21-315 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.

Stay current on claims reimbursement and code edits to make sure your claim submissions are 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 a new payment policy for:

• Robotic surgery

Refer to the table on page 3 of this update for a description of the policy.

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 following two options to view policies in the Provider Library.

Options	Go to...
Option 1 – Log on to the provider website	Log in to the provider website. From the home page, scroll to the bottom and select the Provider Library  tile. 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.
Option 2 – Go directly to the Provider Library	Go to the 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
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
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

*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.

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	Email Address
Cal MediConnect – Los Angeles County	1-855-464-3571	provider_services@healthnet.com
Cal MediConnect – San Diego County	1-855-464-3572