21-314 New Payment Policies and ICD-10 Code Editing Update
Date: 05/05/21
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.
Stay current on claims reimbursement and code edits to make sure your claims submission is compliant
Claims received for payment are subject to editing to make sure the claim complies with the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) and the ICD-10-CM Official Guidelines for Coding and Reporting. Participating providers need to adhere to NCCI standards to avoid denial of claims.
New payment policies
Effective July 12, 2021, Health Net will have two new payment policies for:
- Robotic surgery
- 340B Drug Payment Reduction for Medicare claims
Refer to the table below for a description of the policies.
ICD-10 diagnosis code edits added
Health Net reviews claims for correct coding to align with NCCI and ICD-10 coding requirements. To avoid denials based on incorrect coding, be sure to assign the correct diagnosis codes. If you receive a denial determination on the remittance advice (RA) for incorrect coding, refer to the ICD-10 Manual for the code sources.
Effective July 12, 2021, these three ICD-10 code edits will be used to verify correct coding:
- Laterality Diagnosis to Diagnosis Mismatch
- Laterality Diagnosis to Modifier Mismatch
- Mutually Exclusive Diagnosis Codes
Refer to the table below for details about the edits.
Access new policies easily
Use one of the two options below to view policies in the Provider Library.
Option 1 – Log on to the provider website
If you are serving members enrolled in ... | Go to... |
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Option 2 – Go directly to the Provider Library
- Go to the Health Net Provider Library.
- Once in the Provider Library, select a line of business, then go to Provider Manual > Claims Coding Policies and select Payment Integrity Policies for the respective policy.
The following ICD-10 code edits will be noted with a denial code on the remittance advice:
- EXwd: diagnosis code incorrectly coded per ICD-10 Manual.
- Denial code 255.
Reason description | Edit details |
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Laterality Diagnosis to Diagnosis Mismatch | Laterality Diagnosis to Diagnosis Mismatch: Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate to report unspecified, or left and right diagnosis codes when a more specific (e.g. bilateral) code is available. This edit will monitor laterality mismatch between the diagnosis codes on a claim line. |
Laterality Diagnosis to Modifier Mismatch | Laterality Diagnosis to Modifier Mismatch: Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate to report unspecified, or left and right diagnosis codes when a more specific (e.g. bilateral) code is available. This edit will monitor laterality mismatch between a diagnosis code and the procedure code modifier on a claim line. |
Mutually Exclusive Diagnosis Codes | Mutually Exclusive Diagnosis Codes: ‘Excludes 1’ Notes are located under the applicable section heading or specific ICD-10-CM code to which the note is applicable. When the note is located following a section heading, then the note is applicable to all codes in the section. This edit will monitor proper billing of diagnosis codes identified in the ‘Excludes 1’ Note. |
Payment Integrity Policies
The following chart lists the policy number, policy name, a description of the policy, applicable providers and applicable lines of business.
Policy number | Policy name | Description of policy | Providers | Lines of business |
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CC.PP.050 | Robotic Surgery | The use of a robotic surgical device is a method of performing a surgical procedure and not a requirement of the procedure, nor one that ensures a more successful outcome if a robotic approach had not been used. The health plan will disallow reimbursement for CPT S2900 – Surgical Techniques requiring the use of a robotic surgical system. This code is billed along with a primary surgical procedure code, and is an add-on code that denotes separate reimbursement for the robotic technique. This policy will not apply if a provider’s contract specifically allows for this service. | Physicians, participating physician groups, hospitals and ancillary providers | Commercial* Medicare Medi-Cal Cal MediConnect |
CC.PP.070 | 340B Drug Payment Reduction | The purpose of this policy is to ensure that providers participating in the 340B Drug Pricing Program are correctly reporting 340B acquired drugs according to guidelines established by the Centers for Medicare & Medicaid Services (CMS). CMS reduces payment to participating providers paid under an Outpatient Prospective Payment System (OPPS) for specific drugs acquired through the 340B program. Providers are required to report either modifier “JG” or “TB” on these claims. Modifier “TB’ is reported for informational purposes. Modifier “JG” indicates the 340B drug is payable at a reduced rate of Average Sales Price (ASP) minus 22.5 percent. | Physicians, participating physician groups, hospitals and ancillary providers | Medicare |
*Commercial includes HMO, POS, HSP, PPO, EPO and products offered through Covered California.
Claims Reimbursement for Contracted Providers
Health Net’s reimbursement to contracted providers for covered services is based on specific negotiated contract provisions supplemented by the contents of disclosed and consistent fee schedules, payment policies and coding methodologies.
Additional information
Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library, located on Health Net’s provider website as listed below.
If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center by email within 60 days, by telephone or through the Health Net provider website as listed below.
Line of Business | Telephone Number | Provider Portal | Email Address |
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EnhancedCare PPO (IFP) | 1-844-463-8188 |
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EnhancedCare PPO (SBG) | 1-844-463-8188 |
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Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 1-800-641-7761 |
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IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO) | 1-888-926-2164 |
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Medicare (individual) | 1-800-929-9224 |
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Medicare (employer group) | 1-800-929-9224 |
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Medi-Cal | 1-800-675-6110 |
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