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Enforcement of Correct Coding Guidelines

Release Date: July 31, 2012

Blue Cross and Blue Shield of North Carolina (BCBSNC) reserves the right to implement system edits to apply correct coding guidelines for CPT, HCPCS, and ICD-9 and ICD-10 diagnosis and procedure codes.  Effective October 1, 2012, ICD-9 codes should be assigned to the highest level of specificity using the fourth and fifth digits where applicable.  Once a final ruling has been made on the proposed ICD-10 implementation delay, ICD-10 codes should be submitted in alignment with the compliance date and assigned to the highest level of specificity applying up to the seventh digit where applicable, and providing the highest degree of accuracy and completeness. BCBSNC system edits are in place to enforce and assist in a consistent claim review process. 

BCBSNC system edits reflect guidelines derived from industry-standard and essential clinical coding sources, including: 

  • Current Procedural Terminology (CPT®)
  • Healthcare Common Procedure Coding System (HCPCS)
  • International Classification of Diseases Clinical Modification (ICD-CM)
  • American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) guidelines
  • Specialty society guidelines
  • Medical policy and literature research and standards
  • Input from academic affiliations

System edits provide BCBSNC with sufficient information to determine:

  • The correct amount to be paid;
  • Whether the provider is authorized to perform the service;
  • Whether the provider is eligible to receive payment;
  • Whether the service is covered, correctly coded, and correctly billed to be eligible for reimbursement;
  • Whether the service is provided to an eligible beneficiary; and
  • Whether the service was provided in accordance with BCBSNC Medical Coverage Guidelines, benefit plans and/or other BCBSNC policies.

Providers are expected to use the most appropriate code as of the effective date of the submission. Unlisted, unspecified and nonspecific codes should be avoided.