Clinical edits implemented this August

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 were implemented in August 2023:

ESRD Services Billed More Than Once Per Month

Product: All | Provider type: Professional

Effective: Aug. 15, 2023

CPT Professional Edition guidelines provide specific guidance for reporting ESRD services. Pay close attention to the timing defined in the codes below for accurate reporting. Services will deny if the frequency doesn’t align with the code definition.

  • 90951 – 4 or more face-to-face visits by a physician or other qualified health care professional per month and the patient is younger than 2 years of age
  • 90954 – 4 or more face-to-face visits by a physician or other qualified health care professional per month and the patient is 2-11 years of age.
  • 90957 – 4 or more face-to-face visits by a physician or other qualified health care professional per month and the patient is 12-19 years of age.
  • 90960 – 4 or more face-to-face visits by a physician or other qualified health care professional per month and the patient is 20 years of age or older.
  • 90952 – 2-3 face-to-face visits by a physician or other qualified health care professional per month and the patient is younger than 2 years of age.
  • 90955 – 2-3 face-to-face visits by a physician or other qualified health care professional per month and the patient is 2-11 years of age.
  • 90958 – 2-3 face-to-face visits by a physician or other qualified health care professional per month and the patient is 12-19 years of age.
  • 90961 – 2-3 face-to-face visits by a physician or other qualified health care professional per month and the patient is 20 years of age or older.
  • 90953 – 1 face-to-face visit by a physician or other qualified health care professional per month and the patient is younger than 2 years of age.
  • 90956 – 1 face-to-face visit by a physician or other qualified health care professional per month and the patient is 2-11 years of age.
  • 90959 – 1 face-to-face visit by a physician or other qualified health care professional per month and the patient is 12-19 years of age.
  • 90962 – 1 face-to-face visit by a physician or other qualified health care professional per month and the patient is 20 years of age or older.

Anterior Cervical Procedures Performed on the Same Day

Product: Commercial | Provider type: Professional

Effective: Aug. 15, 2023

Pay close attention to coding guidelines for statements that direct specific coding guidance. Failure to follow the CPT defined coding guidelines can result in claim denials.

For example: An anterior cervical interbody fusion and an anterior cervical discectomy performed on the same date (same or different providers). The CPT Professional Edition coding guidelines states, "Do not report 22554 in conjunction with 63075, even if performed by a separate individual." CPT redirects to use CPT 22551: "To report anterior cervical discectomy and interbody fusion at the same level during the same session, use code 22551.”

Unattended Home Sleep Studies & Modifier TC

Product: Commercial | Provider type: Professional

Effective: Aug. 29, 2023

Pay close attention to CPT descriptions to accurately align place of service (POS) and applicable modifiers. When CPT codes specifically define where a service is being performed, such as unattended home sleep studies (codes below), the POS reported must align with the code description.

  • 95800
  • 95801
  • 95806
  • G0398
  • G0399
  • G0400

Services rendered in the home setting should align with place of service 12 – Home.

Consultation Services

Product: Commercial | Provider type: Professional

Effective: Aug. 29, 2023

Pay close attention to coding consultations services. Consultation services are coded when physicians receive a request from the attending or treating physician for an opinion on the member’s medical care. This consultation service requires:

  • Documentation of the request
  • Detail of opinion
  • Response to the requesting provider

This assumes the member care management and/or follow up services initiated by the consulting provider should be coded with an E/M service (99211-99215). The only time additional consult codes could be coded for this member is when subsequent requests are made by the referring provider based on a status change, new problem or additional information is available.

References:

AMA CPT Professional Edition:

  • "If subsequent to the completion of the consultation the consultant assumes responsibility for the management of a portion or all of the patient's condition(s), the appropriate Evaluation and Management services code for the site of service should be reported...In the office setting, the consultant should use the appropriate office or other outpatient consultation codes and then the established patient or other outpatient services codes."
  • "Follow-up visits in the consultant's office or other outpatient facility that are initiated by the consultant or patient are reported using the appropriate codes for established patients in the office (99212, 99213, 99214, 99215) or home or residence (99347, 99348, 99349, 99350)."

AMA Principles of CPT Coding:

  • “However, the office or other outpatient consultations codes may be reported again if this same consultant receives a subsequent request from the attending physician or other appropriate source to offer his or her opinion on the same patient for the same problem in response to a change in the patient's status or to the availability of new information (eg, test results) or a completely different problem.”

Radiology Services with Professional & Technical Components

Product: All | Provider type: Professional

Effective: Sept. 24, 2023

When coding for services that contain both a professional and technical component, services can be reported as:

  1. A global service,
  2. Professional only service, or
  3. Technical component only

We will only reimburse a radiology service once, whether it is reported as global or broken out to technical and professional components. These services are reimbursed based on the first claim received.

Example: If we receive radiology service 74020 billed as a global service, no separate reimbursement for additional claims for the same date of service received with modifier 26 or TC would occur. The same denial would exist if we received the professional and/or technical components and then a global service, this global service would be denied.

If services are repeated, append the appropriate repeat service modifiers.