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ClaimsManager
<Client>
Product Assessment Report
Professional Editing
<Date>
NOTICE OF CONFIDENTIALITY
The information in this document includes trade secrets and confidential property of OptumTM. Under
no circumstances may this document be copied, transferred, or distributed to corporations or individuals
that have not signed appropriate confidentiality agreements with Optum.
DISCLAIMER
This Product Assessment Report has been performed on the data submitted by the prospective client, to
whom the report is delivered, using the Optum ClaimsManager software. Optum has relied on the
prospective client to determine that its data meets the Optum ClaimsManager data submission guidelines.
The information contained in this report is provided only for the use of the prospective client to whom
the report is delivered, and only for the purpose of identifying potential problem areas in the claims
submission/reimbursement process for such prospective client. CPT codes, descriptions, and other CPT
material only are copyright 2013 American Medical Association (AMA). All Rights Reserved. AMA
assumes no liability for data contained or not contained herein.
Copyright © 2014 Optum
Table of Contents
Section
Page
Report Summary ............................................................................................................... 1 Return on Investment ................................................................................................................ 2 Data Validation .......................................................................................................................... 4 Data Overview ............................................................................................................................ 4 Annual Cost Justification .................................................................................................. 5 Edit Reporting Categories ......................................................................................................... 6 Commercial Detailed Results ........................................................................................... 8 Category I – Non-billed Code Edits .......................................................................................... 8 Category II – Resubmission/Review Edits ..............................................................................10 Category III – Potential Denial Edits .......................................................................................12 Category IV – Informational Edits............................................................................................ 14 Medicaid Detailed Results ............................................................................................. 16 Category I – Non-billed Code Edits .........................................................................................16 Category II – Resubmission/Review Edits ..............................................................................17 Category III – Potential Denial Edits .......................................................................................19 Category IV – Informational Edits........................................................................................... 20 Medicare Detailed Results.............................................................................................. 22 Category I – Non-billed Code Edits ........................................................................................ 22 Category II – Resubmission/Review Edits ............................................................................. 24 Category III – Potential Denial Edits ...................................................................................... 26 Category IV – Informational Edits........................................................................................... 27 Category V – Medicare Edits ................................................................................................... 29 Appendix A – Data Validation ........................................................................................ 31 Appendix B – CERT Error Rates ................................................................................... 32 Appendix C – Contact Information ................................................................................ 33 Confidential
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OptumInsight Product Assessment for <Client>
Report Summary
Optum is pleased to present the Product Assessment findings that are based on the file of claims
submitted by <Client>. The data submitted represents X months of billing activity based on charges that
were submitted between <date> and <date>. The purpose of this analysis is to demonstrate the
capabilities of ClaimsManager as well as demonstrate a potential Return on Investment (ROI). The
results are not intended to be an exact representation of how ClaimsManager will function within your
environment.
This analysis is based strictly on general coding rules and sourced industry standard edits contained within
ClaimsManager. In addition, you may identify requirements for custom rules specific to your
environment and/or payers. For the purpose of this analysis, we did not include the additional benefits
or potential for additional ROI that are derived when the system is installed and you are able to customize
these rules to reflect the unique reimbursement methodologies of your regional payers.
Data submitted included Commercial, Medicaid, and Medicare lines of business, which were run through
the professional module of the ClaimsManager software based on unmodified or standard rulesets. The
Commercial line of business claims were edited using the Commercial ruleset. The Medicaid line of
business claims were edited using the Medicaid ruleset. The Medicare line of business claims were edited
using the Medicare ruleset including Medicare Coverage Data for <State>.
Optum’s approach for this analysis is as follows: 1) Date of service is the source for edits that occur,
process date is not utilized, and 2) review and update of millions of edits on a quarterly basis. The editing
product will potentially elicit multiple edits on any given claim line that it analyzes. In order to provide
mutually exclusive reporting, Optum utilizes a methodology that prioritizes the edits on each claim line
and only counts the single highest priority edit that occurs on each claim line.
Ultimately, as this report illustrates, ClaimsManager will provide <Client> with the following benefits:
 Cost savings and improved staff productivity
o Correct issues at the least costly point in the workflow (up-front vs. back-end as claim
rejection)
o Using the quarterly updates Optum provides in the ClaimsManager knowledgebase
rather than building hard-coded edits or clinical coding scenarios
o Instead of excessive manual review and labor intensive charge corrections, leverage
technology to automate workflow with ClaimsManager
o Increase staff productivity, with far fewer manual activities
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With greater staff productivity, position your organization to more easily grow your
business without having to add new FTEs
Improved cash-flow
o Fewer claim rejects leads to quicker overall payment
Increased revenue
o Identify legitimate additionally billable revenue by auto-identifying incomplete charges
Support your compliance
o Reduce the risk associated with Provider compliance to government guidelines
o Provide detailed reporting to trends of both over-coding and under-coding
o Provide detailed reporting to provide education to both providers and coding staff
o Improve consistency and accuracy of coding and billing
o



