Our health plan utilizes Change Healthcare (formerly known as McKesson) claim edits, Medicare's National Correct Coding Initiative (NCCI) and customized editing rules as the basis for clinical edits. Our claim adjudication systems are updated on a quarterly basis to recognize the most recent Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes as well as changes from the Relative Value Units (RVU) File. Please review your CPT and HCPCS coding publications for codes that have been added, deleted or changed, and use only valid codes. Please append modifiers to HCPCS and CPT codes when correct coding indicates a modifier is appropriate.

When submitting claims, procedures should be reported with the CPT/ HCPCS code that describes the services performed to the greatest specificity possible and only if all services described by that code are performed. CPT code definition and rules are used in applying clinical edits.  Unbundling occurs when multiple codes are used to report a procedure covered by a single comprehensive CPT/HCPCS code.

We will implement quarterly updates to edits approximately one month after the effective date retro-active to the 1st day of the quarter (excludes outpatient code editor (OCE) edits).  Claims received before our systems are updated will not be adjusted. 

3rd quarter implementation date: 7/28/2019

2nd quarter implementation date: 4/28/2019

1st quarter implementation date: 1/27/2019

4th quarter implementation date: 10/28/2018

We will implement updates on National Coverage Determination (NCD)/Local Coverage Determination (LCD) within one month of receipt/delivery of edits from Change Healthcare. NCD/LCD updates will be effective retro-active to the date specified by the Centers for Medicare & Medicaid Services (CMS) or Noridian. Claims received before our systems are updated will not be adjusted.

Quarterly implementation date archive

3rd quarter implementation date:  7/29/2018

2nd quarter implementation date: 4/29/2018

1st quarter implementation date: 1/21/2018

4th quarter implementation date: 10/29/2017

3rd quarter implementation date: 7/23/2017

2nd quarter implementation date: 4/30/2017

1st quarter implementation date: 1/29/2017

4th quarter implementation date: 10/31/2016

3rd quarter implementation date: 7/31/2016

ClaimsXten editing

We use ClaimsXtenTM, a clinical code editing software developed by Change Healthcare. ClaimsXten logic is based upon a thorough physician review of current clinical practices, physician specialty society guidance, and industry standard coding and guidelines. These edits are proprietary to Change Healthcare and, therefore, we cannot provide the editing detail.

ClaimsXten provides a web-based tool, Clear Claim Connection that allows providers to model claim editing.

When utilizing the Clear Claim Connection tool to model claims editing, the claim processing of procedures must be on the same claim.  If all procedures are submitted on the same claim, the Clear Claim Connection tool will provide information on how your claim would be processed.

ClaimsXten rules

The following is a list of many of the ClaimsXten rules that we have implemented. This list is subject to change from time to time.  This is not an exhaustive list of claim edits; refer to our individual reimbursement policies for more detail.

Edit name Edit description
Correct Coding Initiative Edits claim lines for which the submitted procedure is not recommended for reimbursement when submitted with another procedure as defined by a code pair found in the National Correct Coding Initiative (NCCI).
Incorrect Bilateral Surgical Billing

Bilateral Billing identifies when two claim lines are submitted on the same date of service with the same procedure code, and one line (or both lines) has been reported with modifier 50.  Only one line with the modifier 50 will be allowed.

When multiple bilateral units are billed on a single line, the system will split the units to create separate claim lines.  The line with one unit will be allowed and the line(s) with remaining units will be denied.

Surgical Supplies Included with Surgery Identifies inclusive supply codes that are reported by the same provider reporting a surgical or medical procedure for the same date of service. Surgical supplies and materials are not eligible for separate reimbursement when reported by the provider rendering the primary service.
Unbundled Code Pairs

Occurs when two or more procedure codes are used to describe a service when a single, more comprehensive procedure code exists that more accurately describes the complete service performed. These code pairs supplement NCCI.

Incidental/Integral: "An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure." A procedure determined to be incidental/integral to another procedure will not be eligible for reimbursement.

Mutually Exclusive/Redundant: "Mutually exclusive edits consist of combinations of procedures that differ in technique or approach but lead to the same outcome. In some instances, the combination of procedures may be anatomically impossible. Procedures that represent overlapping services or accomplish the same result are considered mutually exclusive. In addition, reporting an initial service and subsequent service is considered mutually exclusive." A procedure determined to be mutually exclusive to another procedure will not be eligible for reimbursement.

E&M Billed on Same Day as Surgery Edits claim lines with evaluation & management (E&M) CPT codes billed on the same date of service as a procedure code with a global period established by CMS or the plan.
Pre-Operative Period E&M Denial Edits claim lines containing E&M codes billed within the pre-operative period.
Post Operative Period E&M Denial Edits claim lines containing E&M codes billed within the post-operative period.
CMS Fee Schedule T Status Bundling Identifies claim lines containing T status procedure codes that are not payable when billed on the same date of service as any procedure payable under the physician fee schedule for the same member and same provider.
CMS Practitioner MUE

This rule identifies claim(s) where the total units of service of a HCPCS/CPT submitted on a single date of service for a member by the same provider exceed(s) the Centers for Medicare & Medicaid Services (CMS) practitioner medically unlikely edits (MUE) value.

