April 6, 2023
In July 2023, Premera is replacing its prepayment claim editor from Claim Editing System (CES) to ClaimsXten® editor. The new claim editor will continue to enforce correct coding and billing practices as well as evaluate current claims against Premera’s historical claims for editing purposes.
ClaimsXten will continue to use the following sources:
- Premera’s payment and medical policies
- CMS medical coding policies
- CPT, HCPCS, and ICD-10 coding guidelines
- Local and regional Medicare policies
- Nationally recognized academy and society guidelines (coding and clinical)
ClaimsXten will expand existing edits such as but not limited to:
- National bundling edits including the National Correct Coding Initiative (NCCI) edits
- Global surgery periods (90/10/0 global days)
- Co-surgeon, team surgeons and assistant surgeon modifiers
- Multiple procedure reductions
- Modifier-procedure code usage
- Add on code usage
- MUE Unit limitations
ClaimsXten will also be introducing some new edits. For example, the following two new edits will be introduced during the “go live” of ClaimsXten:
- Medicare Status T Codes
As noted in the current CMS National Physician Fee Schedule (NPFS), codes assigned a “Status Code” of “T-Injections” will be considered bundled into other payable codes on the NPFS when provided on the same date of service by the same provider. Modifier overrides will not prevent the code from bundling. Status T codes will be separately reimbursed only when billed alone on a claim or with another Status T service and no other payable services on the same date of service billed by the same provider.
NOTE: The Medicare Indicator Status B Services payment policy will be updated to add the Status T codes as well.
- Surgical Supplies
A subset of surgical supplies billed on professional claims that are submitted on the same date of service as a surgical procedure(s) will be considered bundled with the surgical procedure based on Centers for Medicare & Medicaid
Services guidelines. This edit will enforce surgical supply guidelines in the existing “Global Surgery” payment policy. This group of supply codes includes but is not limited to such items as dressing changes, local incisional care, removal of
operative packs, removal of sutures/staples, lines, wires, tubes, drains casts, insertion/irrigation/ removal of urinary catheters to name a few. Codes within the HCPCS code ranges of A4206-A4640, A4649-A5200, A6000-A8004. A9279 and A9900-A9999
will be considered bundled with a surgical procedure when billed on the same date of service, by the same provider. The “Global Surgery” payment policy already speaks to surgical supplies as a bullet point in the policy section titled “Services
Included in the Global Surgery Payment”, so this edit is just enforcing this criterion.
With the change of the claim editor, you’ll notice new and changed adjustment codes on your explanation of payments. Provider News will have additional information on the implementation status of the new claim editor ClaimsXten® and related payment policy updates.
NOTE: With this change, our
current Claims Editor-What If Tool will be retired and replaced with Clear
Claim Connection (C3). More information to come in Provider News.