The additional information provided in the Category III (Potential Denial Edits) and Category IV
(Informational Edits) edits provide a substantial opportunity to improve your workflow and claims
process, thus providing more additive value from ClaimsManager.
Return on Investment
Based on the data received, and using conservative calculation methodologies (which are further
delineated in this document), the potential calculated return on investment (ROI) is X:1. For unbilled
revenue and expenses relating to resubmission of denied claims, the Commercial dataset identified $X,
the Medicaid dataset identified $X, and the Medicare dataset identified $X. This results in a Total Annual
Impact of $X divided by the annual system cost of $X. Details of these findings are outlined in the
Annual Cost Justification section of this report.
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<Client> First Pass Rate Optimization
Based on the sample provided, Category II ClaimsManager edits identified errors that would have delayed
reimbursement on X out of X claim lines (X%).
<Client> Overall Edit Rate
Based on the sample provided, the four categories of ClaimsManager edits identified errors, potential
errors, and informational requirements on X out of X claim lines (X%).
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Data Validation
Prior to analyzing claims data through the ClaimsManager application, Optum evaluated the data through
a data validation process. Below we have listed the results of that process and listed the data elements
that were removed from the data.
Professional - Data Validation
Claim Lines
Submitted $
X
$X
(X)
($X)
X
$X
Description
Submitted to Optum
Removed due to various data errors (See Appendix A)
Included in study (X% of original sample)
Data Overview
The table below describes summary information of the data analyzed.
Commercial
Medicaid
Medicare
Total Claims
X
X
X
Total Lines
X
X
X
Total Billed Amount
$X
$X
$X
Average Lines Per Claim
X
X
X
Unique Patients
X
X
X
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Annual Cost Justification
The following table summarizes the annual opportunity costs and the total dollars that ClaimsManager
could potentially return to your organization.
<Client> ClaimsManager Projected ROI
Period Findings
Annualized
Findings
Category I Non-billed Code Edits
$X
$X
Category II Resubmission/Review Edits
$X
$X
Category I Non-billed Code Edits
$X
$X
Category II Resubmission/Review Edits
$X
$X
Type of Edit
Commercial
Medicare
$X (Annual Impact)
RETURN ON INVESTMENT (ROI)
$X (Annual System
Cost)
X:1
Table Notes:
Using conservative calculations, the resubmission costs were calculated using $25 per claim. This
estimated cost includes the typical cost of labor to pull the patient’s record, compare the documentation
to the codes assigned, make a decision regarding a more appropriate code combination, and finally the
costs tied to actual resubmission of the claim to the payer.
Note: Estimated typical cost of $25 to resubmit a claim is a value calculated by the American Medical Association
Practice Management Center (PMC). Standardizing CPT Codes, Guidelines and Conventions, Administrative
Simplification White Paper. May 19, 2009: Page 7.
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Edit Reporting Categories
The Product Assessment report categorizes the ClaimsManager output into five categories that are
weighted in importance and thus prioritized as follows:
Category I – Non-billed Code Edits
These edits identify services that were provided, but for which charges were not submitted.
Category II – Resubmission/Review Edits
These edits typically cause claim payment denials for coding and demographic errors, or errors that would
result in reduced payment. By 1) correcting the errors identified on these patient bills or 2) following
recommendations to send supporting documentation to justify services, a reduction in the number of
times patient bills are resubmitted to a payer is realized.
Category III – Potential Denial Edits
These edits identify bundle issues (unbundle and rebundle errors), global period errors and other
erroneous code relationships, which indicate a need for additional review of the use of codes or
modifiers. They frequently identify scenarios where submission of additional documentation to the payer
is needed to justify payment. In other cases, code combinations are identified that 1) could result in
legitimate claim denials and 2) identify patient bills that may trigger reviews by outside agencies. In these
cases, correction of the claim is accomplished by deleting the line containing the inappropriately billed
code.

