While code editing software is a useful tool to ensure provider compliance with correct coding, it does not wholly evaluate all clinical patient scenarios. Consequently, Health Net uses clinical validation by a team of experienced nursing and/or coding experts to further identify claims for potential billing errors. Clinical validation allows for consideration of exceptions to correct coding principles and may identify where additional reimbursement is warranted. For example, clinicians review all claims billed with Modifier 25 and Modifier 59 for clinical circumstances which justify separate reimbursement for the service performed.

Code Editing and the Claims Adjudication Cycle

Code editing is the final stage in the claims adjudication process. Once a claim has completed all previous adjudication phases (such as benefits and member/provider eligibility review), the claim is ready for analysis. As a claim progresses through the code editing cycle, each service line on the claim is processed through the code editing rules engine and evaluated for correct coding. As part of this evaluation, the prospective claim is analyzed against other codes billed on the same claim as well as previously paid claims found in the member/provider history. The software may make the following recommendations:

Deny: Code editing rule recommends denial of a service line. The appropriate explanation code is documented on the provider’s explanation of payment along with reconsideration/appeal instructions.

Pend: Code editing rule recommends that the service line pend for clinical review and/or validation. This review may result in a pay or deny recommendation. The appropriate decision is documented on the provider’s explanation of payment along with reconsideration/appeal instructions.

Replace and Pay: Code editing rule recommends the denial of a service line and a new line is added and paid. In this scenario, the original service line is left unchanged and a new line is added to reflect the software’s recommendations. For example, an incorrect CPT code is billed for the member’s age. The software denies the original service line billed by the provider and adds a new service line with the correct CPT code, resulting in a paid service line. This action does not alter or change the provider’s billing, as the original billing remains on the claim.

Claims Editing Software Updates

Claims editing software is updated quarterly to incorporate the most recent medical practices, coding principles, industry standards and annual changes to CPT and CMS guidelines.

Edit Sources

Claims editing software contains a comprehensive set of rules addressing coding inaccuracies such as: unbundling, frequency limitations, up-coding, duplication, invalid codes, mutually exclusive procedures, and other coding inconsistencies. Each rule is linked to a generally accepted coding principle. Guidance surrounding the most likely clinical scenario is applied. This information is provided by clinical consultants, health plan medical directors, research, etc.

The software applies edits that are based on the following sources:

• Centers for Medicare & Medicaid Services’ (CMS) National Correct Coding Initiative (NCCI) for professional and facility claims. The NCCI edits include column 1/column 2, medically unlikely edits (MUE), mutually exclusive and outpatient code editor (OCE) edits. These edits were developed by CMS to control incorrect code combination billing contributing to incorrect payments.
• Public domain specialty society guidance (i.e., American College of Surgeons, American College of Radiology, American Academy of Orthopedic Surgeons, etc.).
• CMS Claims Processing Manual CMS Medicaid NCCI Policy Manual State Provider Manuals, Fee Schedules, Periodic Provider Updates (bulletins/transmittals)
• CMS coding resources, such as HCPCS Coding Manual, National Physician Fee Schedule, Provider Benefit Manual, Claims Processing Manual, MLN Matters and Provider Transmittals
• AMA resources
  • CPT Manual
  • AMA Website
  • Principles of CPT Coding
  • Coding with Modifiers CPT Assistant
  • CPT Insider’s View
  • CPT Assistant Archives
  • CPT Procedural Code Definitions
  • HCPCS Procedural Code Definitions
• Billing Guidelines Published by Specialty Provider Associations
  • Global Maternity Package data published by the American Congress of Obstetricians and Gynecologists (ACOG)
  • Global Service Guidelines published by the American Academy of Orthopedic Surgeons (AAOS)
  • Etc.
  • State-specific policies and procedures for billing professional and facility claims Health Plan policies and provider contract considerations.

• ClaimsXten
  • ClaimsXten™ is a software application that edits claims for adherence to Centene Corporation policies, reimbursement coverage policies, benefit plans, and industry-standard coding practices based mainly on CMS and AMA guidelines. ClaimsXten facilitates accurate claim processing for medical and behavioral claims submitted on a CMS 1500 claim form and for certain claims submitted on a UB04 claim form. Code editing within ClaimsXten is based on assumptions about the most common clinical scenarios for services performed by a health care professional for the same patient, and the logic within ClaimsXten is based on a thorough review by doctors of current clinical practices, specialty society guidance, and industry standard coding.

• Cotiviti
  • Cotiviti PCI offers claims editing solutions that validate, identify and review claims to comprehensively address Fraud Waste and Abuse, reducing waste and improving payment accuracy. This process detects common errors such as duplicates, improper frequency, the unbundling of services, and inappropriate modifier use.
  • Cotiviti PCI uses clinical validation by a team of experienced nursing and coding experts to further identify claims for potential billing errors. Clinical validation allows for consideration of exceptions to correct coding principles and may identify when additional reimbursement is warranted. For example, clinicians review all claims billed with modifiers -25 and -59 for clinical scenarios which justify separate payment for the service billed.

