Subject: Claim Editing Overview IN, KY, MO, OH WI Policy: 0027 Effective: 01/01/2018 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed below. This reimbursement policy also applies to Employer Group Retiree Medicare Advantage programs. Description The Health Plan uses member benefits, Health Plan reimbursement policies, claim editing software such as McKesson Inc. s ClaimsXten and other proprietary software programs licensed from vendors for the majority of the claim editing in its adjudication of claims. Our claim editing software applies claim management rules in support of claim edits. These claim management rules are applied to Current Procedural Terminology (CPT ), Healthcare Common Procedure Coding System (HCPCS Level II), and International Classification of Diseases, 9 th Revision, Clinical Modifications (ICD-9-CM) or International Classification of Diseases, 10 th Revision, Clinical Modifications (ICD-10-CM) codes reported on a Form CMS-1500. The claim management rules assess the relationship of such codes to the rules. The edit(s) that is/are associated with a claim management rule causes an audit action on a claim that directs how procedure codes and procedure code combinations will be adjudicated. The edits associated with the claim editing software claim management rules identify, for example and without limitation: age; duplicate codes; incidental procedures; unbundled/rebundled procedures; mutually exclusive and/or redundant procedures; place, time and type of service; incorrect coding of specific codes; service utilization, such as the administration of anesthesia and/or use of an assistant surgeon; and services integrally related to a surgery (global surgery). A list of our claim editing software claim management rules that have been adopted by the Health Plan and their associated edits can be found in the policy section below. Line items denied by the claims editing systems may be found on the provider remittance. ClaimsXten can be identified by a four-digit disposition code. The second position of a ClaimsXten disposition code contains the letter X Our claim editing software programs also provides the editing tools to incorporate the administration of many of the Health Plan s reimbursement policies. The editing logic for the rules considers AMA/CPT coding guidelines, national specialty society and academy guidelines, the Centers for Medicare & Medicaid Services (CMS) coding guidelines, CMS IN, KY, MO, OH, WI 0027 Claims Editing Overview Page 1 of 11
national and local coverage determinations (NCD/LCDs), input from the physician consultants, and Health Plan guidelines. The Health Plan reserves the right to make customizations to the claim editing software packages. These customizations are made periodically (generally, on a quarterly basis) and may be based on claims analysis, including the identification of improper coding (e.g., inappropriate use of modifier 59). Policy I. Documentation and Reporting All claims submitted by a provider must be in accordance with the reporting guidelines and instructions contained in the American Medical Association (AMA) CPT codebook, cpt Assistant, HCPCS, ASA Relative Value Guide, and ICD-9-CM or ICD-10-CM publications. Providers are responsible for accurately reporting the medical, surgical, diagnostic, and therapeutic services rendered to a member with the correct CPT and/or HCPCS codes, and for appending the applicable modifiers, when appropriate. The code(s) and modifier(s) must be active for the date of service reported, and describe the services provided during the patient encounter. The member s medical records must legibly and accurately describe the services that warranted the use of a specific CPT /HCPCS code. The Health Plan reserves the right to perform audits or investigations to confirm appropriate reporting of services provided to our members and initiate recovery for inappropriate reimbursement. Based on audit findings and/or published reporting guidelines (for example, CPT guidelines), we may update our professional reimbursement policies and claims editing system. If a denial related to one of the rules listed below is received on a remit, please review the billing for the submitted claim or claim line prior to initiating an appeal. If an error in coding is detected, please correct the information and resubmit as needed. II. Claim Editing Software Changes The Health Plan implements the proprietary claim editing software changes (e.g., customization, updates, upgrades, and professional reimbursement policy changes) on a periodic basis. These changes will reflect the addition of new/revised CPT/HCPCS codes and the Health Plan s associated edits, Correct Coding Initiative (CCI) updates and/or revisions, and changes identified through the Health Plan s regular review or due to inquiry. Additionally, these changes will include edits associated with the Health Plan s professional reimbursement policies. Health Plan reserves the right to change our professional reimbursement policies and claim editing system without prior notice. III. Claim Editing Rules Many claim editing rules incorporate same provider editing which results in the denial of separate reimbursement for services rendered on the same day (or across dates of service for Pre-Op/Post Op days and Frequency Validation) by the same provider. This editing identifies same provider as any provider with the IN, KY, MO, OH, WI 0027 Claims Editing Overview Page 2 of 11
