March 15, 2018
When a claim is not coded or billed correctly, your patient can be liable for costs. We’re introducing new coding edits to support the correct coding of services that you submit to us for reimbursement. These new edits and policies will become effective with claims processed after June 15, 2018.
The new coding edits will enforce coding guidelines established in the AMA CPT Professional Codebook and other standard industry coding sources. Some of these edits will include the following topics:
Multiple Evaluation & Management (E&M) codes: multiple initial hospital visits, multiple discharge submissions, multiple new office visits by providers in same clinic or same provider. When multiple visits are billed and only one is indicated per coding criteria, the new edits will deny reimbursement of the second and subsequent submissions.
Correct submission of add-on codes: add-on codes are always submitted with an appropriate primary/parent code and never submitted alone or with an inappropriate service. When an add-on code isn’t submitted with an appropriate primary/parent code on the same claim, the new edits will deny reimbursement. It’s important to know the correct primary codes to bill with the add-on code(s).
Post-operative visits in a global period: correct submissions of related or unrelated post-operative visits and their required appropriate appended modifiers. We’ll apply new edits to post-operative visits submitted by all providers within the same clinic and billing under the same Tax Identification Number.
Global/26/TC Split Codes: correct submissions of professional, technical, and global versions of a code, with no duplication of services on both professional and facility claims. If we already paid a global submission of a code, we’ll use new edits to deny reimbursement of the professional and technical versions of the code. If we already paid for the professional or technical version of a code, we’ll deny reimbursement for the global service.
Correct modifier usage: correct submissions of modifier, particularly those submitted for the sole purpose of overriding a claim edit. One key modifier that will be addressed includes (but isn’t limited to) Modifier 62-Two Surgeons. The modifier’s correct use will be based on the Co-Surgeons indicator flag for co-surgeons, as described in the National Physician Fee Schedule.
Modifier 90 –Reference (Outside) Laboratory: We’ll expand the policy on this modifier to include all providers. We won’t reimburse this modifier. The provider/laboratory that actually performed the laboratory test will need to submit the laboratory services to us.
These categories will result in a number of new edits and possible new Payment Policies. Make sure your business office staff is prepared.