New Claims Editing Rules To Be Implemented in December 2026
Aug. 21, 2026
On or after Dec. 1, 2026, we’ll update the Lyric software database to better align provider coding with industry standards. Claims that receive a primary or secondary edit will reflect ineligible reason codes that begin with an alpha character of ‘G.’
These are the changes:
J0897 – Denosumab (Prolia) | This rule identifies claims billed with J0897 and limits a maximum of 60 units every 6 months when billed with a diagnosis of osteoporosis. This rule is appropriate for professional and outpatient facility claims. |
J0178 – Aflibercept (Eylea) | This rule identifies claims billed with J0178 and limits a maximum of 4 units every four weeks. This rule is appropriate for professional and outpatient facility claims. |
J2778 – Ranibizumab (Lucentis) | This rule identifies claims billed with J2778 and limits a maximum of 5 units every four weeks. This rule is appropriate for professional and outpatient facility claims. |
J2502 – Pasireotide (Signifor) | This rule identifies claims billed with J2502 and limits a maximum of 60 units every 4 weeks when billed with a diagnosis of acromegaly. This rule is appropriate for professional and outpatient facility claims. |
Q5128 – Ranibizumab-eqrn (Cimerli) | This rule identifies claims billed with Q5128 and limits a maximum of 10 units every four weeks when billed with a diagnosis of wet Age-related Macular Degeneration, Retinal Vein Occlusion and Myopic Choroidal Neovascularization. This rule is appropriate for professional and outpatient facility claims. |
Drug Wastage | This rule identifies claims billed with single use vial or package drug codes and the drug wastage or discarded modifiers JW or JZ are missing or not applied appropriately. This rule is appropriate for professional and outpatient facility claims. |
To determine how coding combinations may be evaluated during claim adjudication, use Clear Claim ConnectionTM. Learn more about ClaimsXtenTM and Clear Claim Connection.
ClaimsXten and Clear Claim Connection are trademarks of Lyric, an independent company providing coding software to Blue Cross and Blue Shield of New Mexico. Lyric is solely responsible for the software and all the contents. BBCBSNM makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.
The information provided does not constitute coding or legal advice. Physicians and other health care providers should use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment, and to submit claims using the most appropriate codes based upon the medical record documentation, coding guidelines and reference materials.
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