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Providers
June 2024
In This Issue
► June news: Executive summary
► New effective date for annual fee schedule update: Aug 15
► August 2024 code edit changes
► Medicare Advantage ID cards now available via Availity portal
► Introducing Prosano Circle
► We’re now using Availity for Medicare Advantage provider resources
August 2024 code edit changes
We use ClaimsXten™ to apply standard and customized code edits. In August, 2024, we will add two edits and update some existing edits. See below for details.
Two new code edits start August 1
We will use these new edits for all professional claims.
1. Obstetric Package
This edit checks for global maternity service codes that are billed more than once, or along with other obstetric care codes, by the same or multiple practices. The edit denies this type of duplicate billing when it occurs across an average pregnancy and postpartum time period. It does make exceptions for the delivery of twins or other multiples.
Examples
• A practice bills global maternity code 59400 for Provider A. The same or another practice then bills postpartum code 59430 for Provider B. The edit will not allow reimbursement for code 59430.
• A practice bills global maternity code 59510 for Provider A. The same or another practice then bills cesarean delivery code 59514 for Provider B. The edit will not allow reimbursement for code 59514.
2. Frequency Across Dates
These edits check procedures or groups of procedures that may only be billed a certain number of times across specific time periods. Some of the edits limit billing across one provider. Others limit billing across all providers in the same practice (tax ID) and specialty.
Examples
• A practice bills psychiatric care code 99492 (first calendar month). It then bills subsequent psychiatric care code 99493 (second calendar month) for the same member. The edit will not allow reimbursement for code 99493 if the date of service is in the same calendar month as 99492.
• A practice bills neonatal care code 99468 for Provider A (critical care per day). It then bills the same code for the same service for the same member on the same date for Provider B. The edit will not allow reimbursement for Provider B.
• For Medicare Advantage only: A practice bills annual wellness visit code G0439 for Provider A. It then bills the same code for the same service (within 330 days), for the same member, for Provider B. The edit will not allow reimbursement for Provider B.
Four code edit updates start August 22
We currently apply the following code edits to services billed by the same provider. Starting August 22, we will apply them across all providers in the same practice (tax ID) and specialty.
Medically Unlikely Edits (MUE) Practitioner 
This edit checks for daily unit limitations, as defined by CMS.
We run this edit on all professional claims.
Pre- and Post-Operative Edit
This edit denies evaluation and management (E&M) services when they are billed with surgical services associated with pre- or post-operative time periods (as defined by CMS). It also denies a global surgical code when the service is performed in the same post-operative period covered by an initial global surgical code.
We run this edit on all professional claims.
Unbundled Pairs
This edit finds procedure codes that may not be reimbursed when they are billed with certain other codes on the same date of service.
We run this edit on all professional and outpatient claims except those for Medicare Advantage members.
Correct Coding Initiative (CCI)
This edit finds procedure codes that may not be reimbursed when they are billed with certain other codes on the same date of service (as defined by the CMS Correct Coding Initiative).
We run this edit on all professional claims.
We run this edit on all outpatient claims except those for Medicare Advantage members.
More AZ Blue code edits
See our Code Edit Guidelines for a full list of our code edits. You can find it online in the AZ Blue provider portal under Provider Resources at “Guidelines > Claim Coding > Code Edit Guidelines and C3 Tool.”
Questions? 
Your Provider Relations Contact can help you with any questions you might have. Or you can call us at or 1-800-232-2345, ext. 4231. 
In This Issue
► June news: Executive summary
► New effective date for annual fee schedule update: Aug 15
► August 2024 code edit changes (effective July 1)
► Medicare Advantage ID cards now available via Availity portal
► Introducing Prosano Circle
► We’re now using Availity for Medicare Advantage provider resources
The ClaimsXten software is owned by Lyric, a separate, independent third-party vendor that is solely responsible for its products and services.

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