The Daily Dose
April 2020 Code Auditing Changes
Every quarter CDPHP® implements appropriate code auditing changes to remain current with industry standard coding updates. Updates are made to our code auditing software Change Healthcare Technologies, LLC ClaimsXten™ 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 April 2020 changes are taking effect for claims processed on or after July 15, 2020. Below is a high level summary of some of the changes. This is not an all-inclusive list.
Updates are related to the 04/01/2020 quarterly code release of CPT®, HCPCS and ICD-10 codes, including the removal of CCI edits by CMS on covered telehealth services as a result of the COVID-19 pandemic.
Other CCI and OCE_CCI v26.1 Addition and Changes: Modifier overrides follow CMS guidelines.
| Denied Code | Description | Paid Code | Description |
|---|---|---|---|
| 28100 | Removal of Ankle/Heel Lesion | 29898 | Ankle arthroscopy/Surgery |
| 27635 | Remove Lower Leg Bone Lesion | 29898 | Ankle arthoscopy/Surgery |
| 11103 | Tangntl Bx Skin Ea Sep/Addl | 17110 | Destruct B9 Lesion 1-14 |
| 36012 | Place Catheter in Vein | 00560 00562 | Anesth Heart Surg w/o Pump Anesth Hrt Surg w/ PMP Age 1+ |
| 21615 | Removal of Rib | 64713 | Revision of Arm Nerve(s) |
| 49650 | Lap Ing Hernia | 55866 | Laparo Radical Prostatectomy |
CMS:
| Denied Code | Description | Paid Code | Description |
|---|---|---|---|
| 11103 11107 | Tangtnl Bx Skin Ea Sep/Addl Incal Bx Skn Ea Sep/Addl | 17311 17312 17313 17314 17315 | MOHS 1 Stage H/N/HF/G MOHS Addl Stage MOHS 1 Stage T/A/L MOHS Addl Stage T/A/L MOHS Surg Addl Block MOHS 1 Stage T/A/L |
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).
If you have any questions, please call the CDPHP provider services department at (518) 641-3500 or 1-800-926-7526.
CPT® is a registered trademark of the American Medical Association
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