Unbundling - PTP Practitioner and Hospital Edits

Unbundling refers to two or more procedure codes used to report a service when a single, more comprehensive code should have been used. The less comprehensive code is denied. As part of the National Correct Coding Initiative (NCCI) to prevent inaccurate claims payment, CMS has designated combinations of codes that should not be billed together. CMS developed Procedure to Procedure (PTP), also known as Column I/Column II, edits to detect incorrect claims submitted by providers. The column I procedure code is the most comprehensive code and reimbursement for the column II code is subsumed into the payment for the comprehensive code. The column II code is considered an integral component of the column I code. While these codes should not typically be billed together, there are circumstances when a modifier may be appended to the column II code to identify a significant and separately identifiable or distinct service. When these modifiers are billed, clinical validation will be performed. PTP practitioner edits are applied to claims submitted by physicians, non-physician practitioners and ambulatory surgical centers. PTP hospital edits apply to hospitals, skilled nursing facilities, home health agencies, outpatient physical therapy, speech-language pathology providers and comprehensive outpatient rehabilitation facilities.

Medically Unlikely Edits (MUEs) for Practitioners, DME Providers and Facilities

Also within CMS NCCI guidelines, MUEs reflect the maximum number of units that a provider would typically bill for a single member on a single date of service. These edits are based on CPT/HCPCS code descriptions, anatomic specifications, the nature of the service/procedure, the nature of the analyte, equipment prescribing information and clinical judgment.

Code Bundling Rules Not Sourced to CMS NCCI Guidelines

Many specialty medical organizations and health advisory committees have developed rules around how codes should be used in their area of expertise. These rules are published and are available for use by the public domain. Procedure code definitions and relative value units are considered when developing these code sets. Rules are specifically designed for professional and outpatient facility claims editing.

Mutually Exclusive Editing

These are combinations of procedure codes that may differ in technique or approach but result in the same outcome. The procedures may be impossible to perform anatomically. Codes may also be considered mutually exclusive when an initial or subsequent service is billed on the same date of service. The procedure with the highest Relative Value Units (RVU) is considered the reimbursable code.

Global Surgical Period Editing/Medical Visit Editing

CMS publishes rules surrounding payment of an Evaluation and Management (E/M) service during the global surgical period of a procedure. The global surgery data is taken from the CMS Medicare Fee Schedule Database (MFSDB).

Procedures are assigned a 000, 010, or 090 day global surgical period.

Procedures assigned a 090 day global surgery period are defined as a major surgical procedure. If an E/M service is provided on the same date of service as a the major surgical procedure decision to perform the surgical procedure, then the E/M service would be separately reportable with using the Modifier 57, Decision for Surgery. Any other E/M service provided on the same date of service are not separately reportable and would be included in the payment for the surgical procedure under the global period. E/M services for a major procedure (90-day period) that are reported 1 one day preoperatively on the same date of service or during the 90-day postoperative period are not recommended for separate reimbursement.

Procedures assigned a 000 or 010 global surgical period are defined as minor procedures. E/M services that are reported with minor surgical procedures on the same date of service or during the 10-day global surgical period are not recommended for separate reimbursement. E/M services for established patients that are reported with surgical procedures that have a 0-day global surgical period are not recommended for reimbursement on the same day of surgery because there is an inherent E/M service included in all surgical procedures.

Global Maternity Editing

Global periods for maternity services are classified as “MMM” when an evaluation and management service is billed during the antepartum period (270 days), on the same date of service or during the postpartum period (45 days). E/M services are not recommended for separate reimbursement if the procedure code includes antepartum and/or postpartum care.

Diagnostic Services Bundled to Inpatient Admission (3-Day Payment Window)

This rule identifies outpatient diagnostic services provided to a member within three days prior to and including the date of an inpatient admission. When these services are billed by the same admitting facility or an entity wholly owned or operated by the admitting facility, they are considered bundled into the inpatient admission and therefore are not separately reimbursable.

Multiple Code Rebundling

This rule analyzes if a provider billed two or more procedure codes when a single more comprehensive code should have been billed to represent all of the services performed.

Frequency and Lifetime Edits

The CPT and HCPCS manuals define the number of times a single code can be reported. There are also codes that are allowed a limited number of times on a single date of service, over a given period of time or during a member’s lifetime. State fee schedules also delineate the number of times a procedure can be billed over a given period of time or during a member’s lifetime. A frequency edit is applied when the procedure code is billed in excess of these guidelines.

Duplicate Edits

Code editing evaluates prospective claims to determine if there is a previously paid claim for the same member and provider that is a duplicate to the prospective claim. The software also looks across different providers to determine if another provider was paid for the same procedure, for the same member on the same date of service. Finally, the software analyzes multiple services within the same range of services performed on the same day.

National Coverage Determination Edits

CMS establishes guidelines that identify whether some medical items, services, treatments, diagnostic services or technologies can be paid under Medicare. These rules evaluate diagnosis to procedure code combinations.