UniCare ClaimsXten TM Rules (Version 4.4) Effective February 15, 2013 Rules Edit logic Example Supported After Hours 99050 not Reimbursable with Preventive Diagnosis Qualitative Drug Screening This will deny 99050 (services provided when the office is usually closed) when billed with a preventive diagnosis and/or a preventive This will deny codes 80100, 80101, and 80104. Qualitative drug screening will now only be reimbursable using codes G0431 and G0434. Both codes G0431 and G0434 will be eligible for 1 unit of reimbursement per date of Use of code G0431 is limited to only high complexity testing, and documentation of FDA approved complexity level for instrumented equipment utilized, and/or CLIA Certificate of Registration, Compliance, or Accreditation as a high complexity lab, may be requested as a condition for reimbursement. Code 99050 will be denied when billed with diagnosis V202 Code 80100 is submitted, this line will be denied or UniCare After Hours Applied to dates of service on or after ICD 10 diagnosis UniCare Bundled Services and Supplies Qualitative Drug Screen Testing Edit effective for or after 1
Morton s Neuroma: 64450, 64640, and 20550 Not Reimbursable with Diagnosis 355.6 Durable Medical Equipment billed without DME modifier (NU, UE, RR, RA, RB, or MS) Maintenance and Servicing of Durable Medical Equipment (Modifier MS) Maintenance and Servicing of DME frequency (modifier MS) Maximum DME Rental Allowable Has Been Reached (modifier RR) This will deny 64450, 64640 or 20550 when billed with diagnosis 355.6. This is supported which developed specific codes for these services for this diagnosis. This will deny the DME code if the code is billed without the appropriate DME modifier (NU, UE, RR, RA, RB, or MS). This will deny specific rental DME billed with modifier MS (6 month s maintenance and service fees, parts and labor). Refer to the DME reimbursement policy. This will determine if maintenance and servicing is allowed. When allowed, a DME code with modifier MS will be denied if maintenance and servicing has been reported within the previous six months. This editing will deny DME codes billed as a rental with modifier RR when the item has been rented for more than 10 months. Code 64450 will be denied if billed with diagnosis 355.6. Code E0250 will be denied when billed without a DME modifier. Code E0935 when billed as a rental with modifier MS will be denied. Code E0574 is eligible for maintenance and servicing but a history line for same item has modifier MS within six months. The current claim line will be denied. DME Code K0813 modifier RR has been previously billed for 10 months. When the claim with the 11th occurrence of rental is received, the claim will be denied. Centers for Medicare & Medicaid Services () or Applied to dates of service on or after ICD 10 diagnosis DME Edit applied to all claims processed on or after02/15/2013, regardless of date of UniCare DME Edit applied to or after DME Edits applied to or after DME Edit applied to all claims processed on or after02/15/2013, regardless of date of 2
Purchase of Rental DME previously Rented (modifiers RR, NU, UE, NR) Rental of DME previously purchased (modifiers RR, NU, UE, NR) Repair and Replacement of Rented Durable Medical Equipment (modifiers RA, RB, KC) Modifier 25: Multiple Evaluation and Management procedures billed with modifier 25 This will pend the line when durable medical equipment is billed with modifier NU, UE or NR and prior claims have been billed with modifier RR within prior 10 months. The purchase claim will be reviewed to ensure that the allowable for the rental and purchase do not exceed the maximum allowable for the item. This editing will deny durable medical equipment when billed with rental modifier (RR) if same item has been previously purchased (modifiers NU UE or NR) in the member's claim history. This will deny line billed for a rented durable equipment item with modifier(s) RA, RB and/or KC. UniCare does not reimburse for these services for rented equipment. This will deny the lower valued evaluation and management procedures when two preventive or two problem oriented E/Ms are billed on the same date of Modifier 25 does not override this edit. Current line: E0574/NU for date of service 10/01/2010, Paid History line: E0574/RR for date of service 03/01/2010 03/31/2010. They will pend for review and pricing. DME procedure code K0813 modifier RR is billed and the member s history indicates this same item was previously purchased (modifier NU, UE or NR). The Rental line will be denied. Code E0935 has been rented and is billed with modifier RA. This charge line will be denied. Code 99213 is billed twice for the same date of service, and modifier 25 is added to one procedure. Only a single visit will be allowed. or DME Edits applied to dates of service for the purchase on or after DME Edits applied to dates of service for the rental on or after UniCare DME Edit applied to or after Standard CPT/AMA Evaluation and Management Services and Related Modifiers 25 & 57 More Than 1 Same Day E/M service section Edit applied to all claims processed on or after 02/15/2013, regardless of date of 3