Compliance Benefits: Since deletion of lines from the claims containing these edits occurs, this
category of edits cannot be used to calculate return on investment. However, there is financial risk
with any of these code combinations that could trigger an audit by a payer.

Accounts Receivable Impact: With the opportunity to remove inappropriately billed services from
claims prior to posting to Accounts Receivable, a practice can improve upon the accuracy in the
amount of dollars it posts to A/R.
Category IV – Informational Edits
Informational edits are not directly related to savings, but they can be utilized in investigations and other
measures that can bring benefits to a practice.
Category V – Medicare Edits
This category provides a list of all Medicare-specific edits that hit in Categories I-IV for a particular
Medicare dataset.
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ClaimsManager
Commercial Claims
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Commercial Detailed Results
Category I – Non-billed Code Edits
Edit
Description
Occurrences
Billed $
Non-billed
Occurrences
Non-billed
$
VEN
Venipuncture
X
$X
X
$X
INJ1
Injection Procedure Not Reported
with Reported Supply
X
X
X
X
SUB
Add-on Procedure without Primary
Procedure
X
X
X
X
EST
Established Patient Code for New
Patient
(X)
(X)
INJ
Injected Supplies
(X)
(X)
X
$X
X
$X
Totals
Table Notes
Occurrences
The Occurrences column represents the number of times each edit appears in the
data.
Billed $
The Billed $ column represents the submitted charge associated with each line that
elicits an edit.
Non-billed Occurrences The Non-billed Occurrences is the number of occurrences in which the elicited edit
has the highest priority for the claim line. The VEN edit will occur on each lab
procedure and is only counted once per claim.
Non-billed $
Non-billed $ represents dollars associated with codes that may be appropriate but
do not appear in the data. Non-billed $ are portrayed as 100% of the Medicare
Physician Fee Schedule (adjusted for your locality) for ease of interpretation.
Category I results are factored into the return on investment.
Listed below are areas of interest identified for review.

The VEN edit (Venipuncture) occurs on claims where a code for a lab test that may require a
blood specimen was billed but there was no code on the claim for the actual blood draw, for
example 36415 Collection of venous blood by venipuncture.

The INJ1 edit (Injection Procedure Not Reported with Reported Supply) occurs on lines from
claims containing only an injected solution and not the code for the injection procedure. Optum
calculates non-billed dollars for this edit by assuming the missing injection procedure is 96372
Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.
HCPCS code J1745 Injection infliximab, 10 mg accounted for X% of the occurrences. HCPCS code
J1756 Injection, iron sucrose, 1 mg accounted for X% of the occurrences. Provider ID
XXXXXXXXXX accounted for X% of the occurrences.

The SUB edit (Add-on Procedure without Primary Procedure) …
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
The EST edit (Established Patient Code for New Patient) …

The INJ edit (Injected Supplies) …
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Category II – Resubmission/Review Edits
Edit
Description
Occurrences
Billed $
Resubmit $
NPD
Not a Primary Diagnosis Code
X
$X
$X
UOV
Unbundle Procedure - Modifier Override
X
X
X
MFD
Typical Daily Frequency Exceeded
X
X
X
HOV
History Unbundle Procedure - Modifier Override
X
X
X
MOD
Modifier Not Appropriate with Procedure Code
X
X
X
LNM
Inappropriate Use of Repeat Modifier
X
X
X
GSP
Post-Op Surgery by Provider
X
X
X
RDL
Repeat Radiology Requires Repeat Modifier
X
X
X
GFP
Global Follow-Up by Provider
X
X
X
M26
Modifier 26 Required
X
X
X
ISX
Diagnosis Not Typical with Patient Gender
X
X
X
CAG
Procedure Not Typical with Patient Age
X
X
X
CPO
Care Plan Oversight
X
X
X
PCM
Invalid Professional Component Modifier
X
X
X
IAG
Diagnosis Not Typical with Patient Age
X
X
X
IMC
Inappropriate Modifier Combination
X
X
X
BPS
Missing or Invalid Place of Service
X
X
X
LPR
Repeat Lab Procedure Requires Modifier
X
X
X
PRH
Pre-Op Procedure One Day Before Surgery History
X
X
X
IDX
Nonspecific Diagnosis Code
X
X
X
ICD
Invalid Diagnosis Code
X
X
X
PRE
Pre-Op Procedure One Day Before Surgery
X
X
X
CSX
Procedure Not Typical with Patient Gender
X
X
X
M62R
Modifier 62 Required for TAVR/TAVI Codes
X
X
X
HBS
Hysterectomy by Specialty
X
X
X
CPT
Invalid Procedure Code
X
X
X
S51
Add-On Code with Modifier 51
X
X
X
NPT
New Patient Code Billed for Established Patient
Totals
Table Notes:
Occurrences
Billed $
(X)
(X)
X
$X
$X
The Occurrences column represents the number of times each edit appears in the
data.
The Billed $ column represents the submitted charge associated with each line that
elicits an edit.
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Resubmit $
Resubmit costs are based on the number of times an edit appears in the data (X),
divided by the average number of lines per claim (X), multiplied by the estimated
typical cost to resubmit a claim ($25).
Category II results are factored into the return on investment.
Listed below are areas of interest identified for review.

