Clinical relationship logic (code-to-code edits)

Clinical relationship logic pertains to the edits used to appropriately adjudicate claims in a claims processing system. Clinical relationship logic, or code-to-code edits (e.g., incidental, integral, component, mutually exclusive, etc.), is applied to claims submitted on the CMS-1500 claim form or through the 837P transaction.

This is not an all-inclusive list of claims editing that may be applied. Services continue to be subject to Independence Blue Cross claims adjudication logic, eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Independence policies.

Specific code-to-code edits that are applied to claims are described below.

Procedure terminology-based combinations

Procedure terminology-based combinations and logic for similar codes are applied to claims that are processed on the claim processing platform when submitted on the CMS-1500 claim form or through the 837P transaction.

For information regarding procedure terminology-based combinations as well as the specific procedure terminology-based combinations, please refer to our 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.” “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) when there is an AMA CPT^®¹ parenthetic note indicating, “Do not report (code) in addition to (code).”

Medicare’s National Correct Coding Initiative (NCCI) edits

Medicare’s NCCI edits are applied to claims. For information regarding NCCI edits, please visit the Centers for Medicare & Medicaid Services.