Home Administrative Billing & Reimbursement BlueCard® Health and Wellness Medical PEAR portal Pharmacy Products Quality Management

Reminder: Clinical Relationship Logic and Code-to-Code Edits

March 31, 2016

Clinical Relationship Logic, or Code-to-Code Edits (e.g., Incidental, Integral, Component, Mutually Exclusive, etc.), pertains to the edits used to appropriately adjudicate claims in a claims processing system. As previously communicated, Independence completed its transition to a new claims processing platform.

On the new claims processing platform, procedure terminology-based combinations and logic for similar codes are applied to claims submitted on the CMS-1500 claim form or through the 837P transaction. In addition, Medicare?s National Correct Coding Initiative (NCCI) edits are also applied.

Procedure terminology-based combinations

For information regarding procedure terminology-based combinations as well as the specific procedure terminology-based combinations, please refer to the recently updated code-to-code list.

Logic for similar codes

When two or more procedure codes represent services that are considered to be similar in nature to one another, the procedure codes are identified as ?similar codes? on the new platform. ?Similar codes? are defined as any code(s) that should not be reported with or appended to another code by the same provider on the same date of service when:

  1. The codes are clinically duplicative; OR
  2. There is an AMA CPT1 parenthetic note indicating, ?Do not report (code) in addition to (code).?

Medicare?s NCCI edits

For information regarding NCCI edits, please visit the Centers for Medicare & Medicaid Services website.

For more information on Clinical Relationship Logic, visit our website.

1AMA CPT ? American Medical Association® Current Procedural Terminology®

CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of Independence Blue Cross. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
Connect with us     Facebook     Twitter     Flickr     YouTube     Walk the Talk    Independence Pinterest    Independence LinkedIn    Independence Instagram Site Map        Anti-Fraud        Privacy Policy        Legal        Disclaimer
© 2023 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.