New clinical edits for professional and facility claims

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.

Starting now through July 2022, we'll begin implementing the new clinical edits outlined below:

Professional claims

All products

Ambulance During Inpatient Stay

Ambulance services are not separately payable when reported with a date of service within an admission and discharge date of an inpatient claim per PH payment policy. The service is considered bundled to the inpatient stay and will be denied. The edit will not apply if the service was provided on the day of admission or day of discharge of the inpatient stay. Ambulance services provided during an inpatient leave of absence (LOA) that have denied with the edit may be reconsidered via the Reviews & Appeals process.

Antepartum Care Codes Submitted in History Prior to OB Package Code

The maternity global package codes include routine antepartum care, delivery and postpartum care per CPT guidelines. Antepartum care only codes will be denied when reported by the same provider within 280 days prior to a global delivery code.

Anatomical Modifiers Use Max Frequency

Claims will deny excess units when any provider bills more than one unit of service with an anatomical modifier E1-E4 (Eyes), FA-F9 (Fingers), and TA-T9 (Toes).
Anatomical modifiers of E1-E4, FA-F9, TA-T9 have a maximum allowable of one unit per anatomical site for a given date of service. Any service billed with an anatomical modifier for more than one unit of service will be adjusted accordingly. See our Anatomic modifiers page.

Obstetric Services, Global Care

Claims will deny Evaluation and Management services (99202-99215) when billed with a diagnosis of post-partum care uncomplicated postpartum care (ICD-10 codes Z39-Z39.2), contraceptive management (ICD-10 codes Z30.011, Z30.013-Z30.09), or family planning advice when a delivery care only service (59409, 59514, 59612, 59620) has been billed in the past 42 days (6 weeks) by any provider.

AMA CPT manual instructs postpartum care cannot be reported as a separate E/M service during the postpartum period, whether performed by the same provider who performed the delivery or by a different provider. Postpartum care is correctly reported. See our Prenatal, delivery and postpartum care page.

Surgical Supplies

Claims will deny when surgical dressings A6010-A6011, A6021-A6025, A6196-A6224, A6228-A6248, A6250-A6262, A6266, A6402-A6404, A6407, A6413, A6441-A6456 are billed in the provider's office (POS 11). According to CMS policy, when a physician applies surgical dressings as part of a professional service, the surgical dressings are considered incident to the professional services of the health care practitioner and are not separately payable. See our Global surgical packages page.

Vaccines and Administration

Claims will deny immunization administration (90460-90461, 90471-90474) when billed without a vaccine/toxoid code (90476-90750, 90756, 90758, 90759, J3530, Q2034-Q2039) by any provider on the same date of service. AMA CPT Manual and the HCPCS Level II Manual, immunization administration for vaccines and toxoids (90460-90461, 90471-90474) must be reported in addition to the vaccine and toxoid codes (90476-90750, 90756, 90758, 90759, J3530, Q2034-Q2039).

For Priority Health Medicaid, vaccines should be reported with a zero allowed amount for vaccines supplied though the State as part of the Vaccine for Children (VFC) program. See page 20 of Michigan VFC Provider Manual for additional detail.

See our Vaccines and vaccine administration page.

Commercial products

Multiple Gestation Delivery

Diagnosis codes for multiple gestation and outcome of delivery should be reported when billing multiple vaginal or cesarean procedure codes for the delivery of multiple gestations. Multiple vaginal or cesarean procedure codes reported without a multiple gestation diagnosis code and an outcome of delivery code will be denied.

Facility claims

All products

Covid-19 Lab Add-On Code Reported Without Required Primary Procedure

Procedure code U0005 is reported in addition to either HCPCS code U0003 or U0004 per HCPCS guidelines. Procedure code U0005 reported without U0003 or U0004 for the same date of service will be denied.

Duplicative Laboratory Professional and Facility Procedures

The professional component of a laboratory service should only be reported by either the practitioner or facility; likewise, the technical component of a laboratory service should only be reported by either the practitioner or facility. The laboratory service will be denied when the same laboratory service component has been reported for the same date of service on a professional claim.

Critical Access Hospital (CAH) Bilateral Procedures Rule

Modifiers LT (left side) and RT (right side) should not be reported when modifier 50 (bilateral procedure) is applicable. A CAH bilateral service will be denied when it is reported with the same service date on two separate claim lines, once with modifier LT and again with modifier RT. A CAH bilateral service will also be denied when it is reported on a single claim line with both modifier LT and RT.

Additional information on our clinical edits policy is available online.