When multiple units are billed on a single line, the system will split the units to create separate claim lines.  One line will be allowed with the appropriate number of units and the line(s) with remaining units will be denied.

CMS DME MUE

This rule identifies claim(s) where the total units of service of a Durable Medical Equipment (DME) HCPCS code submitted on a single date of service for a member by the same provider exceed(s) the CMS DME MUE value.

When multiple units are billed on a single line, the system will split the units to create separate claim lines.  One line will be allowed with the appropriate number of units and the line(s) with remaining units will be denied.

Inappropriate Frequency Billing

This rule identifies claim(s) where the total units of service of a HCPCS/CPT code submitted on a single date of service or within a date range for a member by the same provider exceed the units defined by Change Healthcare ClaimsXten editing.

When multiple units are billed on a single line, the system will split the units to create separate claim lines. One line will be allowed with the appropriate number of units and the line(s) with remaining units will be denied.

Maternity Care Services This rule audits potential overpayments for obstetric care. It will evaluate claim lines to determine if any global obstetric (OB) care codes (defined as containing antepartum, delivery and postpartum services, e.g. CPT code 59400) were submitted with another global OB care code or a component code such as the antepartum care, postpartum care, or delivery only services, during the average length of time of the typical pregnancy (and postpartum period as applicable) 280 and 322 days respectively. This edit fires on the same provider or different providers.
Component Billing - different provider

Identifies claim lines with procedure codes which have components (professional and technical) to prevent overpayment for either the professional or technical components or the global procedure. The rule also detects when duplicate submissions occurred for the total global procedure or its components across different providers.

The claim line may be modified to add a Modifier 26/TC or remove Modifier 26/TC.

Component Billing - same provider Identifies when a professional or technical component of a procedure is submitted and the same global procedure was previously submitted by the same provider ID for the same member for the same date of service.
Ineligible Co-Surgeon Identifies claim lines containing procedure codes billed with a co-surgery modifier that typically do not require co-surgeons according to CMS.
Established Patient Billed as New Patient Identifies new patient E&M procedure codes that are submitted for established patients. According to the American Medical Association (AMA), "A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the last three years."  If our editing system detects a new or established E&M reported within the last three years by the same provider, the new patient E&M code will be replaced with a comparable established patient code.
Missing Professional Component Modifier 26

Identifies claim lines where a modifier 26, denoting professional component, should have been reported for the procedure performed at the noted Place of Service (POS).

The claim line will be modified to add a Modifier 26.

National and Local Coverage Determination - NCD/LCD (Medicare Advantage only) These rules identify claim lines for certain procedure codes associated with diagnoses, frequencies and ages where the procedure is not considered medically necessary, is not payable or has payment constraints according to NCDs or LCDs. Appropriate coding of ICD-10 diagnoses is essential for accurate payment.
Inappropriate Procedure for Age Edits claim lines containing procedure codes inconsistent with the patients age.
Replacement of Procedure for Age Identifies claim lines containing procedure codes that are inconsistent with the member's age.  The code will be replaced by a more appropriate code.
Modifier to Procedure Validation Edits procedure codes when billed with any payment-affecting modifier that is not likely or appropriate for the procedure code billed.
Positive Airway Pressure Supplies Identifies supply codes associated with the Continuous Positive Airway Pressure or Bi-level Positive Airway Pressure (CPAP/BIPAP) therapy that are being submitted at a rate that exceeds the usual or customary rate.
Diabetic Monitors and Supplies Identifies codes associated with glucose monitors that are being submitted at a rate that exceeds the usual or customary rate.

 

Global periods

Global periods have been established for certain surgical procedures when the CMS has not established a global period of a specific number of days.

To view how our health plan's Global Periods are applied for Commercial business, visit our Clear Claim Connection tool.

View CMS global periods that are applied for Medicare business.

Clinical edits

Updates to our lists are posted on a monthly basis.

The following lists are organized by line of business and are based on our Medical and Reimbursement Policy.

Note: Codes for all services and supplies that require pre-authorization can be found on our pre-authorization lists.

Commercial

The Clinical edits by code list applies to all commercial lines of business except Medicare. It is sorted by code and contains all cosmetic, investigational, non-reimbursable services and supporting documentation requirements for each.

View past lists in the archive.

Uniform Medical Plan (UMP) clinical edits by code list

The UMP clinical edits by code applies only to UMP. The list is sorted by code and contains all cosmetic, investigational, non-reimbursable services and supporting documentation requirements for each.

View past lists in the archive.

Medicare

The Always not medically necessary denials list applies to our Medicare Advantage lines of business. The list contains codes that are always denied as being not medically necessary.

View past lists in the archive.

Note: We will not routinely require submission of clinical information in connection with adjudication of claims except for unlisted codes, codes without allowables, claims to which a modifier 22 is appended, facility claims containing revenue code 0624, or other limited categories of claims included on the clinical edits by code list.

Bundling edits

We utilize Medicare's National Correct Coding Initiative (NCCI) as the basis for clinical edits. NCCI identifies pairs of services that normally should not be billed by the same physician for the same patient on the same day. NCCI also promotes uniformity among the contractors that process Medicare claims in interpreting Medicare payment policies.

