Claim Adjustment Notification: Correct Coding/Code-Editing Guidelines

Horizon NJ Health is working with a vendor, Cotiviti, to identify nationally-recognized coding/claim edits that are not incorporated into our systems and captured through Change Healthcare’s CXT claim edits. The absence of these nationally-recognized coding/claim edits has resulted in our reimbursement for services that should have been denied.

On or about June 1, 2020, Horizon NJ Health will begin adjusting certain professional claims processed between January 2019 and December 2019 to ensure that the submitted procedure codes are processed in accordance with nationally-recognized coding and code-editing guidelines.

This includes guidelines implemented by the Centers for Medicare & Medicaid Services (CMS), National Correct Coding Initiative (NCCI), Outpatient Code Editor (OCE), American Medical Association (AMA), Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS) and the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM).

For more information on the implemented guidelines, review the Correct Coding/Code-Editing Guidelines.

Published on: April 23, 2020, 10:05 AM ET
Last updated on: April 23, 2020, 10:13 AM ET
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Correct Coding/Code-Editing Guidelines

On or about June 1, 2020, Horizon NJ Health will begin adjusting certain professional claims processed between

January 2019 and December 2019 to ensure that they are processed in accordance with the following nationally-

recognized coding and code-editing guidelines.

Please note that the correct coding guidelines listed here are part of a larger Horizon NJ Health effort to

address/correct claims not processed in accordance with nationally-recognized coding and code-editing guidelines.

Additional notices will be posted on horizonNJhealth.com/providernews in the future to advise of additional claim

adjustment efforts to be conducted.

Add-on Code Policy

Guideline Action

Add-on Codes

Deny an add-on code when the primary code is absent or has been denied for

other reasons.

Bilateral Procedures Policy

Guideline Action

Procedures that are Bilateral in Nature (Bilateral

Indicator 2) Apply policy set for Bilateral Indicator 2 (CMS and Cotiviti Supplement).

Bundled Services Policy

Guideline Action

Bundled Services Not Payable Under Any

Circumstances

Deny bundled services for which payment is always routinely bundled into

other services and supplies.

CMS Coverage Policies

Guideline Action

Chiropractic Manipulation

Deny chiropractic manipulation (98940-98942) when billed without a primary

diagnosis of subluxation and a secondary diagnosis for the symptoms

associated with the diagnosis of subluxation is not present.

Bariatric Surgery for Treatment of Morbid Obesity

Deny 43644, 43645, 43770, 43775 or 43845-43847 (Gastric restrictive

procedure, with gastric bypass) when billed without a requisite comorbid

diagnosis.

Bariatric Surgery for Treatment of Morbid Obesity

Deny 43644, 43645, 43770, 43775 or 43845-43847 (Gastric restrictive

procedure, with gastric bypass) when billed and a diagnosis of BMI greater

than or equal to 35 is not present.

Bariatric Surgery for Treatment of Morbid Obesity

Deny 43644, 43645, 43770, 43775 or 43845-43847 (Gastric restrictive

procedure, with gastric bypass) when billed with a primary diagnosis of

morbid obesity and a requisite comorbid related diagnosis is not present on the

claim header and a diagnosis for Body Mass Index equal to or greater than 35

is also not present on the claim header.

Osteogenic Stimulators

Deny E0760 (Ultrasonic osteogenesis stimulator) when billed without a

required diagnosis.

Ambulatory Electroencephalographic (EEG)

Monitoring

Deny an ambulatory EEG (95950 or 95953) when billed and a resting EEG

(95812-95827) has not been billed by any provider on the same day or within

the past twelve (12) months.

Intensive Behavioral Therapy for Obesity

Deny G0447 or G0473 (Face-to-face behavioral counseling for obesity) when

billed without a diagnosis of Body Mass Index 30 or greater.





Diagnosis Code Guideline Policy

Guideline Action

Secondary Diagnosis Codes

Deny procedures or services received with a secondary diagnosis code as the

principal or primary diagnosis.

