As a reminder, claims received by AmeriHealth on or after June 10, 2018, are subject to a claim editing process during prepayment review to ensure compliance with current industry standards and support the automated application of correct national coding principles.* By applying these principles, we will be consistent with other payers in the region and will apply claim payment principles that are national in scope, simple to understand, and continue to comply with industry standard sources, including:

• Centers for Medicare & Medicaid Services (CMS) standards such as the National Correct Coding Initiative (NCCI), modifier usage, and global surgery guidelines
• American Medical Association (AMA) Current Procedural Terminology (CPT^®) coding guidelines
• CMS HCPCS LEVEL II Manual coding guidelines
• ICD-10 Instruction Manual coding guidelines

Please be advised that as guidelines from these sources are updated, our claim edits will be reviewed and additional claim edits will be implemented as applicable.

*Self-funded groups have the option to opt out of the enhanced claim edits; therefore, your outcomes may vary by plan.

Areas of focus: Professional reporting of hospital observation care

Observation care is a well-defined set of specific, clinically appropriate services that include short-term treatment, assessment, and reassessment, which are furnished to a patient while a decision is being made to determine if the patient will require admission as an inpatient or can be discharged.

Initial observation care codes are for all care rendered by the ordering physician on the date the patient’s observation services began. Procedure codes 99218, 99219, and 99220 are per day codes and are only eligible to be reported once per day per patient by the ordering physician. All other physicians who provide services, evaluations, or consultations while the patient is receiving hospital observation care must bill the appropriate outpatient service codes.

Similar to initial observation care codes, subsequent observation care codes are for all care rendered by the treating physician of record on the day other than the initial observation care or discharge date. Procedure codes 99224, 99225, and 99226 are per day codes. Only the treating physician of record is eligible to report observation care for the patient. All other physicians who provide services, evaluations, or consultations while the patient is receiving observation care must bill the appropriate outpatient service codes.

A hospitalist orders observation services and then asks another physician to evaluate the patient. Only the hospitalist may bill the initial and subsequent observation care codes. The other physician who evaluates the patient must bill the appropriate new or established office or other outpatient visit code.

Resources

For additional resources on our enhanced claim editing process, please review the information below:

• Automated claim edits. Examples of the higher volume enhanced claim edits we continue to see.
• Claim review requests and identifying claims. How to submit claim review requests through the NaviNet^® web portal (NaviNet Open) and easily identify claims that went through the claim editor process.
• Claim edit enhancements: Frequently asked questions (FAQ). The FAQ includes additional information on our claim editing process as well as rules specific to:
  • durable medical equipment (DME) and prosthetic and orthotic (P&O) billing providers
  • injectable drugs and biological agents
  • professional reporting of hospital observation care

Learn more

If you still have questions after reviewing the FAQ, please send an email to ahclaimeditquestions@amerihealth.com.

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