Diagnosis billing updated for facility lab claims

Blue Cross Blue Shield of Michigan has updated the outpatient facility lab claims process. Facilities should bill with a routine preventive diagnosis as the primary diagnosis when diagnoses for both routine preventive and medical diagnostic care are billed on the same claim.

This update will be effective July 1, 2024. Previously, claims were processed based on the primary diagnoses reported on outpatient facility lab claims.

Background

• Outpatient facility claims are billed with a claim-level string of diagnoses, including a primary diagnosis and multiple supporting diagnoses.
• Unlike professional claims, no pointers assign a specific diagnosis to a specific service line on a claim.
• Outpatient facility lab claims may include lab procedures that were done for routine preventive reasons or for medical diagnostic purposes.
• Some lab procedures are not payable as routine preventive and may reject as “not a benefit” if the primary diagnosis on the claim is routine preventive.
• Most routine preventative services are payable at 100% with no member out-of-pocket costs, but deductibles and copayments may apply when the primary diagnosis is medical diagnostic.

What does this mean to facilities?

Facilities will now bill the routine preventive diagnosis as the primary diagnosis when diagnoses for both routine preventive and medical diagnostic care are applied to the same claim. This allows us to identify services that are not payable as routine (highest benefit) and apply a payable medical diagnostic care diagnosis, if present.

Future process

Currently, we’re reviewing options for an automated, technical solution where we can process these codes based on the claim-level diagnosis billed, regardless of what diagnosis is listed as primary.