same tax identification number (TIN) or the individual provider identification number. Some rules that incorporate the same provider identification are: Always Bundled Services and Supplies and Supplies for Same Day Surgery Pre-Op/Post-Op Days Base Code Validation and Base Code Quantity Technical/Professional Component Billing Frequency Validation Bilateral and Endoscopic Surgical Billing Anesthesia The following is a list of many of the claim editing software rules adopted by the Health Plan. This list is subject to change from time to time. Also, where applicable, reference to a Health Plan reimbursement policy is indicated. This is not an exhaustive list of claim edits; refer to individual Health Plan reimbursement policies: Age Specific: identifies when an age-specific procedure code is reported for a patient whose age is outside the designated age range. In these instances, when an inconsistency is identified, the code(s) will not be eligible for reimbursement. Age to Diagnosis: identifies when an age-specific diagnosis code is reported for a patient whose age is outside the designated age range for that diagnosis. Codes with an age edit are identified in ICD-9-CM or ICD-10-CM by one of the following symbols to the right of the code description: N = Newborn age: 0 years, P = Pediatric age: 0-17years, M = Maternity age: 12-55 years, and A = Adult Age: 15-124 years. Anesthesia: identifies anesthesia services reported in the code range of 00100-01999 that are performed on the same date of service by the same provider. Editing for this rule is based on American Society of Anesthesiologists (ASA) billing guidelines which states: When multiple surgical procedures are performed during a single anesthetic administration, only the anesthesia code with the highest base unit value is reported. 1 If two anesthesia services are reported, the less complex procedure (s) will not be eligible for reimbursement. See our Anesthesia Services professional reimbursement policy Assistant Surgeon: identifies procedure codes with an assistant surgeon modifier appended that do not typically require an assistant. If the procedure code is listed in our Assistant Surgery Policy as a code which does not allow surgical assistant benefits, the line item will not be eligible for reimbursement. See our Assistant Surgery professional reimbursement policy Base Code Quantity: identifies a claim reporting a primary service with a base-code that has a quantity greater than one, rather than reporting the appropriate add-on code. The line item with the base code quantity greater than one will be denied and replaced with a line item that allows payment for only one procedure. This edit also identifies multiple occurrences of a base code reported on separate lines. The additional base code line item(s) will not be IN, KY, MO, OH, WI 0027 Claims Editing Overview Page 3 of 11
eligible for reimbursement. See CPT Appendix D for the list of add-on codes. See our Frequency Editing professional reimbursement policy Bilateral Surgical Billing: identifies when two claim lines are submitted with the same procedure code, and one line (or both lines) has been reported with modifier 50. When a bilateral surgical service is submitted on two lines, the two claim lines will be denied and replaced with a single line item with modifier 50 adding the charges. Reimbursement will be made for the added line. This rule is based on CMS and Health Plan guidelines. See our Multiple and Bilateral Surgery Processing professional reimbursement policy Bundled Services and Bundled Supplies: identifies certain services and supplies that are considered part of overall care and are not separately reimbursed. Editing for this rule is based on CMS, McKesson, proprietary software programs and Health Plan sourcing. For example: Always Bundled Services and Supplies: identifies all-inclusive procedure and supply codes that are not reimbursed even when reported alone. See our Bundled Services and Supplies professional reimbursement policy Bundled Services and Supplies: identifies services and/or supplies that are not eligible for reimbursement when billed with another specific service or supply. See our Bundled Services and Supplies professional reimbursement policy Same Day Screening Services with Preventive or Problem Oriented E/M Services: identifies screening services, (e. g., G0101, G0102) that