ICD-10-CM Excludes 1 Notes Policy

Deny claim lines reported with mutually exclusive code combinations

according to the ICD-10-CM Excludes 1 Notes guideline policy.

Secondary Diagnosis Codes

Deny procedures or services received with a secondary diagnosis code as the

only diagnosis on the claim.

ICD-10-CM Laterality Policy

Apply the ICD-10-CM Laterality policy for Diagnosis-to-Diagnosis

comparison.

ICD-10-CM Laterality Policy

Apply the ICD-10-CM Laterality policy for Diagnosis-to-Modifier

comparison.

Manifestation Codes

Deny all services received with a manifestation code billed in the primary,

first listed or principal diagnosis position.

ICD-10-CM Sequela (7th character "S") Codes
Deny any procedure or service received with a ICD-10-CM sequela (7th

character "S") code billed in the primary, first listed or principal diagnosis

position.

Manifestation Codes

Deny all services received with a manifestation code billed as the only

diagnosis on the claim.

Factors Influencing Health Status and Contact with

Health Services Diagnoses and Non-Routine

Examinations

Deny E/M services (excluding normal newborn care) billed with 99381-99429

(Preventive medicine services) when reported with an ICD-10 "Z" diagnosis

code as the only diagnosis on the claim.

ICD-10-CM Sequela (7th character "S") Codes Deny any procedure or service received with a ICD-10-CM sequela (7th

character "S") code billed as the only diagnosis on the claim.

Arthrocentesis

Deny 20610 or 20611 (Arthrocentesis, aspiration and/or injection; major joint

or bursa [eg, shoulder, hip, knee joint, subacromial bursa) when submitted

without an appropriate diagnosis code.

Diagnosis Specificity

Deny claim line if all ICD codes are not coded to the highest level of

specificity.

Duplicate Services Policy

Guideline Action

Duplicate Claims From Any Provider ID Under

Same Tax ID and Specialty Deny duplicate claim lines using the 9 basic elements.

Duplicate Claims From Same Provider ID Under

Any Tax ID and Specialty

Deny the same codes billed for the same date of service by the same Provider

ID regardless of Tax ID number or Specialty.

Duplicate Claim Logic for Global Surgery

Procedures

Deny 0, 10 or 90 day procedures when the same code has been billed for the

same date of service with the same number of submitted units by a different

Tax ID, different Provider ID, and any Specialty.

Evaluation and Management Services Policy

Guideline Action

New Patient Visits

Deny a new patient visit when any face-to-face service has previously been

billed by the same physician or a physician from the same group practice

(with the same specialty and subspecialty) within the last three years.

Multiple Inpatient Admission or Consultation

Services

Deny the second initial hospital care service (99221-99223) when an inpatient

consultation (99251-99255), subsequent hospital care (99231-99233), or

another initial hospital care service has been billed in the previous week for

the same place of service, and a discharge service (99238-99239) has not also

been reported in the previous week.




New Patient Visits

Deny a new patient visit when any face-to-face service has previously been

billed by the same provider ID, regardless of Tax ID or specialty in the last

three years.

Multiple Inpatient Admission or Consultation

Services

Deny an inpatient hospital consult (99251-99255) to a subsequent inpatient

visit (99231-99233) if any type of inpatient visit (initial inpatient admission,

inpatient hospital consult, subsequent hospital care) has been billed in the

previous week for the same place of service, and an inpatient discharge visit

(99238-99239) has not also been billed.

Observation Services

Deny 99218-99220, 99224-99226, 99234-99236 (Observation services) when

billed for more than one unit per date of service in any combination by any

provider and the place of service is 19 (Outpatient hospital - off campus), 21

(Inpatient hospital), 22 (Outpatient hospital - on campus), 23 (Emergency

department), 24 (Ambulatory Surgical Center).

Outpatient Consultations

Deny outpatient/office consultation services (99241-99245) billed in the office

setting when any other evaluation and management service has been billed in

any place of service in the previous year.

