Procedure and Diagnosis Codes and Guidelines

Blue Cross uses Physicians’ Current Procedural Terminology (CPT), ICD-10-CM and HCPCS codes for processing claims. Participating providers should follow the coding guidelines published in the current edition of the CPT code book when submitting claims to Blue Cross and HMO Louisiana for processing.

Blue Cross follows these coding guidelines unless otherwise identified in our policies. Because medical nomenclature and procedural coding is a rapidly changing field, certain codes may be added, modified or deleted each year. Please ensure that your office is using the current edition of the code book, reflective of the date of service of the claim. The applicable code books include, but are not limited to, ICD-10-CM

Volumes 1, 2 and 3; CPT and HCPCS.

New CPT codes will be accepted by Blue Cross as they become effective.

Helpful Hints for Diagnosis Coding

• Always report the primary diagnosis code on the claim form. Principal Diagnosis – “Reason for service or procedure”

• Report up to 12 (four per line) diagnosis codes when services for multiple diagnoses are filed on the same claim form

• Report all digits of the appropriate ICD-10-CM code(s)

• Report the date of accident if the ICD-10-CM code is for an accident diagnosis

• HIPAA regulations require valid ICD-10-CM diagnosis codes

Commercial Risk Adjustment

Blue Cross is using the Commercial Risk Adjustment (CRA) model that the Afordable Care Act (ACA) has adopted to predict healthcare costs based on enrollees in risk-adjustment-covered plans. The model incorporates organized diagnosis codes also known as HCCs (hierarchical condition categories) that correlate or link to corresponding diagnosis categories. It is critical that Blue Cross receive complete and accurately coded claims to properly indicate our members’ health status.