundling edits, created and sponsored by CMS (Centers for Medicare & Medicaid Services) and separated into two major categories: The Comprehensive and Component procedure code edits, and the Mutually Exclusive procedure code edits. Wellmark will adopt CCI for outpatient facility services effective with dates of service September 15, 2006, and after. Correct Coding Initiative edits are for services performed by the same facility on the same date of service only. Note that CCI edits applicable to outpatient hospital services are one version behind the CCI edits applicable to professional claims. More information may be obtained through the CMS Web site. Maximum Unit PolicyWellmark has assigned a maximum daily unit to each CPT/HCPCS code. Daily maximum units that have been exceeded can be identified with remittance advice message I512, a denial for maximum daily units or I563, a reduction in maximum daily units. Daily maximum units are guidelines that accommodate most "normal" services. For those services exceeding the maximum daily units, please submit a provider inquiry attaching the medical documentation to support the units of service. ModifiersWellmark is now able to process modifiers for outpatient facility claims. We will process up to four modifiers per claim line. Please note that our process may change the order of the modifiers based on an established priority. Modifiers that affect payment will be listed first, with informational modifiers secondary. Providers receiving an electronic remittance advice will see up to four modifiers. Paper remittance advices do not include modifiers. Inappropriate use of modifiers will cause a service to deny. For example, modifier -25 is appropriate for use with E/M codes services only. If billed with a surgical procedure, such as 52000, the surgery will deny as an inappropriately coded procedure. Additional information about specific modifiers follows: Modifier-50 indicates a bilateral procedure. Based on our current outpatient payment methodology, Wellmark will continue to reimburse bilateral procedures at 100 percent each. Bilateral procedures must continue to be reported on two lines with one unit of service per line. Modifiers -52 (reduced services) and -73 (discontinued procedure prior to the administration of anesthesia) will be reimbursed at 50 percent of the MAF. You may request any modifier change using one of the following methods:
Claims corrections will appear on your remittance advice as an adjustment to the original claim number so you can easily track and reconcile corrections. Recode or DenyIn some instances, iCAP will recode or deny the claim to avoid claim processing delays. For example, procedures submitted for an age that is inconsistent with the procedureal description will be adjusted in one of the following ways: When a procedure code for a particular age is submitted that does not match the claim information, the procedure will be recoded to a more appropriate procedure for the patient’s age. For example, we receive a claim for a newborn’s circumcision: If submitted with code 54161 (circumcision, except newborn) the code would be changed to 54160 (circumcision, newborn). When a more appropriate procedure code does not exist for the patient’s age, the procedure will be denied. For example, we receive the following code for a patient who is over 30 days of age: Code will deny if submitted for a patient over 30 days of age: 36510 (catherterization of umbilical vein; newbornBundled ServicesWellmark initially communicated in our June 2006 Blue Ink Supplement that we would be acknowledging all “N” status codes. Wellmark has developed a customized list and will be bundling only these codes. Download the Wellmark Bundled Codes (pdf) Inpatient Only ProceduresIf a service on the inpatient only list is provided in the outpatient setting, please submit a provider inquiry along with medical record documentation for payment consideration. Download the Wellmark Inpatient Only List. I Message TablesIn order to assist you with claim line messages, Wellmark has created a table listing the “I” message and the corresponding 835 ANSI message. Download the table. Submitting Medical RecordsDo not submit medical records when requesting a claim review if your claim needs a coding change. This includes CPT, HCPCS, ICD-9, modifier or date of service changes. Simply make the necessary change on a corrected claim and attach it to a Provider Inquiry form. Wellmark will not add, change or delete codes or modifiers based upon a review of medical records. |
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