Appeals on incorrectly coded claims will result in upheld denials starting May 1

Accurately coding claims the first time helps to ensure timely claim processing and reimbursement and avoids the need for appeals. In support of this and in alignment with industry standards, we’re making the following update to our claim appeals process.

Effective May 1, 2024, appeals received on incorrectly coded claims will result in the denial being upheld. Remember, you only have one opportunity to appeal per claim.

If your claim isn’t correctly coded when you first submit it, submit a corrected claim with the accurate coding.

Things to keep in mind

Accurately coded claims often need the following (note this isn’t an exhaustive list):

  • Coding the diagnosis to the highest level of specificity
  • Using the correct place of service (POS) code
  • Appending the appropriate, required modifiers for services rendered

Using modifiers correctly

Please note these commonly missed modifiers and how to use them correctly:

Anatomical modifiers

  • Situation: We edit the surgical code when anatomical modifiers (50, LT, RT, E1, E2, E3, E4, F1, F2, F3, F4, F5, F6, F7, F8, F9, FA, T1, T2, T3, T4, T5, T6, T7, T8, T9, TA, LC, LD, RC, LM, RI) are appropriate but not appended to the claim line.
  • Solution: Submit a corrected claim appending the appropriate modifier for reconsideration of services.

Repeat procedure modifiers

  • Situation: The same radiology procedure code that is on the current claim was found on another claim for the same date of service in the member’s claim history.
  • Solution: In situations where a repeat radiology procedure occurs on the same date of service, a repeat procedure modifier is required. Submitting a corrected claim appending the appropriate repeat procedure modifier (for example, modifiers 76 or 77) is the appropriate step for claim processing.

Modifier 27

  • Definition: Modifier 27 is for hospital/outpatient facilities to use when multiple outpatient hospital E/M encounters occur for the same member on the same date of service. Modifier 27 is exclusive to hospital outpatient departments, including hospital emergency departments, clinics, and critical care.
  • How to use: Append modifier 27 to a separate, subsequent and distinct E/M service if the patient receives more than one E/M service in the same hospital, on the same day, with different providers.

Modifier FT for unrelated critical care services

  • Modifier FT may be used to report an unrelated E/M visit during a postoperative period, or on the same day as a procedure or another E/M visit.
  • Providers may report modifier FT when an E/M visit is furnished within the global period but is unrelated, or when one or more additional E/M visits furnished on the same day are unrelated.
  • This modifier may be used for critical care performed by a surgeon during a global period; however, the critical care must be unrelated to the procedure/surgery done.

Find additional information