Screenings with preventive or problem oriented E/Ms Health and Behavioral Assessments 96150 96155 Not Reimbursable with any Mental Health Diagnosis Lab Service in Facility Place of Service This will deny screening services G0101, G0102 and Q0091 and annual exam codes (S0610, S0612, and/or S0613) when reported with a preventive E/M When Screening services are performed at the same time as a problem oriented exam, the screening service should be taken into account when determining the correct level of problem oriented E/M service (99201 99215) to report. Modifiers 25 or 59 will not override the edit. This will deny codes 96150 96155 when billed with any diagnosis contained within the Mental Disorders chapter of the ICD 9 CM reference book (code range 290 319) This editing will deny the line if the National Physician Fee Schedule Relative Value File (NPFSRVF) designates that the concept of a separate professional and technical component does not apply to a laboratory procedure (PC/TC indicator of 3 or 9), and the procedure is billed in facility place of G0101 25 & G0102 25 will deny when billed with 99384 or 99213. S0612 will deny when billed with 99384. Codes 96150 96155 will be denied if submitted with diagnosis 295.0. A lab code that a PC/TC indicator of 3 or 9 in the NPFSRVF file on the date of service billed (e.g., 80050) with place of service outpatient hospital (22). Will be denied. UniCare UniCare Evaluation and Management Services and Related Modifiers 25 & 57 Screening Services with Evaluation and Management Health and Behavior Assessment/ Intervention Laboratory and Venipuncture Services, Technical/Professional Modifiers TC/26 section. or edits, applied to dates of service on or after Edit applied to or after 1/01/2013. ICD 10 diagnosis Edit applied to or after 1/01/2013. 4
Multiple Diagnostic Imaging Reductions Patient Home Sleep Studies Prolonged Services 99354, 99355 Not Reimbursable with Diagnosis Anesthesia Complicated Emergency Situations 99140 Not Reimbursable with Diagnosis Following () policy, this will reduce the technical component of the diagnostic imaging procedures that have a Multiple Procedure Indicator of 4 on the National Physician Fee Schedule (NPFS) 50% (based on the RVU for the date of service) when multiple diagnostic imaging procedures with a MPI of 4 are billed for the same date of Note: when codes are submitted unmodified, an algorithm will be applied to determine the percentage of the charge for the technical component and the reduction will be applied to this percentage of total charge. This editing will deny the charge for attended sleep study procedures when billed with place of service home (12). This will deny code 99354 or 99355 when the diagnosis submitted is not on the UniCare list. This will deny code 99140 (anesthesia complicated emergency situation) when billed with a routine maternity diagnosis in the UniCare list. CXT 4.4 Revision Additional diagnoses have been added; refer to the Anesthesia for additional details. Codes 72146 TC and 72148 TC same day are submitted. Code 72146 has a higher RVU value, 100% of the technical fee schedule amount will be allowed. Code 72148 has a lower RVU than 72146, 50% TC fee schedule amount and 100% of the 26 fee schedule amount will be allowed. Code 95808 will be denied when billed with place of service home (12). Codes 99354 or 99355 will be denied when billed with diagnosis 077.0. Code 99140 will be denied when billed with diagnosis V22.0, V22.1, 650, etc. Multiple Imaging Diagnostic Procedures Subsequent procedure that has an MPI of 4 in the multiple procedure column of the National Physician Fee Schedule (NPFS) or Edit applied to or after 1/01/2013 if not present in provider contract with earlier effective This does not apply to UniCare Blue Cross Medicaid (MediCal, L.A. Care, MRMIP, P, AIM and Healthy Families) UniCare Place of Service Edit applied to or after UniCare Prolonged Services Edit applied to or after ICD 10 diagnosis UniCare Anesthesia Revised Revised edit applies to all dates of ICD 10 diagnosis 5