Observation Services

Deny initial observation care codes (99218-99220) or codes that include the

initial observation care (99234-99236) when an initial observation care code

has been billed for the previous day by any provider.

Observation Services

Deny 99217 (Observation care discharge service) if the qualifying 99218-

99220 (Initial observation care admission service), 99224-99226 (Subsequent

observation care) or a 0, 10 or 90-day global service has not been billed by

any provider within the previous three days (CMS + Cotiviti Supplement).

Outpatient Consultations

Deny outpatient/office consultation services (99241-99245, 99446-99449,

99451, S0285) when a face-to-face service or clinic visit has not been billed

by a different provider on the same date of service or in the previous year.

Inpatient Neonatal and Pediatric Critical Care and

Intensive Care Services

Limit any combination of 99468-99476 (Neonatal and pediatric critical care)

to one unit per date of service by any provider.

Transitional Care Management (TCM) Services

Deny Transitional Care Management (TCM) services (99495-99496) when

billed and a facility E/M service has not been billed by any provider for the

same date of service or in the previous 30 days, unless POS 21 is reported

with a qualifying E/M service for the same date or in the previous 30 days.

Evaluation and Management Services with Critical

Care

Deny E/M services (99201-99215, 99221-99223, 99231-99233, 99460) when

billed with critical care service (99291) and the place of service is the same,

except when evaluation and management services (including critical care

services) are appended with modifier 25.

New Patient Visits

Deny a new patient visit when billed by a non-physician practitioner and any

face-to-face service has previously been billed by the same group practice

(same Tax ID, any specialty) within the last three years and the primary

diagnosis on the new patient visit matches any diagnosis on the previous face-

to-face service.

Discharge Services

Deny hospital discharge services (99238-99239) when 99238 or 99239 has

been billed for the same date of service.

Discharge Services

Deny hospital discharge services (99238-99239) when 99238 or 99239 has

been billed the previous day.

Multiple Evaluation and Management Services on

the Same Day

Deny the E/M code with the lower RVU price, when multiple E/M services

are billed for the same date of service, provider group and specialty, except

when modifier 25 is appended to the additional E/M service.

Multiple Preventive Medicine Evaluation and

Management Services

Deny the preventive medicine E/M service with the lower RVU price when

multiple preventive medicine E/M services are billed for the same date of

service.




Global Obstetrical Policy

Guideline Action

Multiple Obstetrical Deliveries

Deny subsequent delivery codes if more than one delivery code is billed for

the same date of service or within the previous six months by any provider or

specialty.

Global Obstetrical Package

Deny Evaluation and Management services when billed with a diagnosis of

post-partum care, contraceptive management, or family planning advice when

a delivery care only service has been billed in the past 42 days (6 weeks) by

any provider.

Global Obstetrical Package

Deny separate reimbursement for those services which are included in the

global obstetrical package for uncomplicated maternity cases when billed on

the same day as the delivery.

Incident To Services Policy

Guideline Action

Incident To Services

Deny an "incident to" service when billed with a place of service code 02, 19,

21, 22, 23, 24, 26, 31, 34, 41, 42, 51, 52, 53, 56, or 61.

Maximum Units Policy

Guideline Action

Daily Maximum Units

Deny excess units when any provider bills a certain number of units that

exceed the daily assigned allowable unit(s) for that procedure for the same

member.

Modifier Policy

Guideline Action

Inappropriate Service Modifiers Deny services that are billed with inappropriate service modifiers.

