Code auditing changes effective June 15, 2022

For claims processed on or after June 15, 2022, you may notice differences 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. Here is a high level summary of some of the changes. This is not an all-inclusive list.

• Numerous updates due to the release of April 1, 2022 CPT® and HCPCS codes additions, changes and deletions.

CCI v28.1 and OCE_CCI v28.1 additions, deletions, and changes including when modifier overrides are allowable per CMS guidelines.

For professional claims, Modifier FT – Unrelated evaluation and management (E/M) visit on the same day as another E/M visit or during a global procedure (preoperative, postoperative period, or on the same day as the procedure, as applicable): Modifier FT should only be reported with critical care visits 99291 and 99292 provided by the surgeon during the global period when the critical care visits are unrelated to the procedure or surgical procedure performed, or when one or more additional evaluation and management services are provided on the same day during the global period and are unrelated.

For professional claims, Modifier 78 – Return Trips to the Operating Room During the Postoperative Period: For codes valid with modifier 78, procedures assigned as zero day, XXX, YYY, and ZZZ procedures will have an intraoperative value of 1.0 and will be sourced to CMS.

For reference to the claims-processing 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. 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. 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 other factors, such as member eligibility or other claim processing and/or pricing logic.

For more information, please call CDPHP Provider Services at (518) 641-3500 or 1-800-926-7526.