New clinical edits went into effect in July
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.
The following clinical edits went into effect this month:
Discontinued Coverage for 58565 & A4264
Product: Medicaid | Provider type: Professional
Effective: July 11, 2023
The Michigan Department of Health and Human Services (MDHHS) issued Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) code updates in January 2020 (see MSA 20-01). These updates included discontinued coverage for the following codes, effective Dec. 31, 2019:
- CPT 58565: Under Laparoscopic/Hysteroscopic Procedures on the Corpus Uteri
- HCPCS A4264: Permanent implantable contraceptive intratubal occlusion device(s) and delivery system
As these codes are not covered, they will be denied.
Opioid Treatment Program Billed Above Allowed Limit
Product: Medicare | Provider type: Professional
Effective: July 11, 2023
We’re aligning with Centers for Medicare & Medicaid Services (CMS) billing guidelines to deny Opioid Treatment Program (OPT) services billed more frequently than Medicare’s allowed limit. Below are the OPT G-codes and when the clinical edit will apply:
- G2067, G2068, G2071, G2074, and G2075 occurring more than once in a 7-day period
- G2069 and G2073 occurring more than once in a 4-week period
- G2070 and G2072 occurring more than once in a 6-month period
- G2078 or G2079 each occurring more than three times in a 1-month period
FS Modifier Reported with Office Visits by POS Code
Product: Commercial | Provider type: Professional
Effective: July 25, 2023
We’re aligning with Centers for Medicare & Medicaid Services (CMS) policy and the American Medical Association (AMA) to deny claims coded with the FS modifier (split or shared evaluation and management (E&M) visit) when reported with office visit codes with the following place of service (POS) codes: 03, 04, 05, 07, 09, 11, 15, 17, 20, 26, 49, 50, 57, 65, 71, 72