Unrelated Procedure/Service by the Same Physician

During the Postop Period

Deny procedures appended with modifier 79 when the same or different 0, 10

or 90 day procedure code has not been billed on the same day for a code with

a 0-day post-operative period, on the same day or in the previous 10 days for a

code with a 10-day post-operative period, on the same day or in the previous

90 days for a code with a 90-day post-operative period. (CMS + Cotiviti

Supplement)

Return to the OR for a Related Procedure During the

Postop Period

Deny procedures appended with modifier 78 when the same or different 0, 10

or 90 day-procedure code has not been billed on the same day for a 0-day

post-operative period, on the same day or in the previous 10-days for a code

with a 10-day post-operative period, or on the same day or in the previous 90

days for a code with a 90-day post-operative period. (CMS + Cotiviti

Supplement)

National Correct Coding Initiative Policy

Guideline Action

Column One and Column Two Code Edits for

Practitioner Medicaid CCI

Deny Column two procedure code when billed with associated Column one

procedure code. Non-Mutually Exclusive Edits.

Mutually Exclusive Edits for Practitioner Medicaid

CCI

Deny Column two procedure code when billed with associated Mutually

Exclusive Column one procedure code.

Column One and Column Two Code Edits for

Practitioner Medicaid CCI

Deny Column two procedure code when billed with associated Column one

procedure code when billed by the same Provider ID regardless of Tax ID and

Specialty. Non-Mutually Exclusive Edits.

Mutually Exclusive Edits for Practitioner Medicaid

CCI

Deny Column two procedure code when billed with associated Mutually

Exclusive Column one procedure code when billed by the same Provider ID

regardless of Tax ID and Specialty.

Correct Coding Initiative Policies and Guidelines

Deny procedures considered to be inappropriately coded based on National

Correct Coding Initiative Policies and Guidelines.




Obstetrics and Gynecology Policy

Guideline Action

Ultrasound (Non-Obstetric)

Deny 76856 (Ultrasound, pelvic [non-obstetric], real time with image

documentation; complete) or 76857 (Ultrasound, pelvic [non-obstetric], real

time with image documentation; limited or follow-up) when billed with 76830

(Ultrasound, transvaginal).

Ultrasound (Obstetric)

Deny transvaginal ultrasound (76817) when billed with transabdominal

ultrasound (76801-76812).

Place of Service Policy

Guideline Action

Supplies and Equipment Provided in the Facility

Setting

Deny medical and surgical supplies and DME when reported by professional

providers with inpatient or facility places of service. (CMS-1500)

Physician Fee Schedule Non-Facility NA Indicator

Deny services with a Non-Facility NA Indicator of "N/A" when billed in place

of service 11. (CMS + Cotiviti Supplement)

Inpatient Only Services

Deny inpatient only procedures (CMS + Cotiviti Supplement) billed by

professional providers with any place of service other than 21. (CMS-1500)

Professional Component of Radiology Services in

Facility Places of Service

Deny professional radiology services when billed by a cardiologist in the

inpatient or outpatient hospital setting.

Professional Component of Radiology Services in

Facility Places of Service

Deny professional radiology services when billed by a provider other than an

anesthesiologist, cardiologist, multispecialist, neurologist, physical medicine

specialist, radiologist, or radiation oncologist in the inpatient or outpatient

hospital setting.

Evaluation and Management Place of Service

Restrictions - Part 1

Deny Emergency department visits (99281-99285, G0380-G0384) when

billed in any place of service other than 23 (Emergency Department).

Procedure Code Definition Policy

Guideline Action

Procedure Code Definition Deny procedures based on CPT and HCPCS procedure code definition.

Procedure Code Guidelines

Deny services that are coded inappropriately based on CPT/HCPCS Procedure

Code Guidelines.

Professional, Technical, and Global Services Policy

Guideline Action

Technical Component in the Facility Setting

Deny technical component only procedures in the inpatient or outpatient

facility setting (CMS + Cotiviti Supplement).

Clinical Laboratory Services

Deny clinical laboratory services with modifier 26 for those codes that do not

have a separately payable professional service (CMS + Cotiviti Supplement).

Quality of Care Policy

Guideline Action

Scope of Services Billed by Certain Specialties

Deny any procedure billed by a pathologist that is outside the scope of

pathology practice.

Separate Procedures Policy

Guideline Action

CPT Codes and Separate Procedures Deny separate procedures when billed with the associated major procedures.














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