June 23, 2020 Network in the Know

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 CodeDescriptionPaid CodeDescription
28100Removal of Ankle/Heel Lesion29898Ankle arthroscopy/Surgery
27635Remove Lower Leg Bone Lesion29898Ankle arthoscopy/Surgery
11103Tangntl Bx Skin Ea Sep/Addl17110Destruct B9 Lesion 1-14
36012Place Catheter in Vein00560
Anesth Heart Surg w/o Pump
Anesth Hrt Surg w/ PMP Age 1+
21615Removal of Rib64713Revision of Arm Nerve(s)
49650Lap Ing Hernia55866Laparo Radical Prostatectomy


Denied CodeDescriptionPaid CodeDescription
Tangtnl Bx Skin Ea Sep/Addl
Incal Bx Skn Ea Sep/Addl
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

Alexa Kerins
About the Author

Alexa is a senior communications consultant at CDPHP who plans, writes, and edits communications for a variety of projects. She is an eternal optimist who likes good food, fun exercise classes, traveling, and spending quality time with her family and friends. You can often find her obsessing over her mini golden doodle and uttering cheesy quotes like “you’re the bee’s knees” and “team work makes the dream work."

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