December 28, 2020 Network in the Know

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 CodeDescriptionPaid CodeDescription
73565X-ray Exam of Knees73562X-ray Exam of Knee 3

End Dated

Denied CodeDescriptionPaid CodeDescription
73562X-ray Exam of Knee 373565X-ray Exam of Knees

Source: CCI v26.3 Addition and Changes: Modifier overrides follow CMS guidelines.

New

Denied CodeDescriptionPaid CodeDescription
73565X-ray Exam of Knees73562X-ray Exam of Knee 3

End Dated

Denied CodeDescriptionPaid CodeDescription
73562X-ray Exam of Knee 373565X-ray Exam of Knees

Source: OCE_CCI v26.3 Addition and Changes: Modifier overrides follow CMS guidelines

New

Denied CodeDescriptionPaid CodeDescription
26055Incise Finger Tendon Sheath26160Remove Tendon Sheath Lesion
93290Interrog Dev Eval ICPMS IP93282, 93283, 93284, 93285Prgrmg Eval Implantable Dfb, Prgrmg Dev Eval Scrms IP

Source:  CMS

End Dated

Denied CodeDescriptionPaid CodeDescription
26160Remove Tendon Sheath Lesion26055Incise 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).  

Adele O'Connell
About Author

Adele joined CDPHP in 2004 as an internal communications and event specialist. She then spent eight years coordinating the company’s community relations and corporate events program, in which capacity she worked with a host of non-profit organizations and co-chaired the CDPHP annual Charity of Choice campaign. Currently, she is a communications specialist and coordinator of corporate member engagement and serves on the boards of two local charities. Prior to CDPHP, Adele served as a legislative assistant for a trade association and as an acquisitions and developmental editor, specializing in educational and medical publishing. She earned a bachelor’s degree in English from Rosemont College.

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