The NPD edit (Not a Primary Diagnosis Code) occurs on lines where the Primary ICD-9 code is
not allowed for reporting alone or as a primary diagnosis (i.e., sequenced first). ICD-9-CM
guidelines indicate to ‘code first underlying disease’ or ‘nature of the condition’ and use the E or
V code for detailed analysis. ICD-9 code V58.69 Long-term (current) use of other medications
accounted for X% of the occurrences. ICD-9 code V42.0 Kidney replaced by transplant accounted
for X% of the occurrences. Overall, V codes accounted for X% of the occurrences. Provider
IDs XXXXXXXXXXX and XXXXXXXXXX accounted for X% and X% of the occurrences,
respectively.

The UOV and HOV edits (Unbundle Procedure – Modifier Override and Unbundle Procedure –
Modifier Override in History) …

The MFD edit (Typical Daily Frequency Exceeded) …

The MOD edit (Modifier Not Appropriate with Procedure) …
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Category III – Potential Denial Edits
Edit
Description
Occurrences
Billed $
UNB
Unbundle Procedure – Unbundle or Incidental
X
$X
DAP
Review Add-On Procedure
X
X
REB
Rebundle to Appropriate Procedure Code
X
X
UEX
Unbundle Procedure – Exclusive
X
X
HNB
History Unbundle Procedure – Unbundle or Incidental
X
X
TCM
TCM and Services Included During Same 30 Day Period
X
X
HEX
History Unbundle Procedure – Exclusive
X
X
UNID
Unbundle Interrogation Device Evaluation in Person and
Remote by the Same Provider in a 90 Day Period
X
X
HRB
History Rebundle
X
X
X
$X
Totals
Table Notes:
Occurrences
Billed $
The Occurrences column represents the number of times each edit appears in the
data.
The Billed $ column represents the submitted charge associated with each line that
elicits an edit.
The edits in Category III are not factored into the return on investment.


The UNB and HNB unbundle edits (Unbundle Procedure – Unbundle or Incidental and History
Unbundle Procedure – Unbundle or Incidental) identify procedure code combinations where an
unbundle relationship exists and cannot be overridden with a modifier.
o
For UNB – CPT code 99070 Supplies and materials (except spectacles), provided by the physician
or other qualified health care professional over and above those usually included with the office visit or
other services rendered (list drugs, trays, supplies, or materials provided) billed with Medicine codes
96365-96367, 96372, 96375, 96413, 96415, and 96417 accounted for X% of the
occurrences. Overall, the Medicine codes (90281-99199 and 99500-99607) billed with
various other codes accounted for X% of the occurrences. Provider ID
XXXXXXXXXX accounted for X% of the occurrences.
o
For HNB – CPT codes 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance
or drug); subcutaneous or intramuscular and 96402 Chemotherapy administration, subcutaneous or
intramuscular; hormonal anti-neoplastic billed with code 99070 Supplies and materials (except
spectacles), provided by the physician or other qualified health care professional over and above those
usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials
provided) in history accounted for X% of the occurrences. Overall, the Medicine codes
(90281-99199 and 99500-99607) billed with various other codes accounted for X% of
the occurrences. No particular provider trending identified.
The DAP edit (Review Add-On Procedure) …
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
The REB edit (Rebundle to Appropriate Procedure Code) …

