Fragmented Coding Information

The Blue Cross and Blue Shield of Alabama fragmented coding program is designed to prevent fragmentation of charges, keep costs from rising unnecessarily, and to ensure accurate processing of claims on the first pass.

Fragmented billing or unbundling is the use of more than one procedure code to bill for a procedure or service that may be adequately described by a lesser number of codes.

Fragmented billing practices are identified as claims are received. Maximum reimbursement is provided for the global procedure(s) while the fragmented procedure(s) are paid as part of the global procedure.

Blue Cross’ fragmented coding edits are established by a committee of physicians and nurses along with physician advisors from various specialties. The fragmented coding edit logic is designed in conjunction with the Blue Cross fee schedule. Publications (i.e., American College of Cardiology, Global Service Data for Orthopeadic Surgery, National Correct Coding Initiative, etc.) that give fragmented coding and/or billing information do not determine Blue Cross fragmented coding edits.

Draft fragmented coding edits are posted to the Blue Cross web site for provider review and comment beginning on or around the 15th of each month. Access to these edits is restricted to providers with provider access log-on and password. After the 45-day review and comment period all feedback, submitted literature, and comments are reviewed. A decision is made on each edit and the final fragmented coding edits are posted on our web site.

Reconsideration Requests

Reconsiderations will be performed upon request on any claim or line item that has been denied due to fragmented coding. Please be sure to include any supporting information or explanation, including any relevant procedural notes.

There are some claims that will not edit for fragmented coding, and will therefore be reimbursed according to contract benefits. The following categories will not edit for fragmented coding:

• Medicare Primary/Blue Cross and Blue Shield of Alabama Secondary
• Other Insurance Primary/Blue Cross and Blue Shield of Alabama Secondary
• Contracts with prefix “XAW”

Send requests for reconsideration of claims rejected for fragmented coding (code 97 on remittance) to the Special Claims Operations department at the address or fax below:

Blue Cross and Blue Shield of Alabama
Attention: Special Claims Operations
Post Office Box 362025
Birmingham, Alabama 35236

Fax Number: 205 220-9605

The request should be in the form of a letter explaining the reason for the reconsideration request. Pertinent medical documentation should be attached to the letter. Write “Do Not Open in the Mailroom” on the front of the envelope.

Last Updated November 2007