21-622 Claims Editing Updates
Date: 09/09/21
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.
New guidelines to ensure your claim submissions comply with coding and reporting requirements
Effective November 15, 2021, the claims editing guidelines described in this update will be applied to claims submitted for payment.
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 must adhere to NCCI standards to avoid denial of claims.
Edit added for procedures requiring modifier
According to CMS and the American Medical Association, to facilitate claim processing and prevent claim denials, procedures which can be performed on different sides of the body, separate anatomical areas, or separate patient encounters require the use of modifiers whenever appropriate. The provider specialties that will be impacted the most by this change are physical therapy providers.
The following CMS Manual code edits will be noted with a denial code on the remittance advice:
- EXwe: Procedure modifier revenue necessary.
- Denial code 255.
Reason description | Edit details |
|---|---|
Procedure Modifier Revenue Necessary | The Procedure Modifier Revenue Necessary (PMRN) edit will deny procedures that require an associated modifier. The edit also identifies situations where a correct modifier and a correct revenue code are required. This edit applies to professional (HCFA) and outpatient facility (UB-04) claims. |
Enhancement to five existing correct code edits
According to the CMS Manual Chapter 12 Section 3.6, the criteria for the following correct code edits will be expanded. Per CMS, the physicians in the same group and specialty must bill and be paid as though they were a single physician. Expanded criteria will match on:
- Provider identification (ID).
- Provider National Provider Identifier (NPI).
- Provider specialty.
- Provider tax identification number (TIN).
Rule name | Description |
|---|---|
MCAR_MUE_PRACTITIONER | MUE has been exceeded per Practitioner MUE table. |
NTIS_ALL | Code pair found to be unbundled according to CMS National Correct Coding Initiative. |
PREOP_VISIT | Procedure codes billed by the same provider within a procedure’s pre-operative period. |
POSTOP_VISIT | Procedure codes billed by the same provider within a procedure’s post-operative period. |
UNBUN_PAIRS | Procedure codes that are typically not recommended for reimbursement when submitted with certain other procedure codes on the same date of service. |
Edits added for CMS National Coverage Determinations for Medicare claims
Claim editing to be implemented for the following National Coverage Determinations (NCDs) effective November 15, 2021, for Medicare Advantage only.
NCDs | Title |
|---|---|
20.8.3 | Single chamber and dual chamber permanent cardiac pacemakers |
150.3 | Bone density studies |
220.13 | Percutaneous image guided breast biopsy |
210.1 | Prostate cancer screening tests |
210.10 | Screening for sexually transmitted infections (STIs) and high-intensity behavioral counseling (HIBC) to prevent STIs |
250.3 | Intravenous immune globulin for the treatment of Autoimmune Mucocutaneous Blistering Diseases |
110.21A | Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions |
Additional information
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days at:
Line of Business | Telephone Number | Provider Portal | Email Address |
|---|---|---|---|
EnhancedCare PPO (IFP) | 1-844-463-8188 | ||
EnhancedCare PPO (SBG) | 1-844-463-8188 | provider_services@healthnet.com | |
Health Net Employer Group HMO, POS, HSP, PPO, & EPO | 1-800-641-7761 | provider_services@healthnet.com | |
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO) | 1-888-926-2164 | provider_services@healthnet.com | |
Medicare (individual) | 1-800-929-9224 | provider_services@healthnet.com | |
Medicare (employer group) | 1-800-929-9224 | provider_services@healthnet.com | |
Medi-Cal | 1-800-675-6110 | N/A | |
| Cal Mediconnect – Los Angeles County | 1-855-464-3571 | N/A | provider_services@healthnet.com |
| Cal Mediconnect – San Diego County | 1-855-464-3572 | N/A | provider_services@healthnet.com |