New professional claim edits going into effect on Apr. 23

Update: Mar. 21, 2023
MDHHS recently announced it will implement changes to their telehealth policy on May 11, 2023. These changes will impact two clinical edits planned for April 23 release for Medicaid only ("Telemedicine Services Billed Without GT Modifier, With POS 02" and "Telemedicine Services Billed With GT Modifier, Without POS 02 or 10"). These clinical edits will not be turned on and they've been removed from this news item.

We value the care you provide our members and strive to reimburse you accurately and fairly for that care. Thoughtful implementation of clinical edits supports this goal, while allowing us to process your claims more efficiently.

On April 23, we’ll implement the new clinical edits listed below, impacting professional claims only:

All products

Trastuzumab Biologics, Multiple Vials

We’re aligning with Centers for Medicare & Medicaid Services (CMS) policy on multi-vial drugs to deny units that align with an entire multi-use vial. Discarded amounts of multi-use vials are not payable. Edits will apply to claims reported with Q5112-Q5117 when billed with units representing a multiple of an entire vial (42, 84 or 126 units) and another claim line for the same drug does not exist on the same claim for the same date of service.

Missing Injection Code on Claim for Xiaflex® for Peyronie’s Disease

We’re adopting CMS policy that requires injections associated with HCPCS J0775 for diagnosis of Peyronie’s disease (N48.6) to be reported on the same date with CPT 54200 (Injection procedure for Peyronie disease). Edits will apply to claims with J0775 when billed with a diagnosis of Peyronie’s disease and injection code 54200 has not been billed for the same date of service by any provider.

Misuse of JW Modifier

We’ve defined billing guidelines associated with the use of the JW modifier. The JW modifier is used to identify waste or discarded amounts not administered to the member. See our JW modifier page for guidelines on reporting the JW. An edit will apply to a drug when billed with modifier JW (drug amount discharged / not administered to any patient) and another claim line does not exist for the same drug on the same date of service. 

Learn more

Additional information on our clinical edits policy is available online. You can also see recent and upcoming clinical edits for professional claims in the PDF linked below. Bookmark it in your internet browser to ensure you always have the latest updates.

Recent professional clinical edits

Recent facility clinical edits