​​​​​​​Claim edit enhancements: Frequently asked questions

November 2, 2020


This FAQ was revised on November 2, 2020.


The following frequently asked questions (FAQ) were developed to provide more detailed information about the implementation of a claim editing process that will ensure compliance with current industry standards and support the automated application of correct coding principles.* By applying these principles, Independence Blue Cross (Independence) will be consistent with other payers in the region, follow principles that are national in scope, that are simple to understand, and comply with industry standard sources.

*Self-funded groups have the option to not participate in the enhanced claim edits; therefore, prepayment review may vary by plan. (Added 4/24/2018)

This FAQ document will be updated as additional information becomes available.

 

1. What changes is Independence making to the claim editing process? (Revised 11/2/2020)

Independence is implementing enhancements to its claim editing process during prepayment review that will follow national industry standards from sources that we currently use such as:

  • 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

In order to verify all providers are adhering to Independence’s claim payment policies and the industry standard source guidelines listed above, starting February 1, 2021, Independence’s Enhanced Claim Editor Program will include coding validation performed by a team of Registered Nurses and Certified Professional Coders from our contracted vendor that will review select professional and outpatient facility claims in conjunction with patient claim history.​

DME and P&O billing providers

Independence expanded the enhanced claim editing process to include additional rules specific to durable medical equipment (DME) and prosthetic and orthotic (P&O) billing providers effective for claims processed as of August 1, 2019. 

The industry standard sources specific to DME and P&O include the following:

  • National and Regional Centers for Medicare & Medicaid Services (CMS) policy
  • Durable Medical Equipment Regional Carries (DMERC) Manual
  • CMS HCPCS LEVEL II Manual coding guidelines
  • Medicare Claims Processing Manual

In addition to the above, Independence enforces CMS rules on modifier usage including the following modifiers:

  • A1 – A9, GY
  • AU, AV, AW, and AX
  • CG
  • FA – F9 and TA ? T9
  • K0 –​ K4
  • KS, KX
  • KX, GA, or GZ
  • NU, UE, and RR
  • RT/LT

For detailed requirements related to these modifiers, please see this document.

Injectable drugs and biological agents

Independence expanded the enhanced claim editing process to include additional rules specific to various injectable drugs and biological agents effective for claims processed as of September 1, 2019. 

The industry standard sources specific to injectable drugs and biological agents are:

  • The manufacturer’s package insert (primary source: Food and Drug Administration [FDA]-approved indications)
    • Other compendia references include, but not limited to:
      • Thomson Micromedex® (DRUGDEX®, DrugPoints®)
      • National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium®
      • American Hospital Formulary System (AHFS®) Drug Information®
      • Elsevier Gold Standard Clinical Pharmacology
    • ICD-10 Instruction Manual coding guidelines
    • Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual

The enhanced claim editing process for injectable drugs and biological agents focuses on the following areas:

  • The diagnosis code(s) billed are consistent with the FDA-approved indications and approved off-label indications. If the ICD-10 code billed on the claim does not match the approved indication, the claim may reject.
  • The diagnosis code(s) billed are consistent with the ICD-10 Instruction Manual coding guidelines.
  • The dosage and frequency of administration is appropriate for the diagnosis for which it is being used.
  • The administration code(s) and hydration services are appropriately reported.

Medicare Advantage

In addition to the above, Medicare Advantage plans comply with the National Coverage Determinations (NCD). The enhanced claim editing process for our Medicare Advantage lines of business continue to focus on ensuring compliance with CMS coverage policies and reporting guidelines. Medicare Advantage plans are subject to edits that comply with clinical and correct coding criteria as defined in CMS publications including but not limited to, the following:

  • Medicare NCD Manual
  • Medicare Claims Processing Manual
  • Medicare NCD Coding Policy Manual and Change Report (ICD-10-CM): Clinical Diagnostic Laboratory Services

In addition to the above, Independence enforces CMS rules on appropriate modifier usage including, but not limited to the following:

  • KX
  • AT
  • Q0

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. 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.
  • Subsequent observation care 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.
  • Example. 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.

ICD-10-CM Excludes Notes

According to the ICD-10-CM Official Guidelines for Coding and Reporting, there are two types of Excludes Notes: Excludes1 and Excludes2. Each type has a different definition for use, but they are both similar in that they indicate that codes excluded from each other are independent of each other. For more information and the specific definition of each type of note, please see the previous Partners in Health UpdateSM article, ICD-10 in Action: Coding guidelines and conventions – Excludes1 and Excludes2 notes

Independence reinstated a portion of the Excludes Notes edits for claims received on or after October 30, 2018. As we continue to align with industry standards, additional ICD-10-CM Excludes Notes edits will be applied and claims that are not billed in compliance with the ICD-10-CM Excludes1 and Excludes2 notes billing rules will be rejected.  If you have been submitting claims based on the ICD-10-CM industry standard coding guidelines as instructed in our various enhanced claim editor communications, you will not see any impacts. However, if your claims submissions have not been incompliance with these billing rules, please be advised that you may see an increase in rejections and/or claim denials. You can identify an Excludes Notes on your Provider Explanation of Benefits (EOB) (professional) or Provider Remittance (facility) billing error when the line is rejected with the reason code E8038.

2. Why is Independence making these changes?

Independence?s claim editing process enhances our ability to administer payment rules consistent with national standards established by CPT, CMS, and specialty societies. These changes should have little or no impact on practices billing in accordance with these guidelines.

3. When will these updates take place? (Revised 11/2/2020)

Claims received by Independence on or after June 10, 2018, are subject to our claim editing process during prepayment review and the review applies to professional claims and to outpatient facility claims (where applicable).