We have created additional code pair edits, found in our Correct Code Editor (CCE), to be used as a supplement to Medicare's NCCI. These code pair edits were developed using nationally accepted, logical and predictable coding principles. In arriving at these supplemental coding edits, the following were taken into consideration:

  • CPT Assistant
  • HCPCS manual
  • Medicare Part B News
  • The CMS Federal Register
  • Centers for Medicare & Medicaid Services (CMS)
  • CPT manual, including code definitions and associated text

Our CCE is updated quarterly (January, April, July and October). Updates are clearly labeled with the corresponding numbered version of CMS' NCCI.

  • January - supplement to NCCI version XX
  • April - supplement to NCCI version XX.1
  • July - supplement to NCCI version XX.2
  • October - supplement to NCCI version XX.3

To provide feedback or get clarification about the CCE code pairs, please contact your provider relations representative.

CCE supplement to CCI version 25.3

For dates of service beginning October 1, 2019:

View past lists in the archive.

ClaimsXten code pairs:

Developed by our vendor partner, Change Healthcare to supplement the NCCI code pairs; all code pairs are incidental or mutually exclusive.

Add-on codes as related to bundling edits code pairs

Some services are reported as add-on codes, which describe work done in addition to primary procedures. Add-on codes are not stand-alone codes, and must always be reported with primary procedures. We will deny reimbursement for an add-on code as a correct coding edit when its primary code is denied as part of an NCCI or correct code edit code pair. When correct coding indicates the use of a modifier is appropriate for the primary code, that modifier must be appended to both the primary code and add-on code.

OCE edits

The following outpatient code editor (OCE) clinical editing is used in addition to our existing medical policy clinical edits and follows our current reimbursement policies. These edits are modeled after the Centers for Medicare & Medicaid Services' (CMS') existing non-outpatient prospective payment system (non-OPPS) OCE edits. These edits apply to all Medicare Advantage plans. All OCE edits follow CMS. For commercial lines of business, including Federal Employee Program, Uniform Medical Plan and BlueCard® , please refer to OPPS (APC) and non-OPPS (non-APC) columns for the edits that are being applied.

New edits published by CMS will take effect based on CMS's published effective date and we will follow our existing process to post updates on a monthly basis.

View past lists in the archive.

NCCI bypass modifiers

NCCI bypass modifiers, as defined by CMS, will be processed in accordance with the current CMS superscript rules except for the published list of service or procedure code combinations that we have determined are not appropriately reported together.

View our code pair edits that do not bypass with any modifier on the Correct Code Editor above.

Maximum allowed units for procedure codes

Our health plan has established a maximum allowed edit for the following the presumptive CPT codes 0007U, 80305, 80306, 80307 and the definitive HCPCS codes G0480, G0481 and G0659.

View the reimbursement policy.

Our health plan has established a maximum allowed edit for the spinal angiography CPT codes 36215, 36245 and 75705.

View the reimbursement policy.

Unlisted codes

Services billed using an unlisted procedure code will not be separately reimbursed when considered incidental to a comprehensive procedure billed on the same date of service.

Similarly, if a procedure or service is determined to be incidental to a more comprehensive procedure described by an unlisted code, separate reimbursement will not be allowed.

Codes without allowables

We may require the submission of clinical information in order to price CPT and HCPCS codes for which an allowed amount has not been established. For questions, please contact your provider relations representative.

Other specific edits

Our health plan considers CPT Codes 0038U and 82306 to be medically necessary ONLY when billed with diagnosis ICD-10 code ranges:

A312, B20, B9733, B9734, B9735, C460, C461, C462, C463, C464, C4650, C4651, C4652, C467, C469, D71, E200-E213, E43-E46, E550, E640, E643, E673, E8330-E8339, E8350-E8359, E892, K700-K709, K7210-K750, K754, K7581, K760, K7689-K769, K831, K900-K904, K9089-K909, K912, M810-M839, M85.80, M85.831-M85.839, M85.851-M85.859, M85.88, M85.89, M85.9, M8970, M89.9, N181-N189, N200-N202, O98711, O98712, O98713, O98719, O9872, O9873, P710-P719, Q442-Q443, Q78.0, Q782, T8601, T8602, T8603, T8620, T8621, T8622, T8623, T8633, T86298, T86810, T86811, T86819, Z114, Z206, Z21, Z4821, Z940, Z941, Z942, Z943, Z944, Z945, Z946, Z947, Z9482, Z9481, Z9483, Z9484.

Our health plan considers CPT Code 82652 to be medically necessary ONLY when billed with diagnosis ICD-10 code ranges:

D860-D869, E200-E213, E550, E643, E7200-E7209, E8330-E8339, E8350-E8359, E892, M830-M839, N200-N209, N22, N2581, P710-P719.

The rationale for these edits is detailed in our Medical Policy, Laboratory 52 Vitamin D Testing.

Virtual care services edit

This edit applies to Virtual Care Services as defined in our administrative reimbursement policy.   This includes criteria between providers as well as between provider and members in relation to telehealth and telemedicine.