As a reminder, claims received by Independence 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 changes to our claim edits will be implemented as applicable.
*Self-funded groups have the option to not participate in the enhanced claim edits; therefore, your outcomes may vary by health plan. See below for more information about self-funded groups.
Areas of focus
Independence's correct coding principles will continue to focus on areas such as:
- National bundling edits, including the Correct Coding Initiative (CCI)
- Modifier usage including, but not limited to, the following:
- Global surgery period
- Add-on code usage
With the implementation of these claim edits, claims submitted with inappropriate coding will be returned or denied. Providers will be notified via the Provider Explanation of Benefits (EOB) (professional) or Provider Remittance (facility), which will include a reason code for the claim return or denial. Any returned claims must be corrected prior to resubmission. These changes should have little or no impact to billing practices for submission of claims that are in accordance with the guidelines listed above and national industry-accepted coding standards.
Claim review requests
We recognize there may be times when you have questions regarding the outcome of a claim edit. As with all claim review requests, these questions should be submitted using the Claim Investigation transaction on the NaviNet? web portal. Claim lines that have gone through the editor can be identified by the alpha-numeric codes and messages beginning with E8 on your Provider EOB or Provider Remittance. Refer to the box at right for more information.
Automated claim edits
Here are some examples of claim edits included in the new claim editing process:
- Excludes1 Notes: Claim lines reported with mutually exclusive code combinations according to the ICD-10-CM Excludes1 Notes will be denied.
- When a code from range H73.0 ? H73.099 (Acute myringitis) is associated to the same claim line as a code in either the range H65 ? H65.93 (Nonsuppurative otitis media) or the range H66 ? H66.93 (Suppurative and unspecified otitis media), then the claim line will be denied.
- Laterality: The Diagnosis-to-Modifier comparison assesses the lateral diagnosis associated to the claim line to determine if the procedure modifier matches the lateral diagnosis. If it does not match, the claim line will be denied.
- DIAG1: H60.332 (Swimmer's ear, left ear)
- CPT: 69000 (Drainage external ear, abscess, or hematoma; simple)
- MOD: RT
- Primary diagnosis code reporting: Certain diagnosis codes cannot be reported as the only or primary diagnosis code on a claim. If one of the following codes is reported as the only or primary diagnosis, then the claim line will be denied:
- Manifestation codes
- External causes (i.e., "V ? Y" codes)
- Secondary codes (e.g., Z33.1)
Evaluation and Management services
- Only one new patient visit will be allowed to the same group practice and specialty within three years.
- Only one initial inpatient hospital visit and inpatient hospital discharge will be allowed per hospital stay.
- Accurate reporting of initial, subsequent, and observation discharge care.
- Accurate reporting of modifiers for the billing of surgical services rendered by one or more providers.
- Primary surgeon should not also report as the assistant surgeon.
- Vaccine toxoid must be reported on the same day as a vaccine administration.
- Ambulance mileage must be reported on the same day as an ambulance transport.
Procedure/Diagnosis vs. Age consistency
Certain procedure and diagnosis codes are limited to a specific age group. The age groups recognized within our edits are as follows:
- Newborn/Neonatal: < 29 days
- Infant: < 1 year (includes newborn/neonatal)
- Child: 1 ? 11 years
- Adolescent: 12 ? 17 years
- Pediatric: 0 ? 17 years (includes newborn/neonatal, infant, child, and adolescent)
- Adult: 15 years and older
- Maternity: 12 ? 55 years
- Geriatric: 70 years and older
For more information
For questions about the claim editing process, please review our Claim edit enhancements: Frequently asked questions (FAQ), which can also be found on Independence NaviNet Plan Central in the Frequently Asked Questions section under Administrative Tools & Resources. Note: The FAQ will be updated as more information becomes available.
If you still have questions after reviewing the FAQ, please send an email to firstname.lastname@example.org.
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