4. How have providers been notified about the new claim editing process? (Revised 11/2/2020)

On March 9, 2018, April 24, 2018, May 15, 2018, June 11, 2018, November 14, 2018, and December 14, 2018, the implementation of a new claim editing process was announced to providers via:

  • Partners in Health UpdateSM, our online provider newsletter;
  • Independence NaviNet® web portal (NaviNet Open) Plan Central in a message containing a summary.

On May 15, 2018, and August 17, 2018, a Provider Bulletin was sent via email to participating hospitals as a reminder of the alignment of enhanced claim edits with industry standard billing rules.

DME and P&O providers

On April 15, 2019, June 12, 2019, and August 5, 2019, the expansion of the claim editing process to include DME and P&O providers was announced to providers via:

  • Partners in Health Update;
  • Independence NaviNet Open Plan Central.

On April 15, 2019, a Provider Bulletin was sent to participating DME and P&O providers as a notification of the expansion of the claim editing process.

Injectable drugs and biological agents

On June 3, 2019, August 5, 2019 and September 4, 2019, the expansion of the claim editing process to include various injectable drugs and biological agents was announced to providers via:

  • Partners in Health Update;
  • Independence NaviNet Open Plan Central.

On June 3, 2019, a Provider Bulletin was also sent to providers as a notification of the expansion of the claim editing process.

Medicare Advantage

On November 20, 2019, the enhanced claim editing process for Medicare Advantage claims was announced to providers via:

  • Partners in Health Update;
  • Independence NaviNet Open Plan Central.

Professional reporting of hospital observation care

On January 8, 2020, the enhanced claim editing process for professional reporting of hospital observation care claims was announced to providers via:

  • Partners in Health Update;
  • Independence NaviNet Open Plan Central.

ICD-10 CM Excludes Notes

On April 3, 2020, information around CID-10 Excludes Notes was announced to providers via:

  • Partners in Health Update;
  • Independence NaviNet Open Plan Central.

Coding validation program

On November 2, 2020, information around a new coding validation program was announced to providers via:

  • Partners in Health Update​;
  • Independence NaviNet Open Plan Central.​

5. How will these changes affect the Independence claim system?

These enhancements will facilitate prepayment review and claim auto-adjudication in alignment with national industry coding standards versus retrospective claim audit adjustments.

6. Will all claims be affected?

No, not all claims will be affected by this claim editing process. In fact, the vast majority of claims that are billed according to accepted standards will pass through our claim payment system without any coding issue.

7. Do these changes affect fee schedule rates?

No, these changes do not affect the fee schedule payment rates.

8. Can I expect claim delays due to the claim editing process?

Independence will continue to meet or exceed claims processing timelines as required by applicable law.

9. Will the Provider EOB or Facility Remittance change?

No, this process will not affect the format of the Provider EOB or Facility Remittance.

10. How can I tell if my claim has gone through an edit? (Revised 5/15/2018)

The edit explanation will be displayed on your electronic remittance report (835) and/or paper Provider EOB or Facility Remittance​​​​. Unique alpha-numeric codes and messages have been created that begin with E8. Should your claim line contain an E8XXX code/message, it means it was affected by the enhanced claim editor. You can also find the E8XXX codes/messages on the Claim Status Inquiry Detail screen in NaviNet Open. To view, hover your mouse over the service line and select View Additional Detail. If you see an E8XXX code/message, the line went through an edit. Only E8XXX codes/messages are part of the enhanced claim editor. All other codes/messages are unrelated to the enhanced claim editor.

11. How can I question or dispute an edit? (Revised 11/2/2020)

Providers should continue to use the Claim Investigation transaction via NaviNet Open to ask questions or request an adjustment on a specific claim. Please reference the enhanced claim editor in the Claim Investigation transaction if the question/comment is in reference to a code/message that begins with E8.

12. Why do I already see these types of denials in my claims experience? (Revised 5/15/2018)

While you may already see some claim outcomes that indicate denials for edits such as post-operative care or add-on codes not payable, our current claim payment system editing has been limited, requiring expansive back-end audits. This enhancement will allow for a more consistent and comprehensive prepayment review application of national coding standards. An additional example is that our system capabilities have been limited to applying the NCCI component tables. The enhanced claim editing process will look across the NCCI policy manual, not just the component tables. Information on NCCI edits is available on the CMS website.

13. Why am I receiving an enhanced claim editor denial when the service billed is preauthorized? (Added 6/3/2019)

An authorization may not supersede a claim line from receiving an edit. For example, if an authorized injectable drug or biologic agent is billed with an ICD-10 diagnosis code(s) that is not consistent with the approved indication, your claim may still be denied.

14. What is the difference between an enhanced claim edit and a coding validator denial? (Added 11/2/2020)

Enhanced claim edits are automated coding rules, whereas coding validator denials are applied only when a Registered Nurse who is also a Certified Professional Coder (CPC) thoroughly reviews the claim coding against pertinent information billed on the claim and the claims in the member’s history.

15. How can I tell the difference between an automated enhanced edit and a coding validator edit? (Added 11/2/2020)

Both the automated enhanced edits and the coding validator edits will show the detailed denial information on NaviNet Open by selecting View Additional Detail​, but only coding validator edits will use rejections that begin E819X.

16. How do I dispute a coding validator denial? (Added 11/2/2020)

While you may use NaviNet Open to view detailed information on a coding validator E819X denial, clinical information is needed in order to dispute the denial.​​​

Resources

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

Learn more

If you cannot find the information you are looking for here and have further questions, please email us at claimeditquestions@ibx.com.

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