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Reminder of Correct Coding Guidelines

Release Date: December 13, 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, ICD-9 and ICD-10 diagnosis and procedure codes, as consistent in following all applicable coding rules and guidelines.

As a reminder, BCBSNC requires that ICD-9 codes should be reported to the highest level of specificity using the fourth and fifth digits where applicable.  BCBSNC makes retrospective and clinical reviews to verify correct sequencing of diagnosis codes and clinical appropriateness, as well as readmissions related to previous hospital admissions and/or discharges.

Effective October 1, 2014,  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, and adjudicate claims based on codes as received.

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(s) as of the effective date of a claim submission. Unlisted, unspecified and nonspecific codes should be avoided.