National Correct Coding Initiative (NCCI) bundling Rules Edit logic Example Supported Diagnosis Invalid for Patient s Age Procedure with date span limits This will deny the charge line for services which are incidental or mutually exclusive to another Edits are defined in the National Correct Coding Initiative Coding lists as maintained and posted to the website. 4.4 Revision Effective with claims processed on or after 12/08/2012, we will be adopting the modifier override that requires the overriding modifier be appended to the denied code. This will deny a line when the referenced diagnosis is inappropriate for the patient s age. CXT 4.4 Revisions: The age range appropriate for reproductive services will be changed from 9 60 to ages 12 55. This editing will limit the reimbursement for procedures which are reimbursable only for a limited number of occurrences within a specified time frame. CXT 4.4 Revisions: Additional rental DME codes have been added to this and will be allowed only once per month. In addition, diabetic supplies such as glucometers, lancets and strips will be limited to specific quantities within a specific time frame appropriate diabetes diagnosis and modifiers KS or KX are required. Code 38206 will be denied NCCI when billed with code Q2043. Code 77332 will be denied NCCI when billed with code 77418. Claim line billed with diagnosis 650 will be denied for a patient age 7 or 70. Procedure code 93294 is billed for date of service 11/15/2011 and also for date of service 12/01/2011. The second submission for this procedure will be denied, as this code is per 90 day period code definition. or Revised Revised Revised edit applies to all dates of This does not apply to UniCare Blue Cross Medicaid (MediCal, L.A. Care, MRMIP, P, AIM and Healthy Families) ICD 10 updates to be Frequency Editing Revised Revised. edits apply to and after 6
Multiple Lab Component Rebundling Rules Edit logic Example Supported Bilateral procedures (modifier 50) Place of Service Pre and post Anesthesia Visits This will deny 2 or more component codes of a multiple component laboratory test and replace them with the more comprehensive lab panel code. Modifier 59 does not override this editing CXT 4.4 Revision: The editing in this will be expanded to all blood panels and complete blood count codes. Bilateral surgery is to be billed on one line with 1 unit and modifier 50. This may recode and/or split the total allowed percentage for the bilateral surgical procedure(s) billed on multiple lines to comply with this requirement (e.g., 75% on line 1 and 75% on line 2 to equal 150%). 4.4 Revisions: Certain coding scenarios will result in a line being considered bilateral without modifier 50. Refer to the policy for more information. This editing will deny the charge line for specific procedures and place of service combinations. 4.4 Revisions: DME when rented for use in a facility or office place of service will be denied. This will deny evaluation and management codes billed the anesthesiologist one day prior to or 10 days post anesthesia. Laboratory tests 82040, 82247 and 82310 are reported for the same date of These are components of the more comprehensive lab panel code 80053. is made on the 80053 Panel test. As an example, when myringotomy procedure code 69420 is billed with modifier 50 on one line and billed again on another line (with or without modifier 50). This will recode the two claim lines to a single line with modifier 50, 1 unit and combine the charges. Codes, 99050 or 77417 will deny when billed in place of service 21. Code E0673 will deny when billed with place of service 24. Code E0676 will deny when billed with place of service 11. Code 99213 billed within 10 days after anesthesia administration the anesthesiologist will be denied.., Custom Laboratory and Venipuncture or Revised Revised edit applies to all dates of Multiple Surgery Revised Revised edit applies to all dates of Place of Service DME Anesthesia, Global Surgery Revised service 7
