Quarterly, Capital District Physicians’ Health Plan, Inc. (CDPHP®) implements appropriate code-auditing changes to remain current with industry standards. 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 coding system.
As a result, you may notice differences in how your claims process related to changes in code pairs in CCI; 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 postoperative periods as defined by CMS; and other standard coding edits.
The July 2019 changes are taking effect for claims processed on or after October 23, 2019. Among the most recent changes are the following (which is not an all-inclusive list):
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 you 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.