First-Quarter 2021 Coding Changes Announced

Quarterly, Capital District Physicians’ Health Plan, Inc. (CDPHP^®) implements appropriate code auditing changes to remain current with industry standard coding updates. Updates to Change Healthcare Technologies, LLC ClaimsXten™, our code auditing software, are based on recommendations from a variety of sources, including the American Medical Association (AMA), Centers for Medicare and Medicaid Services (CMS) Correct Coding Initiative and Medically Unlikely Edits, input from specialty organizations, the CPT^® manual, and the HCPCS Level II manual.

As a result, you may notice differences in how your claim processes related to changes in code pairs in CCI, which includes modifier override changes; daily frequency limits; incidental, mutually exclusive and unbundled code edits; assistant surgeon eligibility; modifier to procedure compatibility; evaluation of incomplete diagnosis; global surgery pre-operative and post-operative periods as defined by CMS; and other standard coding code edits.

The January 2021 changes are taking effect for claims processed on or after April 21, 2021. Below is a high level summary of some of the changes. This is not an all-inclusive list.

Additional changes include:

• Numerous updates due to the release of January 1, 2021 CPT® and HCPCS code additions, changes, and deletions. These include end dating CPT^® code 99201, as well as updates to the Evaluation and Management for CPT^® codes 99202-99215 and prolonged visit codes.

• CCI v27.0 and OCE_CCI V27.0 additions, deletions, and changes, including when modifier overrides are allowable per Centers for Medicare and Medicaid Services (CMS) guidelines.

• CMS updates to the allowable list of procedures that can be reported with modifier CS.

For reference to the ClaimsXten rules currently in place and significant customization, please refer to the Code Auditing Rules and Customization, 1550/20.000162 payment policy. 

As a reminder, Clear Claim Connection is available on the CDPHP Secure Provider Portal. There you can find information regarding code auditing logic. This claims editing tool allows providers to enter a specific coding scenario and view the editing results in place on the date of the inquiry (not on the actual claim date of service). If a denial is issued for the coding scenario, the rationale for the denial is provided. The results of a coding inquiry may differ from the results of an actual claim payment as a claim may be affected by system edits outside of ClaimsXten (e.g., member eligibility, or other claim processing and/or pricing logic).  

Should you have any questions, please call the CDPHP provider services department at (518) 641-3500 or 1-800-926-7526.