are considered a component of a preventive exam and/or a problem oriented E/M service when rendered on the same date of service. Therefore, screening services are not eligible for reimbursement even if billed with modifier 25. Screening services should be taken into account when determining the correct level of the problem oriented E/M service. See our Screening Services with Evaluation and Management Services professional reimbursement policy Services and Supplies with Injection and Infusion Services: identifies services and supplies not eligible for separate reimbursement with injection and infusion services. See our Injection and Infusion Administration and Related Services & Supplies professional reimbursement policy. Supplies for Same Day Surgery: identifies inclusive supply codes that are reported by the same provider reporting a surgical 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. See our Global Surgery professional reimbursement policy Code and Modifier Validation: identifies if a code or modifier is valid. If an invalid procedure, diagnosis code, or modifier-procedure combination is detected, the line item will not be eligible for reimbursement. Procedure validation: editing for procedure code validation uses AMA as the reference source. Diagnosis code validation: ICD-9-CM or ICD-10-CM validation is based on the World Health Organization (WHO) and CMS when determining additional digit requirements (4 th and 5 th digit). IN, KY, MO, OH, WI 0027 Claims Editing Overview Page 4 of 11
Modifier to procedure code validation: editing for validation is based on CPT and CMS sourcing. See our Modifier Rules professional reimbursement policy. Correct Coding Initiative Rules: this rule identifies the CMS National Correct Coding Initiative (NCCI) edits. NCCI edits may be reviewed by visiting: http://www.cms.gov/medicare/coding/nationalcorrectcodinited/ncci-coding-edits.html. NCCI edits consist of those edits listed in the CMS Column One/Column Two Correct Coding edit file (formerly, the comprehensive/component edits). Column One in this edit file represents allowed codes; Column Two represents denied codes. CMS no longer publishes a separate Mutually Exclusive edit file. The edits previously contained in the Mutually Exclusive edit file have not been deleted but have been moved to the Column One/Column Two Correct Coding edit file. Non-site specific modifiers include 24, 25, 57, 58, 59, 78, 79, 91, XE, XP, XS, and XU: may override an NCCI edit with a superscript of 1 when appended to a code listed in column 2, making the column 2 code eligible for separate reimbursement will not override an NCCI edit with superscript of 0 when appended to a code listed in column 2 and therefore the column 2 code is not eligible for separate reimbursement NCCI edits will be applied to code pairs which, under our other reimbursement rules (such as procedure unbundling), might be eligible for separate reimbursement but under NCCI edits are considered incorrect coding, therefore, such code pairs are not eligible for separate reimbursement. NCCI edits will be adjudicated after our claim editing software s unbundling edits have been completed. Duplicate Line Items: identifies a line item as a duplicate submission of a previously submitted claim. Fields that are reviewed to determine duplication are Member ID, Provider ID, procedure code, date of service and billed amount. When the same procedure is performed more than one time per date of service, the subsequent procedure(s) must be reported on the same claim as the first procedure. Appropriate modifiers must be appended, when applicable. Durable Medical Equipment (DME) See our Durable Medical Equipment professional reimbursement policy: Identifies rental vs. purchase Tracks number of months an item has been rented (max 10 month rental) Looks at modifiers to determine if purchase or rental (modifiers are required to determine if item has been rented or purchased) Identifies items that are or are not eligible for repair or maintenance IN, KY, MO, OH, WI 0027 Claims Editing Overview Page 5 of 11
Frequency/Maximum Occurrences: identifies when a procedure code is reported more than once per date of service. or across dates of service which exceeds the number of times its verbiage indicates, when it exceeds the number of times it is clinically appropriate or possible to perform, or when a code that is listed on the CMS Medically Unlikely Edit (MUE) listing has a per day MUE Adjudication Indicator (MAI) of 2.. See our to Frequency Editing professional reimbursement policy When inappropriate units or line items are identified, our editing software will default multiple units to one unit; or deny the multiple line items, and replace the line with the appropriate number of units or a more comprehensive code. In the case of procedures that are allowed with more than one unit per date of service (DOS), the line item