New Correct Coding Claims Edits Coming

  • November 7, 2019

    Over the next couple of months, we will be implementing correct coding edits based on ICD-10-CM guidelines, CPT coding guidelines and correct usage of modifiers. These edits include:

    Principal/First Listed Diagnosis Codes:

    Premera will be enforcing additional correct ICD10-CM diagnosis coding. ICD-10-CM identifies specific diagnosis codes that may only be used as a first-listed or principle diagnosis. In the ICD-10 CM Official Guidelines, Section 1.C.21.c.16, there is a listing of specific diagnosis codes that may only be principal/first listed diagnoses. These Z category diagnosis codes may only be used as a first listed or principle diagnosis. Claims submitted with one of these specified diagnosis in other than the primary position (i.e. not sequenced first) will be denied.

    Non-Primary/Not Sequenced First Diagnosis Codes:

    ICD-10-CM also identifies specific diagnosis codes which are not a primary diagnosis (i.e. sequenced first) codes. Directions can be found throughout the ICD-10-CM Official Guidelines for Coding and Reporting regarding specific codes not recommended for reporting alone or as a primary diagnosis. An example of this are manifestation codes which have in their code titles, in diseases classified elsewhere. Codes with this title are a component of the etiology/ manifestation convention and are never permitted to be used as first-listed or principal diagnosis codes. These codes must be used in conjunction with an underlying condition code and they must be listed following the underlying condition. Claims submitted with an ICD-10-CM code not recommended to be a primary diagnosis in the primary position (i.e. sequenced first) will be denied.

    Correct Modifier Usage

    Professional Services Modifier: The correct use of modifiers to provide additional information on a procedure being rendered will now be enforced. In the CMS National Physician Fee Schedule, there is a PC/TC column which indicates which codes have a Professional/Technical component split. Those that have an indicator of 1 or 6, can be billed with modifier 26 to indicate that only the professional portion of the procedure was rendered. Use of modifier 26 appended to the code also indicates that some other entity billed the technical portion of the service. Claims submitted without the appropriate modifier will be denied.

    Repeat Lab Tests: Clinical lab services performed on the same day for the same patient by the same provider should be reported using the modifier 91 to represent a repeat test as appropriate. Modifier 91 should not be used when tests are rerun to confirm initial results, due to testing problems with specimens or equipment or for any other reason when a normal, one-time, reportable result is all that is required. This modifier should also not be used when another code(s) describes a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). Repeat lab tests submitted without the appropriate modifier will be denied.

    Repeat Procedures Same or Different Provider: Diagnostic Radiology procedures performed the same day for the same patient should be reported using modifier 76 or 77 as appropriate. Modifier 76 is used if the same provider is performing the repeat procedure or service. Modifier 77 is used if a different provider is performing the repeat procedure or service. When it is medically necessary to repeat a service, the first service should be reported in the usual manner. The second and subsequent repeat procedures should be reported on separate lines with modifier 76 if performed by the same provider. If the repeat procedure was performed by a different provider, modifier 77 should be appended to the procedure code.

    Telephone and Online Services

    Effective with claim process dates starting April 6, 2020, procedure codes 99441-99443 and 98966-98968 for telephone services, the exceptions in the Telehealth/Telemedicine Services Payment Policy will no longer be applicable/enforced.

    This will mean that telephone services provided to an established patient by a physician, non-physician or other qualified healthcare professional that are related to a prior E&M service that occurred in the 7 days prior to the telephone service or which lead to another E&M or procedure 24 hours after the telephone service will be considered part of the initial E&M and not separately reimbursed.

    Per the code descriptions for the above codes, telephone E&M service will be covered if they are “…not originating from a related E&M service or procedure within the previous 7 days nor leading to an E&M service or procedure within the next 24 hours or soonest available appointment…”

    The same reporting guidelines also apply to on-line medical evaluations using internet resources when reported to an established patient by a physician, non-physician or other qualified health care professional submitted with procedure code 99444 or 98969 (codes deleted January 1, 2020).

    You are encouraged to review coding guidelines and Appendix A-Modifiers in your CPT Codebook, the current official Coding and Guidelines for ICD-10-CM diagnosis coding and the following Payment Policies:

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