New clinical edits announced in June 2022
In the coming weeks, our teams will turn on the new clinical edits listed below in support of our efforts to drive visible value for our members – getting them the quality care they need at a lower cost.
- Ambulance Required Modifiers for Ambulance Service HCPCS Code Rule: Ambulance origin and destination modifiers should be appended to ambulance services. Ambulance codes that are missing origin and destination modifiers will be denied. Exception – an ambulance service will not be denied for missing origin and destination modifiers if modifier QL is appended to indicate the patient was pronounced dead after the ambulance was called.
- Anatomical modifier not appropriate: Anatomical modifiers are used to designate the area or part of the body on which the procedure is performed. When an anatomical modifier is appended to a procedure code that doesn't match the anatomical site indicated by the modifier, the service will be denied.
- Inappropriate use of modifier 57: Modifier 57 is appropriate for use when the E&M service has resulted in a decision to perform a major procedure. E&M services billed with modifier 57 will be denied if a major surgery isn't reported on the same date of service or one day after the E&M service.
- Inappropriate use of modifier 25: Refer to the Modifier 25, separate E&M service, same physician, same day page in the Provider Manual for information on appropriate use of modifier 25. E&M services billed with Modifier 25 will be denied if the only other service reported for the member for the same date of service is a major surgery.
- Online Digital E/M or Assessment Group Frequency: Online digital evaluation and management (E/M) services may be reported only once in a 7-day period by the same provider per CPT coding guidelines. Online digital evaluation and management (E/M) services reported more than once in a 7-day period by the same provider will be denied.
- Modifier 57 and major planned surgeries: Claim will deny the Evaluation and management (E/M) services with modifier 57 when billed with planned major surgical services. You shouldn't bill modifier 57 which allows the Evaluation and Management (E/M) services to be paid with a surgery that has been planned in advance.
The intended use of modifier 57 (Decision for surgery) is to represent that the decision to perform major surgery has occurred on the date of, or the date prior to the surgery.
Exception: This edit will exclude office consultation codes, CPT codes 99241-99245 with place of service (POS) 11; office consultations, CPT codes 99221-99223 (Initial hospital care) and 99251-99255 (Inpatient consultation) with POS 21 and E/M codes billed within the emergency room setting with POS 23.
- Ambulance Required Modifiers for Ambulance Service HCPCS Code Rule: Ambulance origin and destination modifiers should be appended to ambulance services. A modifier indicating whether the service was provided under arrangement or directly should also be appended. Ambulance codes that are missing origin and destination modifiers and/or a modifier to indicate whether the service was provided under arrangement or directly will be denied. Please refer to the Ambulance services page in the Provider Manual for exceptions and further information.
See more clinical edits
Get descriptions of our upcoming or newly implemented clinical edits, organized by claim and product type.