Anthem – Enhanced Automated Claim Edits

November 2018 ~

Anthem has announced that it will update its editing systems to automate edits supported by correct coding guidelines, as documented in industry sources such as CPT®, HCPCS Level II, and ICD-10.

Effective for professional claims (CMS-1500) processed on or after November 18, 2018, Anthem says it will enhance its editing systems to automate edits supported by correct coding guidelines, as documented in industry sources such as CPT®, HCPCS Level II, and International Classification of Diseases 10 (ICD-10). As a result, according to the insurer, there will be greater focus on identifying incorrect or inappropriate billing of services by multiple providers within the same tax identification number for the same patient on the same day.

Anthem states the enhanced editing automation will promote faster claim processing and reduce follow-up audits and/or record requests for claims not consistent with correct coding guidelines.

Anthem provides the following examples of claim edits that will be automated:

  • Accurate reporting of modifiers, including LT, RT, 54, 55, 56, 62,76, 77, 78, 79, 80, 81, 82, and AS, which are often reported for the billing of services rendered by the same provider or multiple providers.
  • Ensuring global, professional (modifier 26) and technical components (modifier TC) are billed appropriately by one or more providers in facility and office settings.
  • Assessing whether services considered once in a lifetime have been billed more than once.
  • Ensuring the reporting of procedures and the associated diagnosis codes are correctly reported together.
CPT® is a registered trademark of the American Medical Association.

Source(s): Anthem Blue Cross and Blue Shield Network Update August 2018;

 

 

 

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