Coding Resources

Coding and billing guidelines

Find everything you need to know about coding types and sources, special billing situations, and modifiers. View coding and billing guidelines.

Modifiers

The use of modifiers is an important component to coding and billing for services. A modifier is a two-digit character (numeric, alpha numeric, or alpha) designed to provide additional information needed to process a claim or increase or decrease reimbursement. Modifiers allow a provider to identify that a special circumstance has altered a service, but that the basic procedure code description has not changed. Appropriately document the patient’s medical record or chart to support the use of any modifier.

In certain circumstances, multiple modifiers may be necessary to completely describe a service. Our payment system recognizes multiple modifiers to allow you to bill up to four separate modifiers per claim line.

When more than 4 modifiers are needed for a service, modifier 99-Multiple Modifiers should be used to reflect this situation. Make sure that documentation in the member’s medical record supports all the modifiers submitted.

Most Commonly Used Modifiers

We process the following modifiers when appended to an appropriate code(s). Where applicable, the provider's fee schedule allowed amount will be adjusted per any percentage noted. Please note this doesn't represent all of the available modifiers but a list of commonly used modifiers:

*Outpatient and ambulatory surgery center use only

Premera uses multiple claim editors to analyze submitted claims against industry coding and billing standards and Premera payment policies. Each claim editor has an independent, distinct set of claim edits and claim exceptions. This can result in different edits within each editor, due to differences in claim information and contract exceptions.

Premera uses the following sources as the basis for claim editing:

• Premera payment policies
• Center for Medicare and Medicaid (CMS) coding policies
• Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes and guidelines
• International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) coding guidelines
• Local and national Medicare policies
• Nationally recognized medical academies and society guidelines (coding and clinical)

Read the latest payment integrity edit updates in the Reminders and Updates section of Provider News.

First pass editor

Prepayment claim editing is handled through Lyric-ClaimsXten. This editor ensures correct coding and billing practices and evaluates current claims against Premera historical claims for editing purposes. Lyric provides a resource tool, C3 Claims Editor, to check for current editing scenarios which can be accessed securely through Availity. Note: The C3 Claims Editor doesn’t account for edits performed by the the second-pass editor, Cotiviti.

Second pass editor

Prepayment claim editing through Cotiviti ensures payment accuracy and risk adjustment. Premera implemented advanced claim editing on November 15, 2021. This effort complies with the Blue Cross Blue Shield Association (BCBSA) mandate to conduct secondary claim editing. The second-pass editor is applied after claims adjudication and prior to provider payment. The Premera payment integrity team determines the edits that will ensure correct coding/billing and align with our existing payment policies.

Coding validation (CV) edit
A manual claims review by experts within Cotiviti was additionally implemented called “coding validation (CV) edit.” Professional and facility claims are edited by registered nurses and certified coders to promote correct coding and billing practices. This level of claim review takes into consideration historical claims experience to determine if the claim was coded correctly.

Claim types where claim editing doesn't apply

Premera doesn't apply claim editing to the following four claim types/categories:

• Medicare Supplement
• Prepaid claims (such as pharmacy benefit manager (PBM) claims)
• BlueCard home claims
• Dental claims

Resources

Appeals process for clinical edit denials
Denials based on clinical edits may be appealed. Medical records must be submitted to support the billed services. When these medical records are submitted, all information, procedures, and services will be reviewed, including those billed on related claims that aren't being appealed.

For denials specific to coding validation, the first level of appeal is reviewed by registered nurses and certified coders through Cotiviti.

View provider appeal forms and instructions on how to submit an appeal.
Sign in to Availity.
Watch a claims editor tutorial.

View training guides and tip sheets that can support you in caring for your patients and providing accurate coding and documentation.