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

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.