June 11, 2021 Network in the Know

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 CodeDescriptionPaid CodeDescription
87426Sarscov Coronavirus Ag Ia87635 87636 87637Sars-Cov-2 Covid-19 Amp Prb, Sarscov2 & Inf A & B Amp Prb, Sarscov2 & Inf A & B & Rsv Amp Prb
87811Sars-Cov-2 Covid19 W/Optic0240U 0241U 87428 87636 87637Nfct 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 CodeDescriptionPaid CodeDescription
92250Photography of the Retina92201Extended Examination of Eye with Drawing Of Retina
92250Photography of the Retina92202Extended Examination of Eye with Drawing of Optic Nerve and Surrounding Area (Macula)


Denied Code
DescriptionPaid CodeDescription
92201Extended Examination of Eye with Drawing of Retina92250Photography of the Retina
92202Extended Examination of Eye with Drawing of Optic Nerve and Surrounding Area (Macula)92250Photography 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

CPT® is a registered trademark of the American Medical Association.

Karen Faxon
About the Author

Karen Faxon is a registered nurse and certified coder who joined the CDPHP® workforce in 1996. Since then, Karen has worn many hats at CDPHP. Currently, she is a Senior Clinical Configuration analysis ensuring integrity of clinical codes and code auditing software. On weekends, you can often find her gardening or walking her two dogs, Tilly and Jazzy.

2 Responses to “Code Auditing Changes Effective June 16, 2021”

  1. 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.

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