The Daily Dose
Code Auditing Changes Effective June 16, 2021
Quarterly, Capital District Physicians’ Health Plan, Inc. (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 preoperative and postoperative periods as defined by CMS; and other standard coding code edits.
The April 2021 changes are taking effect for claims processed on or after June 16, 2021. Below is a high level summary of some of the changes. This is not an all-inclusive list.
- CCI v27.1 and OCE_CCI V27.1 additions, deletions and changes, including when modifier overrides are allowable per CMS guidelines.
New: Professional claims
| Denied Code | Description | Paid Code | Description |
| 87426 | Sarscov Coronavirus Ag Ia | 87635 87636 87637 | Sars-Cov-2 Covid-19 Amp Prb, Sarscov2 & Inf A & B Amp Prb, Sarscov2 & Inf A & B & Rsv Amp Prb |
| 87811 | Sars-Cov-2 Covid19 W/Optic | 0240U 0241U 87428 87636 87637 | Nfct Ds Vir Resp Rna 3 Trgt, Nfct Ds Vir Resp Rna 4 Trgt, Sarscov & Inf Vir A & B Ag Ia, Sarscov2 & Inf A & B Amp Prb, Sarscov2 & Inf A & B & Rsv Amp Prb |
Source: Health Plan Policy Edits
End Dated
| Denied Code | Description | Paid Code | Description |
| 92250 | Photography of the Retina | 92201 | Extended Examination of Eye with Drawing Of Retina |
| 92250 | Photography of the Retina | 92202 | Extended Examination of Eye with Drawing of Optic Nerve and Surrounding Area (Macula) |
New
Denied Code | Description | Paid Code | Description |
| 92201 | Extended Examination of Eye with Drawing of Retina | 92250 | Photography of the Retina |
| 92202 | Extended Examination of Eye with Drawing of Optic Nerve and Surrounding Area (Macula) | 92250 | Photography of the Retina |
Source: AMA CPT®
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.
Christine Gattuso
Wondering will CDPHP continue with mental health telehealth reimbursement? And, is there a date that essential workers will have to resume paying copays?
Karen Faxon
Hi Christine, CDPHP will continue offering no-cost telehealth services for most plans until June 30, 2021. In accordance with NYS guidance, cost-share will resume under most plans beginning July 1, 2021.