that exceeds the maximum units allowed per DOS will be denied and replaced with a new corrected line item showing the appropriate number of units. Laboratory Multi-code Rebundling: identifies when codes that are part of a comprehensive multiple component blood panel, described in the Laboratory section of CPT, are reported separately. Either the individual codes will be denied and the code representing the comprehensive blood panel code will be added to the claim for reimbursement; or the total amount eligible for reimbursement for the separately reported codes will not exceed the maximum allowance for the single comprehensive code. See our Laboratory and Venipuncture Services professional reimbursement policy Multiple Diagnostic Imaging Services: Diagnostic Radiology Imaging: identifies that when two or more imaging codes with multiple procedure indicator (MPI) of 4 are performed during the same imaging session reimbursement is 100% of the maximum allowance for the imaging procedure with the highest Relative Value Unit (RVU) based on the CMS National Physician Fee Schedule Relative Value File (NPFSRVF), and 50% of the maximum allowance for the technical component plus 100% of the maximum allowance for the professional component for each subsequent procedure eligible for separate reimbursement that has an MPI of 4. See our Multiple Diagnostic Imaging professional reimbursement policy Diagnostic Cardiology: identifies that when two or more diagnostic cardiology codes with a multiple procedure indicator (MPI) of 6 are performed during the same imaging session reimbursement is 100% of the maximum allowance for the imaging procedure with the highest Relative Value Unit (RVU) based on the CMS National Physician Fee Schedule Relative Value File (NPFSRVF), and 75% of the maximum allowance for the technical component only for each subsequent procedure that has an MPI of 6. See our Multiple Diagnostic Cardiovascular Procedures professional reimbursement policy. IN, KY, MO, OH, WI 0027 Claims Editing Overview Page 6 of 11
Diagnostic Ophthalmology: identifies that when two or more diagnostic ophthalmology codes with a multiple procedure indicator (MPI) of 7 are performed during the same imaging session, reimbursement is 100% of the maximum allowance for the imaging procedure with the highest Relative Value Unit (RVU) based on the CMS National Physician Fee Schedule Relative Value File (NPFSRVF), and 80% of the maximum allowance for the technical component only for each subsequent procedure that has an MPI of 7. See our Multiple Diagnostic Ophthalmology Procedures professional reimbursement policy. Multiple Endoscopies: identifies multiple endoscopic surgical procedures within the same family that are subject to multiple surgery reimbursement rules. Endoscopic surgical procedures in the same base family will be reimbursed at 100% of the maximum allowance for the primary procedure and at a lower percentage for each subsequent procedure based on the Health Plan s Multiple Surgery Policy. This will only happen when both endoscopic procedures are performed at the same operative session, with the same endoscopic base code as defined by CMS. See our Multiple and Bilateral Surgery Processing professional reimbursement policy. Multiple Evaluation and Management Services: identifies claim lines containing multiple E/M services (same or different E/M visit codes) provided on the same day, for the same patient, by the same provider. Only one E/M service is allowed per day. See our Evaluation and Management Services and Related Modifiers -25 and -57 professional reimbursement policy. Multiple Surgeries: identifies multiple surgical procedures that are subject to multiple surgery reimbursement rules. Standard multiple surgery reimbursement is 100% of the maximum allowance for the procedure with the highest RVU based on the CMS NPFSRVF for the date of service and 50% of the second highest RVU for the date of service for the second and each subsequent procedure. See our Multiple and Bilateral Surgery Processing professional reimbursement policy New Patient Evaluation and Management: identifies new patient E/M procedure codes that are submitted for established patients. According to the 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. 2. Based on this AMA guideline, when a professional service is identified as reported within the last three years by the same 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, the current new patient E/M code will not be eligible for reimbursement. Obstetric Services: identifies when a physician or other provider with the same tax ID has reported a routine maternity E/M or antepartum care service within 270 days of a global maternity delivery code. If detected, the additional E/M and antepartum care services may be ineligible for reimbursement based on CPT coding guidelines on what is included in the total obstetric package. See our Routine Obstetric Services professional reimbursement policy. IN, KY, MO, OH, WI 0027 Claims Editing Overview Page 7 of 11
