The Daily Dose
Code Auditing Changes Effective January 6, 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 October 2020 changes are taking effect for claims processed on or after Wednesday, January 6, 2021. Below is a high level summary of some of the changes. This is not an all-inclusive list.
In addition to updates related to the 10/01/2020 quarterly code release of CPT®, HCPCS and ICD-10 codes, this update includes the reinstatement of numerous Medically Unlikely Edits (professional and facility claims), CCI (professional claims) and OCE_CCI (outpatient facility) code pair edits by CMS related to telehealth services in place prior to the COVID-19 PHE.
New
| Denied Code | Description | Paid Code | Description |
| 73565 | X-ray Exam of Knees | 73562 | X-ray Exam of Knee 3 |
End Dated
| Denied Code | Description | Paid Code | Description |
| 73562 | X-ray Exam of Knee 3 | 73565 | X-ray Exam of Knees |
Source: CCI v26.3 Addition and Changes: Modifier overrides follow CMS guidelines.
New
| Denied Code | Description | Paid Code | Description |
| 73565 | X-ray Exam of Knees | 73562 | X-ray Exam of Knee 3 |
End Dated
| Denied Code | Description | Paid Code | Description |
| 73562 | X-ray Exam of Knee 3 | 73565 | X-ray Exam of Knees |
Source: OCE_CCI v26.3 Addition and Changes: Modifier overrides follow CMS guidelines
New
| Denied Code | Description | Paid Code | Description |
| 26055 | Incise Finger Tendon Sheath | 26160 | Remove Tendon Sheath Lesion |
| 93290 | Interrog Dev Eval ICPMS IP | 93282, 93283, 93284, 93285 | Prgrmg Eval Implantable Dfb, Prgrmg Dev Eval Scrms IP |
Source: CMS
End Dated
| Denied Code | Description | Paid Code | Description |
| 26160 | Remove Tendon Sheath Lesion | 26055 | Incise Finger Tendon Sheath |
Source: CMS
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).
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