The UEX and HEX unbundle edits (Unbundle Procedure – Exclusive and History Unbundle
Procedure – Exclusive) …
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Category IV – Informational Edits
Edit
Description
Occurrences
Billed $
M51
Modifier 51 Required
X
$X
D59
Documentation Needed with Modifier 59
X
X
DLPB
Possible Duplicate Same Provider
X
X
IAP
Not a Frequent Diagnosis Code with Procedure
X
X
UNL
Unlisted Procedure Code
X
X
DLP
Duplicate Line by Provider
X
X
N51
Modifier 51 Inappropriate
X
X
POS
Place of Service Not Typical with Procedure
X
X
TRA
Transfer to Appropriate Code
X
X
GRP
Retained Procedure Code from Transfer
X
X
X
$X
Totals
Table Notes:
Occurrences
Billed $
The Occurrences column represents the number of times each edit appears in the
data.
The Billed $ column represents the submitted charge associated with each line that
elicits an edit.
The edits in Category IV are not factored into the return on investment.
Listed below are areas of interest identified for review.

The M51 edit (Modifier 51 Required) occurs when the claim has more than one procedure billed
on the same date that is eligible for modifier 51 Multiple procedure. The modifier should be
appended to the subsequent (lower RVU) procedure(s). For the purpose of the analysis, the
Medicare Fee Schedule RVUs are used which may differ from your practice. CPT code 95165
Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single
or multiple antigens (specify number of doses) accounted for X% of the occurrences. CPT codes 36415
Collection of venous blood by venipuncture and 94726 Plethysmography for determination of lung volumes and,
when performed, airway resistance each accounted for X% of the occurrences. Provider IDs
XXXXXXXXXX and XXXXXXXXXX accounted for X% and X% of the occurrences,
respectively.

The D59 edit (Documentation Needed with Modifier 59) …

The DLPB edit (Possible Duplicate Same Provider) …

The IAP edit (Not a Frequent Diagnosis Code with Procedure) …
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ClaimsManager
Medicaid Claims
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Medicaid Detailed Results
Category I – Non-billed Code Edits
Edit
Description
Occurrences
Billed $
Non-billed
Occurrences
Non-billed
$
mSB
Medicare Add-On Procedure without
Primary Procedure
X
$X
X
$X
mVP
Medicare Venipuncture
X
X
X
X
EST
Established Patient Code for New Patient
(X)
(X)
INJ
Injected Supplies
(X)
(X)
X
$X
X
$X
Totals
Table Notes:
Occurrences
The Occurrences column represents the number of times each edit appears in the
data.
Billed $
The Billed $ column represents the submitted charge associated with each line that
elicits an edit.
Non-billed Occurrences The Non-billed Occurrences is the number of occurrences in which the elicited edit
has the highest priority for the claim line.
Non-billed $
Non-billed $ represents dollars associated with codes that may be appropriate but
do not appear in the data. Non-billed $ are portrayed as 100% of the Medicare
Physician Fee Schedule (adjusted for your locality) for ease of interpretation.
Category I results are factored into the return on investment.
Listed below are areas of interest identified for review.

The mSB edit (Medicare Add-On Procedure without Primary Procedure) occurs when an add-on
code is submitted and a primary procedure code is not found on the claim or in history. CPT
code 90461 Immunization administration through 18 years of age via any route of administration, with
counseling by physician or other qualified health care professional; each additional vaccine or toxoid component
administered (List separately in addition to code for primary procedure) accounted for X% of the
occurrences. This code should be billed with Immunization Administration code 90460 as the
primary procedure. Provider ID XXXXXXXXXX accounted for X% of the occurrences.