Place of Service: identifies the reporting of an inappropriate place of service for a particular procedure, either due to the code description or due to published coding guidelines that indicate that a specific procedure is not intended to be reported in a certain setting. See our Place of Service professional reimbursement policy. For example: When an after-hours office visit (99050) is reported in a facility setting the service will not be eligible for reimbursement. When intravenous infusion hydration (96360) is reported in a facility setting, the service will not be eligible for reimbursement. Pre-Op/Post Op: identifies E/M visits that are reported one day prior to a 90 day surgical procedure or during the 10 or 90 day aftercare period. When the E/M code is reported within the global surgery period, then the E/M code will not be eligible for reimbursement. The E/M service will be denied as part of the global surgical reimbursement. See our Global Surgery professional reimbursement policy Note: For global obstetrical E/M services see our Routine Obstetric Services professional reimbursement policy Procedure to Diagnosis: identifies certain procedures that are not eligible for reimbursement with the reported diagnosis code in accordance with the Health Plan s reimbursement policy and/or correct coding guideline. For example: 99050 (services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to basic service) reported with a preventive diagnosis See our After Hours professional reimbursement policy 99140 (anesthesia complicated by emergency conditions) reported with a routine pregnancy and/or delivery diagnosis See our Anesthesia Services professional reimbursement policy. 96150 96154 (health and behavior assessment or intervention) reported with a diagnosis classified as a mental disorder See our Health and Behavior Assessment/Intervention professional reimbursement policy 64450, 64640, and 20550 reported with a diagnosis of lesion of plantar nerve (Morton s Neuroma) 50590 (lithotripsy, extracorporeal shock wave) reported with a diagnosis other than calculus of the kidney, calculus of the ureter, or unspecified urinary calculus 22206, 22207 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, and 22226 (spinal osteotomy) reported with a diagnosis other than kyphosis or scoliosis In addition, please see our Prolonged Services professional reimbursement policy for a list of diagnosis codes that are eligible for reimbursement when reported with CPT codes 99354 and 99355. IN, KY, MO, OH, WI 0027 Claims Editing Overview Page 8 of 11
Procedure Unbundling: 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. In some instances, the codes may be replaced with the more appropriate code by our editing system. Additional details regarding unbundling rules are described by the following edits. 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 separate reimbursement. Procedure Rebundling: identifies unbundled procedure codes used to describe a procedure (e.g. a blood panel) when a single more comprehensive code exists. The correct procedure code that most accurately represents the service will be added to the claim. The identified unbundled procedures will be denied, and the appropriate added code may be eligible for reimbursement. For blood panel rebundling, see our Laboratory and Venipuncture services professional reimbursement policy Same Day Medical Visit: identifies when an E/M visit is reported on the same day as a surgical or substantial diagnostic or therapeutic (such as dialysis, chemotherapy and osteopathic manipulative treatment) procedure by the same provider. Our reimbursement policies state that when the same provider reports an E/M visit and a procedure on the same day the E/M service is included within the global reimbursement for the procedure. See our Global Surgery professional reimbursement policy Technical/Professional Component Billing: identifies proper coding of professional, technical, and global procedures. Modifier 26 signifies the professional component and Modifier TC signifies the technical component. When the CMS NPFSRVF designates that modifier 26 is applicable to a procedure code (PC/TC indicator of 1 or 6), and the procedure code (e.g. radiology, laboratory, or diagnostic) has been reported by a professional provider with a facility place of service, the procedure code must be reported with modifier 26 or it will not be eligible for reimbursement. When the CMS 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 a professional provider has reported the laboratory procedure code with a modifier 26, the laboratory procedure code will not be eligible for reimbursement. When a laboratory procedure with a PC/TC indicator of 3 or 9 is reported by a professional IN, KY, MO, OH, WI 0027 Claims Editing Overview Page 9 of 11
