July 2020 Code Auditing Changes

Effective September 9, 2020

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 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.

The July 2020 changes are taking effect for claims processed on or after September 9, 2020. Below is a high level summary of some of the changes. This is not an all-inclusive list. It includes updates related to the 07/01/2020 quarterly code release of CPT®, HCPCS, and ICD-10 codes, including the updates to the Medically Unlikely Edits by CMS on covered telehealth services as a result of the COVID-19 pandemic.

CCI and OCE_CCI v26.1 Addition and Changes: Modifier Overrides Follow CMS Guidelines

New

Deleted

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.