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Clinical Editing Policy Change

Audience: All Providers

Excellus BlueCross BlueShield uses clinical editing criteria based on code edits recommended by multiple sources for the purpose of coding accuracy.

Effective August 1, 2022, the following changes will be made to support and align with clinical editing optimization recommendations. Beginning August 1, claims that previously recoded in the claims system will no longer recode. These claims will be denied and returned for resubmission with the appropriate CARC and RARC, if applicable.

Example: If a claim in history exists and a new patient is billed, the claim will no longer be recoded to an established patient. The claim will be denied so that the provider can choose the correct established patient Evaluation and Management code.

The policies being implemented support correct coding guidelines. While the Centers for Medicare & Medicaid Services is a primary resource for clinical editing policies, we also use several other resources, including, but not limited to, the American Medical Association and specialty organizations.

Please share this information with your staff and billing department. If you have questions, please contact your Provider Relations representative. 

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