provider with a facility place of service, the laboratory procedure code will be denied since the facility will bill for performing the laboratory procedure. A global procedure code includes reimbursement for both the professional (PC) and technical components (TC) therefore: When both components are performed by the same provider or by associated providers within the same group/tin, the appropriate code must be reported without the 26/TC modifiers. When a provider reports a global procedure and the same procedure with a professional (26) or technical (TC) component modifier on a different line or claim, the procedure reported with component modifier will not be eligible for reimbursement. When a provider reports the global code (no modifiers) with a facility place of service, the code will not be eligible for reimbursement. In addition, when one provider reports a global procedure and a different provider reports the same procedure with a professional (26) or technical (TC) component modifier, the first charge processed by the Health Plan will be eligible for reimbursement and the subsequent charge processed will not be eligible for separate reimbursement. Clear Claim Connection TM : For informational purposes, a web-based tool called Clear Claim Connection TM developed by McKesson Health Solutions is available on the Health Plan s secure Online Provider Services web site. This claims editing tool allows the provider to enter a specific coding scenario and view the editing results in place on the date of the inquiry (not the actual claim date of service). If a denial is issued for the coding scenario, the clinical rationale for the denial is usually provided. The results of a coding inquiry may differ from the results of an actual claim payment since a claim may be affected by system edits outside of ClaimsXten (e.g., member eligibility, or other claim processing and/or pricing logic). For example, the Health Plan s standard multiple surgery reimbursement processing is performed by our claim editing system and not by ClaimsXten; therefore, a Clear Claim Connection inquiry may not reflect the same primary and subsequent procedure ranking. IV. Definitions: Customized Claim Edit: A customized claim edit is an edit that is added or modified for the commercially available claims editing software product in use by the Health Plan. The Health Plan uses ClaimsXten and proprietary software programs licensed vendors as our editing systems. Editing: The practice or procedure pursuant to which one or more adjustments are made to CPT codes or HCPCS codes included in a claim that result in: payment being made based on some, but not all, of the CPT/HCPCS codes included in the claim payment being made based on different CPT/HCPCS codes than those included in the claim IN, KY, MO, OH, WI 0027 Claims Editing Overview Page 10 of 11
payment for one or more of the CPT/HCPCS codes included in the claim being lowered by application of multiple procedure logic payment for one or more of the CPT/HCPCS codes being denied, or any combination of the above History Editing: identifies historical claims that are related to current claim submissions, resulting in adjustments to the previously processed historical claim(s). History editing capability can auto-adjudicate reimbursement policies including, but not limited to: global surgery, same day multiple E/M visits, pre/post-operative visits, new patient visits, frequency rules, incidental, mutually exclusive and rebundle edits and maternity services. For example: When reimbursement is made for an E/M visit code submitted on one claim, and then another claim is submitted with a surgical code for the same date of service, history editing may identify the paid E/M visit code as part of the global surgical allowance. An adjustment of the E/M claim is made for overpayment recovery. Significant Edit: An edit that, based on experience with submitted claims, will cause, on initial review of submitted claims, the denial or reduction in payment for a particular CPT/ HCPCS code more than twohundred and fifty (250) times per year in any state in which Health Plan operates. 1 2013 Relative Value Guide, 2012 American Society of Anesthesiologists, pg. xi 2 Current Procedural Terminology, cpt 2017 Professional Edition, pg. 1 ClaimsXten is a registered trademark of McKesson Information Solutions LLC CPT is a registered trademark of the American Medical Association Clear Claim Connection TM is a registered trademark of McKesson Information Solutions LLC Use of Reimbursement Policy: This policy is subject to federal and state laws, to the extent applicable, as well as the terms, conditions, and limitations of a member s benefits on the date of service. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Anthem Blue Cross and Blue Shield. 2017 Anthem Blue Cross and Blue Shield IN, KY, MO, OH, WI 0027 Claims Editing Overview Page 11 of 11