21-316 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.
This information applies to Medi-Cal in Fresno, Kings and Madera 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 on behalf of CalViva Health, will have a new payment policy for:
- Robotic surgery
Refer to the table below for a description of the policy.
ICD-10 diagnosis code edits added
Claims are reviewed 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.
Options | Go to... |
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| Option 1 – Log on to the provider website |
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Option 2 – Go directly to the Provider Library
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The following ICD-10 code edits will be noted with a denial code on the remittance advice:
- 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 | Medi-Cal |
Claims Reimbursement for Contracted Providers
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 the 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 the provider website.
Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.