Provider Remittance Advices
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1 ene, 2020

Split billing

BCBSRI requires that all services rendered by the same provider on the same date of service to be filed on a single claim. Fragmented or split billing is defined as services rendered by the same provider on the same date of service and submitted on more than a single claim. Fragmented or split billing is inappropriate billing. Failure to file all services rendered on a single claim prevents the application of all necessary claim edits and adjudication logic during claim processing. As a result, claims may be overpaid or underpaid, and member liability may be over applied or under applied. There are limited situations where split billing would be appropriate.

Examples of inappropriate fragmented or split billing:

 

An office visit with modifier 25 and a procedure with 0, 10, or 90 days global.

  • Claim 1 contains a joint injection procedure with a 0-day global period.
  • Claim 2 contains an established evaluation & management service with modifier 25.

 

Per BCBSRI coding and payment guidelines, payment for 99201-99215 or 92002-92014 will be reduced by 50% when billed with a procedure code having a 0-, 10-, or 90-day post-operative period.

 

Two or more procedures with the CMS National Physician Fee Schedule Relative Value Multiple Procedure (MPFS) indicators of 2 and 3 that are subject to Multiple Procedure Payment Reduction (MPPR).

  • Claim 1 contains a lesion removal procedure with an MPFS indicator of 2.
  • Claim 2 contains lesion destruction procedure with an MPFS indicator of 2.

 

Per BCBSRI coding and payment guidelines, the primary procedure is reimbursed at 100% of the allowance, and subsequent procedures are reimbursed at 50% of the allowance (other than add-on or 51 exempt codes.

 

Two or more diagnostic imaging services with an MPFS indicator of 4 that is subject to MPPR.

  • Claim 1 contains a brain MRI global procedure with an MPFS indicator of 4.
  • Claim 2 contains a neck MRI global procedure with an MPFS indicator of 4.

 

Per BCBSRI coding and payment guidelines, the primary procedure is reimbursed at 100% of the allowance, and subsequent procedures are reimbursed at 60.40% of the allowance.

 

Claims found to be split billed will be subject to pre-pay/post-pay audits and recoveries.

 

*Please note the examples provided are not all-inclusive.

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