HEDIS Codes, UM Tool Updates & Coding Advice

Patients Benefit from HEDIS Codes

Blue Cross Blue Shield of Wyoming is enhancing our Health Employer Data and Information Set (HEDIS) metrics for On-exchange and FEP members.

To better support our population, we wanted to remind Providers that HbA1c CAT II code information can improve overall patient health. These codes give us the opportunity to improve our HEDIS scores, so we can provide greater context and improve service capabilities.

Please assist us by using the CPT 83036 for a HbA1c laboratory test and by adding the appropriate Category II code on the same claim. CAT II codes are an informational code and should be billed with either a $0.00 charge or a $0.01 charge if required by your system or clearing house.

BCBSWY appreciates your assistance and dedication to healthy outcomes. Please use the following codes as applicable:

Category II codes (diagnostic/ screening processes or results)

  • 3044F-HbA1c less than 7.0%
  • 3051F-HbA1c greater than or equal to 7.0% and less than 8.0%
  • 3052F-HbA1c greater than or equal to 8.0% and less than 9.0%
  • 3046F-HbA1c greater than 9.0%

New UM Tool Updates Coming in Fall

Coming this fall, we’re updating our UM tools to save Providers money and to further simplify workflows. Some of the features include the following:

Providers can view more real-time information in Availity.

Providers may experience less wait times on authorizations with an enhanced automated process.

Providers have the ability to use a distinct member name for newborn baby authorizations.

Advanced Claim Editing

We are sharing coding advice to help Providers prepare for our automated claims review process starting in March. These ongoing tips help ensure your claims are properly coded.

Coding Advice –

Claim line will deny if claim is submitted with a Revenue Code that CMS indicates requires a HCPCS code and the HCPCS code is omitted.

Examples: 0300 (Laboratory – General), 0320 (Radiology – Diagnostic General), 0760 (Treatment – Observation Room)

Claim line will deny if claim is submitted with mutually exclusive code combinations according to the ICD-10-CM Excludes 1 Notes guideline policy.

  • 02 (Sepsis due to Methicillin Resistant Staphylococcus Aureus) and R78.81 (Bacteremia) should not be reported together.
  • 42 (Flat Foot [pes planus] (Acquired), Left Foot) and Q66.89\ (Other Specified Congenital Deformities of Feet) should not be billed together.
  • 2 (Hypertrophy of Adenoids) and J35.01 (Chronic Tonsillitis) should not be billed together.

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