September 24, 2021 Network in the Know

Summary of new code auditing changes September 2021

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.

  • CCI v27.2 and OCE_CCI v27.2 additions, deletions and changes including when modifier overrides are allowable per CMS guidelines.
  • New patient evaluation and management visit codes will now deny when reported on the same day as a minor surgical procedure with a 0 global period. Modifier 25 will allow the new patient evaluation and management visit when a separate and distinct service was provided.
  • CPT® 86328 will no longer be valid with modifier QW.

New:  Outpatient Facility claims

Denied CodeDescriptionPaid CodeDescription
87798Detect Agent NOS DNA Amp0202UNfct DS 22 Trgt SARS-COV-2
87801Detect Agnt Mult DNA Ampli0202UNfct DS 22 Trgt SARS-COV-2
87804Influenza Assay W/optic0202UNfct DS 22 Trgt SARS-COV-2
U0002COVID-19 Lab Test Non-CDCU00012019-Ncov Diagnostic P
U0004COV-19 Test Non-CDC Hgh ThruU0001, U0002, U00032019-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
1-800-926-7526.

Karen Faxon
About the Author

Karen Faxon is a registered nurse and certified coder who joined the CDPHP® workforce in 1996. Since then, Karen has worn many hats at CDPHP. Currently, she is a Senior Clinical Configuration analysis ensuring integrity of clinical codes and code auditing software. On weekends, you can often find her gardening or walking her two dogs, Tilly and Jazzy.

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