New clinical edits for facility claims going into effect on Sept. 15, 2022
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 Sept. 15, 2022, we’ll implement the new clinical edits outlined below. We adopted each from Center for Medicare and Medicaid Services (CMS) guidelines. These edits will impact facility claims only, for all products.
Device-Intensive Procedures Requiring Device HCPCS Code
Claims submitted for device-intensive procedures require the reporting of the device HCPCS code on the same date of service. Claims submitted without the device HCPCS code will be denied. Discontinued procedures would be excluded from editing (identified by modifiers 73,74) as well as revision procedures (identified by CG modifier).
Multiple Facility E/M Services on the Same Date
When multiple E/M services (including clinic visits) are performed by the same facility on the same date of service, modifier 27 and condition code G0 should be appended to the facility claim to indicate visits were considered distinct and independent from one another. These modifiers and condition codes should be reported on the second claim (and additional) submitted for the date of service. Claims submitted without the appropriate modifier and condition code will be denied.
Revenue Code Requires HCPCS
There are certain revenue codes that require the reporting of a HCPCS code. Claims submitted with revenue codes that are missing the required HCPCS will be denied. This edit will impact claim lines with charges, a revenue code that requires an HCPCS code (not packaged), with no HCPCS codes. The logic Medicare Claims Manual, Section 20.1 General states: “The HCPCS codes are required for all outpatient hospital services unless specifically defined as an exception in manual instructions. This means that codes are required on surgery, radiology, other diagnostic procedures, clinical diagnostic laboratory, durable medical equipment, orthotic-prosthetic devices, take-home surgical dressings, therapies, preventative services, immunosuppressive drugs, other covered drugs, and most other services.''
Resubmissions for Adjusted Claim Type of Bills and Change Reason Codes
For accurate identification of facility claim corrections, facilities should report the appropriate adjustment indicator for a corrected or voided/canceled claim along with the claim change reason code. To accurately identify these, report with one of the following bill types:
- Bill type xx7 should be reported to request an adjustment based on the corrected claim submission along with the appropriate claim change reason code (equal to condition codes D0-D4, D7, D8, D9*, or E0)
- Bill type xx8 should be reported to request the claim be voided or cancelled along with the appropriate claim change reason code (equal to condition codes D5 and D6)
Claims reported without this bill type and correct claim change reason code (see below) will be denied.
Claim change reason codes
D0 - Changes to service dates
D1 - Changes in charges
D2 - Changes in revenue code/HCPC
D3 - Second or subsequent interim PPS bill
D4 - Change in Grouper input (DRG)
D5 - Cancel only to correct a patient's Medicare ID number or provider number
D6 - Cancel only - duplicate payment, outpatient to inpatient overlap, OIG overpayment
D7 - Change to make Medicare secondary payer
D8 - Change to make Medicare primary payer
D9 - Any other changes (should be used only when no other change reason is applicable)
Use of condition code D9 should also include a remark to mirror bold criteria below on the second line of remarks:
- Patient control nbr - changing or adding a patient control number
- Admission hour - changing or adding the admission hour
- Admission type - changing or adding the admission type
- Admission source - changing or adding the admission source
- Medical record number - changing or adding the medical record number
- Condition code - changing or adding a condition code
- Occ codes - changing or adding an occurrence code
- Occ span codes - changing or adding an occurrence span code
- Value codes - changing or adding a value code
- Modifier - changing or adding a modifier
- Date of service - changing a date of service on a line or changing the statement from and to dates, use a D0
- Units - changing units
- Recalculation - claim recalculated for a different payment
- Multiple changes - Please enter your changes
- DX code - changing a diagnosis code on an outpatient claim, inpatient claims would use a D4
- POA - changing, adding, or removing a Present on Admission (POA) indicator, unless you are changing an N to a Y and/or if it affects reimbursement then you would use a D4
- Removed non - removing non-covered charges
- Other - Place this information on the second line of the claim only. On the third line of claim include a brief description of why the claim is being adjusted
Clinical Edits List
See our upcoming or newly implemented clinical edits, organized by claim and product type.