October 2019 Code Auditing Changes

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; 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 October 2019 changes take effect for claims processed on or after December 23, 2019. Below is just one of the changes. This is not an all-inclusive list.

• Updates related to the 10/1/2019 quarterly code release of CPT®, HCPCS and ICD-10 codes.

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.