Clinical Editing Coding

Clinical Editing of Claims

To ensure that the Plan is processing claims in compliance with general industry standards, the Plan utilizes edits for claims coding verification. The Plan’s adjudication edits are based on the following guidelines, as applicable: MassHealth regulations, medical specialty societies, Center for Medicare and Medicaid Services (CMS), National Correct Coding Initiative (NCCI), and the American Medical Association (AMA), standards accepted by the coding industry and applied in Plan policies. These edits are an integral part of our claims system and are designed to ensure consistent processing of professional claims and decrease manual intervention. Using a comprehensive set of rules, the Plan provides consistent and objective claims review by:

• Accurately applying coding criteria for the clinical areas of medicine, surgery, laboratory, pathology, radiology, and anesthesiology as outlined by the AMA’s CPT-4 manual.
• Detecting and documenting coding inaccuracies including, but not limited to: unbundling, place of service and procedure, provider and procedure, global days, duplicate coding, invalid/unlisted codes, incorrect procedures submitted for member’s age or gender, and mutually exclusive procedures.
• Following CMS general and specific guidelines for correct coding.

Some of the more common claims coding edits are listed below.

Assistant Surgeon

The Plan provides assistant surgeon guidelines for all procedure codes. These guidelines identify procedures that require the skills of an assistant surgeon, procedures that never require the skills of an assistant surgeon when performed, and procedures that may require skills of an assistant surgeon under medically complex circumstances. Services identified by industry standards as not needing an assistant surgeon will receive a denial on the remittance advice indicating that an assistant surgeon is not required in the performance of the procedure. Payment for some services that may require the skills of an assistant surgeon under medically complex circumstances may be made after review of operative notes and documentation.

Cosmetic Procedures

The Plan does not cover cosmetic procedures. See Plan policy #OCA: 3.69 for coverage criteria specific to cosmetic procedures that may be covered when performed for medical necessity reasons.

Extreme Age

The Plan will deny procedures that are not appropriate for the member’s age is in the extreme age range. An example of an age edit is when a procedure code lists an age range and the patient’s age is outside of the applicable age range.

Global Days

The term “global” refers to those services that have been bundled into payment for the procedure billed. The Plan has assigned specific global days to the majority of the surgical procedure codes listed in the CPT-4 manual. The remaining procedural codes have not been assigned a global period. The global surgical edit complies with industry standards. The Plan will deny evaluation and management (E&M) services billed during the global surgery period; E&M services are considered part of the global surgical package based on the Plan’s established global periods for surgical procedures. A global period begins one day prior to the procedure and continues for the number of days assigned to the procedure.

Gender (Procedural)

The Plan will deny procedures that are not appropriate for the member’s gender. An example of a gender edit is billing for a hysterectomy on a male patient.

Gender (Diagnosis)

The Plan has enhanced this edit to include claims submitted with specific diagnosis coding that is only applicable to one gender. For example, a diagnosis of pregnancy would not be payable for a male member.

Investigational and/or Experimental Procedures

The Plan denies procedures that are considered investigational and/or experimental based on an assessment of the research and literature. As new technologies arise, the Plan considers each of them on an individual basis, and will issue a determination as to whether or not a procedure is considered investigational and/or experimental. Determinations will be issued in the form of clinical policies, and are based upon many factors, including, but not limited to, clinical evidence, industry standards and FDA approval.

Multiple Surgery

Multiple surgery review is based on Plan guidelines. The full maximum allowable fee will be paid for the primary procedure, and 50 percent of the maximum allowable fee will be paid for each additional procedure. The primary procedure is identified as the procedure with the highest allowable reimbursement rate according to the Plan’s fee schedule. Multiple surgery reduction of payment is not dependent on the submission of correct modifiers by providers.

Inappropriate Modifier Combination

This edit validates the appropriateness of modifier combinations that cannot be billed together. When an inappropriate combination has been submitted, the claim will be denied for resubmission with the correct modifier. Modifier relationships are based on publications from the Centers for Medicare & Medicaid (CMS) and the American Medical Association, CPT Professional and Standard Editions.

Place of Service

The place of service edit indicates the typical place of service (inpatient, outpatient, or both) associated with a procedure. It is designed to reflect a generally accepted level of efficient resource utilization. Claims that do not comply with the place of service edit will be denied. An example of this edit would be the billing of a surgical procedure in a pharmacy place of service.

Unbundling

This edit compares CPT codes to find procedures that should not be submitted together. Unbundling is the act of billing CPT codes that are components of other CPT codes. Unbundling can either be incidental (procedures that are not essential to complete the procedure) or mutually exclusive (related procedures). Depending on the particular code combination, the Plan will deny one or more of the related codes.

• U = Unbundling/Rebundling Certain codes represent procedures that are basic steps necessary to accomplish the primary procedure and are, by definition, included in the reimbursement of that primary procedure. Unbundling is inappropriately billing more CPT/HCPCS codes than necessary. Rebundling is inappropriately billing additional services that are components of or inclusive to a more comprehensive procedure performed in the same session by the same provider.
  
  For example: Laboratories should bill CPT code 80048 (Basic metabolic panel), when coding for a calcium, carbon dioxide, chloride, creatinine, glucose, potassium, sodium, and urea nitrogen performed as automated multichannel tests. It would be inappropriate to report CPT codes 82310, 82374, 82435, 82565, 82947, 84132, 84295 and/or 84520.

• I = Incidental Incidental billing includes procedures that can be performed along with the primary procedure, but are not essential to complete the procedure. They do not typically have a significant impact on the work and time of the primary procedure. Incidental procedures are not separately reimbursable when performed with the primary procedure.
  
  For example : CPT code 58660 Lysis of adhesions is not to be reported separately when done in conjunction with CPT 58661 Laparoscopy, surgical with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy).

• E = Exclusive Mutually Exclusive procedures are a coding combination billed in error that follows one or both of the following criteria: Either the two services cannot reasonably be done in the same session, or the coding combination represents two methods of performing the same service.
  
  For example: CPT code 49200, Excision or destruction by any method of intra- abdominal or retro- peritoneal tumor or cysts or endometriomas, is recognized as mutually exclusive of code 47380, Ablation, open, of one or more liver tumors.

Maximum Frequency per Day

This edit is based on CPT and HCPCS code descriptions that define maximum billable units per procedure, as identified by the AMA current procedural terminology. If a claim line contains units that exceed these limits, the Plan will only allow the appropriate unit values associated with that code.

Not a Primary Diagnosis Code

This edit identifies ICD-9 diagnosis codes that are not allowed for reporting alone or as a primary diagnosis. Claims submitted with these ICD-9 codes will be denied and must be resubmitted with a valid Primary Diagnosis Code.

New Patient Evaluation Management (E/M) with Established E/M Services

CPT and CMS have defined a new patient as a patient who has not seen either a physician or another physician of the same specialty within the same practice within the last three years. The Plan requires proper coding of new patient visits and has implemented an edit that identifies claims submitted where a new patient code has been submitted for a patient previously seen within the practice within the past three years. Claims identified by this rule will be denied and must be resubmitted with an established patient code.

Your attention to these common reasons for denial will help us to pay your claims promptly. MassHealth Regulations will always take precedence over these edits. A listing of denial explanation codes can be found on the Providers page, under RA Explanation Codes.

The Plan reserves the right to add to, change or eliminate coding edits to comply with regulatory requirements or to be consistent with industry standards.