Clinical Relationship Logic, or Code-to-Code Edits (e.g., Incidental, Integral, Component, Mutually Exclusive, etc.), pertains to the edits used to appropriately adjudicate claims in a claims processing system. As previously communicated, we have completed the transition of all AmeriHealth members to a new claims processing platform.

On the new claims processing platform, procedure terminology-based combinations and logic for similar codes are applied to claims submitted on the CMS-1500 claim form or through the 837P transaction. In addition, Medicare?s National Correct Coding Initiative (NCCI) edits are also applied.

Procedure terminology-based combinations

For information regarding procedure terminology-based combinations as well as the specific procedure terminology-based combinations, please refer to the recently updated code-to-code list on the AmeriHealth New Jersey website and on the AmeriHealth Pennsylvania website.

Logic for similar codes

When two or more procedure codes represent services that are considered to be similar in nature to one another, the procedure codes are identified as ?similar codes? on the new platform. ?Similar codes? are defined as any code(s) that should not be reported with or appended to another code by the same provider on the same date of service when:

1. The codes are clinically duplicative; OR
2. There is an AMA CPT¹ parenthetic note indicating, ?Do not report (code) in addition to (code).?

Medicare?s NCCI edits

For information regarding NCCI edits, please visit the Centers for Medicare & Medicaid Services website.

For more information on clinical relationship logic, visit the AmeriHealth New Jersey website or the AmeriHealth Pennsylvania website.

¹AMA CPT – American Medical Association^® Current Procedural Terminology^®

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