For claims processed on or after September 22, 2021, you may notice differences 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.
Here is a high level summary of some of the changes. This is not an all-inclusive list.
New: Outpatient Facility claims
|Denied Code||Description||Paid Code||Description|
|87798||Detect Agent NOS DNA Amp||0202U||Nfct DS 22 Trgt SARS-COV-2|
|87801||Detect Agnt Mult DNA Ampli||0202U||Nfct DS 22 Trgt SARS-COV-2|
|87804||Influenza Assay W/optic||0202U||Nfct DS 22 Trgt SARS-COV-2|
|U0002||COVID-19 Lab Test Non-CDC||U0001||2019-Ncov Diagnostic P|
|U0004||COV-19 Test Non-CDC Hgh Thru||U0001, U0002, U0003||2019-Ncov Diagnostic P, COVID- Lab Test Non-CDC, COV-19 Test Non-CDC Hgh Thru|
Source: OCE_CCI v27.2
For reference to the claims-processing 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. 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. 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 other factors, such as member eligibility or other claim processing and/or pricing logic.
For more information please call CDPHP Provider Services at (518) 641-3500 or