Tools for submitting claims

Horizon NJ Health recently implemented a new secondary editing system. To help ensure your claims are processed correctly, you can stay up to date on the following:

For more information on the secondary claims editing system, view the Frequently Asked Questions.

Frequently Asked Questions

Q1: What does the procedure is inconsistent with the modifier mean?
A1: The procedure is inconsistent with the modifier means an anatomical modifier was not used correctly when there was an appropriate anatomical modifier available for the procedure. According to the Centers for Medicare & Medicaid Services’ correct coding guidelines, an anatomical modifier is required when the diagnosis supports an anatomical site. Anatomical modifiers include Coronary Artery Modifiers (LC, LD, LM, RC, RI), Eye Lid Modifiers (E1-E4), Finger Modifiers (FA-F9), Toe Modifiers (TA-T9) and Site of the Body Modifiers (LT, RT, 50).

The claim will be denied for procedure inconsistent with the modifier, if the modifier:

  1. Is submitted without an anatomical modifier when there is an appropriate anatomical modifier that can be used

  2. Billed does not match the diagnosis used

Q2: What are primary and secondary diagnosis codes?
A2: The Official Guidelines for Coding and Reporting identify which codes may be assigned as:

  • Principal or first-listed diagnosis only
  • Secondary diagnosis only, or
  • Principal/first-listed or secondary (depending on the circumstances)

Q3: Do these diagnostic codes need to be submitted in a certain order?
A3: Yes. There are manifestation and sequela codes that should not be billed in the primary position:

  • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For these conditions, the ICD-10-CM has a coding convention that requires the underlying condition be first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a “use additional code” note at the etiology code, and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
  • A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, due to a previous injury. Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture and infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires that two codes be sequenced. The condition or nature of the sequela is sequenced first. Then, the sequela code is sequenced second.

Q4: What are Excludes Notes?
A4: ICD-10-CM has two types:

  • Excludes1: A type 1 Excludes Note is a pure excludes note. It means “Not coded here.” An Excludes1 Note indicates that the code excluded should never be used at the same time as the code above the Excludes1 Note. An Excludes1 Note is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
  • Excludes2: A type 2 Excludes Note represents “Not included here.” An Excludes2 Note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 Note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

Q5: How do I know if a patient is new or established?
A5: A new patient is someone who has not received any professional services, i.e., E/M services or other face-to-face services from the physician or physician group practice within the previous three years.

Published on: February 4, 2020, 01:27 AM ET
Last updated on: February 6, 2020, 01:08 AM ET