Assistant Surgeon not allowed (modifiers 80, 81, 82, AS) Never Reimbursed with Specific Procedures UniCare Code Bundling Diagnosis Code Inappropriate for Patient's Gender This will deny surgery codes billed with assistant surgeon modifiers 80, 81, 82, or AS if the procedure is on UniCare s list of codes that do not allow for services of an assistant surgeon. codes are updated quarterly when necessary per the policy guidelines. This will deny services which are listed on the UniCare Bundled Services and Supplies when billed with the specific other services as defined in the policy. These are services or items for which UniCare never provides reimbursement when billed in combination with the codes listed in the policy. This will deny the charge line for services which are incidental or mutually exclusive to another procedure for the same date of Please refer to the Modifier 59 and E/M Related Modifiers 25 and 57 for additional details on modifier impacts to this. This editing will deny the charge line if the diagnosis billed is inappropriate for the patient's gender. Code 14041 billed with modifier 80 will be denied. All radiological interpretation codes, as well as radiology codes with modifier 26 are denied when billed with procedures 99281 99285, and 99221 99223. Code Q0091is denied when billed with Preventive and E/M codes such as 99381 99397, G0101, S0610, S0612 and 99201 99215. Procedure codes 72020 and 72072 are billed for the same date of 72020 will be denied as incidental to 72072. 99204 and 99219 are billed for the same date of 99204 will be denied as mutually exclusive to 99219. Diagnosis 617.0 endometriosis of the uterus denies for a male. Diagnosis 600.00 (Benign Prostatic Hypertrophy) denies for a female. American College of Surgeons NCHS Assistant Surgeon and separate list of non allowed codes Bundled Service and Supplies Modifier Rules, Modifier 59 E/M Related Modifiers 25 and 57 or ICD 10 diagnosis 8
Incomplete Diagnosis Diagnosis Code Invalid Patient Visit Code Frequency Limits Procedure Code Deleted (Obsolete) Procedure and Modifier Combination Invalid This editing will deny the charge line if the diagnosis is incomplete. An incomplete diagnosis is one that has not been coded to the ICD9/10 required length as defined the National Center for Health Statistics (NCHS) and The Centers for Medicare and Medicaid Services (). This editing will deny a diagnosis code that is not listed as a valid diagnosis for the date of service the National Center for Health Statistics (NCHS) and The Centers for Medicare and Medicaid Services (). This editing will deny the charge line for a new patient evaluation and management service if a claim has been previously received within a three year period the same provider or providers with the same specialty billing under the same Tax ID. This editing will deny any code which has been end dated or /HCPCS. This editing will deny the line if the billed modifier is invalid with the procedure code. Claim line billed with diagnosis code 410.2 will be denied, as this diagnosis requires a fifth digit for further specificity to be considered complete. As an example, Claim line billed with 424.00 will be denied, as this diagnosis is not a valid diagnosis. patient code 99204 or established visit 99213 is billed for date of service 12/31/2010. If the same physician or another physician with the same specialty billing under the same Tax Id submits 99203 within 36 months of 12/31/2010, the additional new visit charge line will be denied. Code L0100 was end dated in the HCPCS manuals effective 12/31/2006 and would be denied if submitted for a date of service 01/01/2012. Code 99213 is denied when billed with modifier 80 (assistant surgeon). NCHS NCHS AMA/ CPT or ICD 10 diagnosis updates to be done at a later ICD 10 9
Procedure Code Invalid Rules Edit logic Example Supported Procedure allowed once per date of service Procedure allowed limited times per date of service Unilateral Procedures billed Multiple Times when bilateral Code exists Pre Operative Visits Post Operative Visits This editing will deny line containing a procedure code which has never been a valid CPT/HCPCS code. This will limit the number of times the procedure may be billed either on separate lines or units on one line, to a single occurrence per date of This will limit the number of times the procedure may be billed either on separate lines or units on one line, to a maximum allowable amount per occurrence per date of This will replace unilateral procedure codes when billed more than once per date of service if a bilateral procedure code exists for the This editing will deny the line for an evaluation and management code billed within the pre operative period. This editing will deny the line for an evaluation and management code billed within the post operative period. Code 95902 has never been a valid CPT code and would be denied in this editing. Code 27392 (tenotomy open, hamstring, knee to hip; multiple tendons, bilateral) is billed twice for the same date of service will have one unit denied. This procedure, definition, can only be performed once per date of 29125 (application of a short arm splint) is billed three times with right and left modifiers. The second submission of 29125 RT is denied. 