April 2020 Code Auditing Changes (Effective April 8)

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 Medicaid and Medicare 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 include 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 January 2020 changes are taking effect for claims processed on or after April 8, 2020. Below is a high-level summary of some of the changes, including updated code auditing rules related to existing codes, as well as the January 1, 2020 code release of CPT® and HCPCS. This is not an all-inclusive list.

CCI and OCE_CCI v26.0 Addition and Changes:

• 12011 (12011 RPR F/E/E/N/L/M 2.5 CM/<) will no longer deny when reported with 12001 (RPR S/N/AX/GEN/TRNK 2.5CM/<).  12001 will now deny when reported with 12011.
• 12041 (INTMD RPR N-HF/GENIT 2.5CM/<) will no longer deny when reported with 12031 (INTMD RPR S/A/T/EXT 2.5 CM/<). 12031 will now deny when reported with 12041.
• 12051 (INTMD RPR FACE/MM 2.5 CM/<) will no longer deny when reported with 12041 (INTMD RPR N-HF/GENIT 2.5CM/<. 12041 will now deny when reported with 12051.
• 19281 (PERQ DEVICE BREAST 1ST IMAG) will now deny when reported with 19318 (REDUCTION OF LARGE BREAST).
• 31291 NASAL/SINUS ENDOSCOPY SURG will now deny when reported with any of the following codes:  31253 NSL/SINS NDSC TOTAL, 31254 NSL/SINS NDSC W/PRTL ETHMDCT, 31255 NSL/SINS NDSC W/TOT ETHMDCT, 31257 NSL/SINS NDSC TOT W/SPHENDT, and 31259 NSL/SINS NDSC SPHN TISS RMVL.
• 35701 (EXPL N/FLWD SURG NECK ART) will now deny when reported with any of the following codes: 15756 FREE MYO/SKIN FLAP MICROVASC, 15757 FREE SKIN FLAP MICROVASC, 15758 FREE FASCIAL FLAP MICROVASC, 20955 FIBULA BONE GRAFT MICROVASC, 20956 ILIAC BONE GRAFT MICROVASC, 20957 MT BONE GRAFT MICROVASC, 20962 OTHER BONE GRAFT MICROVASC, 20969 BONE/SKIN GRAFT MICROVASC, 20970 BONE/SKIN GRAFT ILIAC CREST, 20972 BONE/SKIN GRAFT METATARSAL, 20973 BONE/SKIN GRAFT GREAT TOE, 43496 FREE JEJUNUM FLAP MICROVASC, and 49906 FREE OMENTAL FLAP MICROVASC.
• 78195 (LYMPH SYSTEM IMAGING) will now deny when reported with 78803 (RP LOCLZJ TUM SPECT 1 AREA).
• 78802 (RP LOCLZJ TUM WHBDY 1 D IMG) will now deny when reported with 78803 (RP LOCLZJ TUM SPECT 1 AREA).
• 93000 (ELECTROCARDIOGRAM COMPLETE) will now deny when reported with G0442 ANNUAL ALCOHOL SCREEN 15 MIN, G0443 BRIEF ALCOHOL MISUSE COUNSEL, G0444 DEPRESSION SCREEN ANNUAL, and G0445 HIGH INTEN BEH COUNS STD 30M. Appropriate modifiers will override the edit if the services are deemed separate and distinct.
• 93297 (REM INTERROG DEV EVAL ICPMS) will now deny when reported with 93295 DEV INTERROG REMOTE 1/2/MLT and 93296 REM INTERROG EVL PM/IDS.
• 93298 (REM INTERROG DEV EVAL SCRMS) will now deny when reported with 93926 (REM INTERROG EVL PM/IDS).
• 97140 MANUAL THERAPY 1/> REGIONS will now deny when reported with 97161 PT EVAL LOW COMPLEX 20 MIN, 97162 PT EVAL MOD COMPLEX 30 MIN, 97163 PT EVAL HIGH COMPLEX 45 MIN, 97165 OT EVAL LOW COMPLEX 30 MIN, 97166 OT EVAL MOD COMPLEX 45 MIN,  and 97167 OT EVAL HIGH COMPLEX 60 MIN.
• 97161 PT EVAL LOW COMPLEX 20 MIN, 97162 PT EVAL MOD COMPLEX 30 MIN, 97163 PT EVAL HIGH COMPLEX 45 MIN, 97164 PT RE-EVAL EST PLAN CARE, 97165 OT EVAL LOW COMPLEX 30 MIN, 97166 OT EVAL MOD COMPLEX 45 MIN, 97167 OT EVAL HIGH COMPLEX 60 MIN, 97168 OT RE-EVAL EST PLAN CARE will now deny when reported with 99281 EMERGENCY DEPT VISIT, 99282 EMERGENCY DEPT VISIT, 99283 EMERGENCY DEPT VISIT, 99284 EMERGENCY DEPT VISIT and 99285 EMERGENCY DEPT VISIT.
• G0442 ANNUAL ALCOHOL SCREEN 15 MIN, G0443 BRIEF ALCOHOL MISUSE COUNSEL and G0445 HIGH INTEN BEH COUNS STD 30M will now deny when reported with a vaccine administration procedures.  Appropriate modifiers will override the edit if the services are deemed separate and distinct.

For OCE_CCI v26.0 Addition and Changes:

• 17000 (DESTRUCT PREMALG LESION) will now deny when reported with 11102 (TANGNTL BX SKIN SINGLE LES).

Other Code Auditing, AMA CPT^®:

• 77003 (FLUOROGUIDE FOR SPINE INJECT) will now deny when reported with 62270 (DX LMBR SPI PNXR) or 62272 (THER SPI PNXR DRG CSF).
• 93290 (INTERROG DEV EVAL ICPMS IP) will now deny when reported with 93260 PRGRMG DEV EVAL IMPLTBL SYS, 93282 PRGRMG EVAL IMPLANTABLE DFB, 93283 PRGRMG EVAL IMPLANTABLE DFB, 93284 PRGRMG EVAL IMPLANTABLE DFB and 93285 PRGRMG DEV EVAL SCRMS IP.

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 Connections 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.