BCBSRI follows the Medicare National Correct Coding Initiative (NCCI) edits to ensure that all claims are coded based on recognized industry standard correct coding guidelines. In 2018 BCBSRI implemented pre-payment review for select procedure codes when submitted with Modifier 59, or XE, XP, XS, XU (X {EPSU}). Please be advised that as of 1 de mayo de 2019, the following codes will no longer require the submission of medical records for review. However, supporting documentation for all services should be retained in the medical record.

• CPT code 43239 – Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple
• CPT code 45380 – Colonoscopy, flexible; with biopsy, single or multiple 

Our review of documentation for the codes above revealed a majority were coded appropriately. However, we found instances in which the documentation did not support the services being billed. Some common findings were as follows:

• Dilatation and biopsy documented in the same site
• Snare and forceps biopsy reported for the same lesion
• The medical record didn’t contain documentation to support all services billed

Although these codes are being removed from pre-payment review, we would like to remind providers of steps that should be taken before claim submission:

• Verify the existence of an NCCI edit before claim submission.
• Appending an NCCI associated modifier should only be done when the documentation in the medical records supports its use.
• Follow CPT guidance on proper code selection including but not limited to technique used to remove lesion(s).

We will continue to monitor the use of Modifiers 59 and XE, XP, XS, XU (X {EPSU}, and any change in pattern may warrant us to perform a post-pay review to ensure services are being coded appropriately.