29125 RT 29125 LT 29125 RT (Deny) Code 70328 (Radiologic examination, unilateral) is billed twice for the same service Both units or lines will be denied and replaced with the corresponding bilateral procedure 70330 1 unit. Code 99213 billed one day prior to surgery code 49000 with the same diagnosis will be denied as a preoperative visit. Code 99213 billed within 90 days post operative period for code 49000 will be denied as a post operative visit. AMA/ CPT or Frequency Editing Frequency Editing Frequency Editing Global Surgery Global Surgery 10
Supplies Same Day as Procedure Duplicate Component Modifier Billing (26, TC) Missing Professional Component in Facility Place of Service Procedure with Modifier 22 Modifier Increase or Decreases This editing will deny the line for supply codes when billed on the same day as a procedure. This editing will deny lines billed with a professional (26) or technical modifier (TC) when the procedure code was previously submitted as a global procedure for the same provider ID, patient, & date of This editing will deny the line when the National Physician Fee Schedule Relative Value File indicates modifier 26 is applicable (PC/TC indicator of 1 or 6), and the procedure is billed without modifier 26 with a facility place of Modifier 26 is required. This will pend the claim for additional review for increase of allowance when the procedure code is billed with modifier 22 to identify unusual procedural services AND the claim is submitted with medical records. UniCare has identified modifiers which will increase or decrease the reimbursement. Please refer to the policy for details. A4206 will be denied when billed with chemo administration codes such as 96405. A7041 will be denied when billed with surgery codes such as 11005. If procedure code 70010 is submitted as global with no component modifier and claim lines are received which contain procedure code 70010 and modifier 26 and/or modifier TC, these claim lines will be denied. Code 78805 is billed without the professional component modifier (26) with a place of service inpatient (21). This line will be denied. Procedure code 58661 is billed with modifier 22 and medical records the claim will be pended for medical review for possible additional allowance. Procedure code 64726 52 (reduced Services) will be reimbursed at 50%. Procedure Code 64726 50 (bilateral) will be reimbursed at 150%. Standard Injection Infusion Administration Bundled Supplies, Always Bundle, and Global Surgery Laboratory and Venipuncture Services Technical/ Professional Modifiers Section Laboratory and Venipuncture Services, Technical/ Professional Modifiers TC/26 section. Modifier Rules Modifier 22 or Modifier Rules 11
Multiple Endoscopy Reductions Multiple endoscopic procedures in the same base family per for the same date of service have special multiple surgery reduction calculations. The secondary procedures are reimbursed at a rate less than 50%. Please refer to the UniCare Multiple Surgery for details. 29887 (RVU 21.95) 29873 (RVU 15.34) 29887 has the highest RVU and will be reimbursed at 100% of the allowed amount. 29873 has the lower RVU and will be reimbursed at 35% of the allowed amount. or UniCare Multiple Surgery This does not apply to UniCare Blue Cross Medicaid (MediCal, L.A. Care, MRMIP, P, AIM and Healthy Families). Multiple Surgery Reductions Maternity Visits When eligible multiple surgeries (having a Multiple procedure indicator of 2 or 3 on the National Physician Fee Schedule Relative value file) are billed for the same date of service a multiple surgery reduction is applied to the code with the lower valued RVU based on the date of Please refer to the policy for additional details. This pends the obstetrical delivery codes for a review of claim history. If E/M codes have been billed the same physician or group within the prenatal period for routine maternity diagnosis, the E/Ms after the initial visit will be denied and overpayments will be recouped. Codes 26433 and 26455 are billed for 07/01/2012. Code 26455 has a lower RVU per the RVU file for date of service 07/01/2012 and will be reimbursed at 50%. Code 99213 with date of service after the initial visit diagnosing pregnancy and prior to the delivery will be denied as included in the global obstetrical procedure allowance. Multiple Surgery Routine Obstetric Services Registered mark of WellPoint, Inc. 2012 WellPoint, Inc. 12