The mVP edit (Medicare Venipuncture) …

The EST edit (Established Patient Code for New Patient) …

The INJ edit (Injected Supplies) …
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Category II – Resubmission/Review Edits
Edit
Description
Occurrences
Billed $
Resubmit $
sUO
Medicaid NCCI Edit - Modifier Required
X
$X
$X
sMUE
Medicaid Medically Unlikely Edits
X
X
X
IAG
Diagnosis Not Typical with Patient Gender
X
X
X
DTU
Date of Service to Units Discrepancy
X
X
X
NPD
Not a Primary Diagnosis Code
X
X
X
CDL
Deleted Procedure Code
X
X
X
GSP
Post-Op Surgery by Provider
X
X
X
CAG
Procedure Not Typical with Patient Age
X
X
X
GFP
Global Follow-Up by Provider
X
X
X
LBS
LCD Part B Missing Required Secondary
Diagnosis
X
X
X
CPT
Invalid Procedure Code
X
X
X
PRE
Pre-Op Procedure One Day Before Surgery
X
X
X
BDS
Missing or Invalid Date of Service
X
X
X
PRH
Pre-Op Procedure One Day Before Surgery History
X
X
X
LBP
LCD Part B Missing Required Primary Diagnosis
X
X
X
CSX
Procedure Not Typical with Patient Gender
X
X
X
ISX
Diagnosis Not Typical with Patient Gender
X
X
X
IMC
Inappropriate Modifier Combination
X
X
X
NPT
New Patient Code Billed for Established Patient
Totals
Table Notes:
Occurrences
Billed $
Resubmit $
(X)
(X)
X
$X
$X
The Occurrences column represents the number of times each edit appears in the
data.
The Billed $ column represents the submitted charge associated with each line that
elicits an edit.
Resubmit costs are based on the number of times an edit appears in the data (X),
divided by the average number of lines per claim (X), multiplied by the estimated
typical cost to resubmit a claim ($25).
Category II results are factored into the return on investment.
Listed below are areas of interest identified for review.

The sUO edit (Medicaid National Correct Coding Initiative Edits, Modifier Required) identifies
procedure code combinations where an unbundle relationship exists, and are billed without a
modifier per Medicaid guidelines. CPT code 90471 Immunization administration (includes percutaneous,
intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) billed
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with Established Patient Office Visit codes 99212, 99213, and 99215 accounted for X% of the
occurrences. CPT code 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug);
subcutaneous or intramuscular billed with Established Patient Office Visit codes 99212 and 99213
accounted for X% of the occurrences. Overall, the E/M codes (99201-99499) billed with
various other codes accounted for X% of the occurrences. Provider ID XXXXXXXXXX
accounted for X% of the occurrences.

The sMUE edit (Medicaid Medically Unlikely Edits) …

The IAG edit (Diagnosis Not Typical for Patient Age) …

The DTU edit (Date of Service to Unit Discrepancy) …

The NPD edit (Not a Primary Diagnosis Code) …

The CDL edit (Deleted Procedure Code) …
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Category III – Potential Denial Edits
Edit
Description
Occurrences
Billed $
sUH
Medicaid NCCI Edit – History
X
$X
sUN
Medicaid NCCI Edit
X
X
ASD
Anesthesia Secondary Procedure
X
X
ASH
Anesthesia Secondary Procedure – History
X
X
X
$X
Totals
Table Notes:
Occurrences
Billed $
The Occurrences column represents the number of times each edit appears in the
data.
The Billed $ column represents the submitted charge associated with each line that
elicits an edit.
The edits in Category III are not factored into the return on investment.
Listed below are areas of interest identified for review.

The sUN and sUH edits (Medicaid National Correct Coding Initiative Edits and Medicaid
National Correct Coding Initiative Edits – History) identify procedure code combinations where
an unbundle relationship exists, and are billed without a modifier per Medicaid guidelines.
o
For sUN – CPT code 90837 Psychotherapy, 60 minutes with patient and/or family member billed
with Established Patient Office Visit codes 99211 and 99213 accounted for X% of the
occurrences. CPT code 90471 Immunization administration (includes percutaneous, intradermal,
subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) billed with
Established Patient Office Visit code 99211 accounted for X% of the occurrences.
Overall, the E/M codes (99201-99499) billed with various other codes accounted for
X% of the occurrences. Provider ID XXXXXXXXXX accounted for X% of the
occurrences.
o
For sUH – Historical Established Patient Office Visit code 99211 billed with codes
90832 Psychotherapy, 30 minutes with patient and/or family member and 90834 Psychotherapy, 45
minutes with patient and/or family member accounted for X% of the occurrences. Overall,
the Medicine codes (90281-99199 and 99500-99607) billed with various other codes
accounted for X% of the historical occurrences. Provider ID XXXXXXXXXX
accounted for X% of the historical occurrences.
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Category IV – Informational Edits
Edit
Description
Occurrences
Billed $
D59
Documentation Needed with Modifier 59
X
$X
IAP
Not a Frequent Diagnosis Code with Procedure
X
X
UNL
Unlisted Procedure Code
X
X
DLP
Duplicate Line by Provider
X
X
POS
Place of Service Not Typical with Procedure
X
X
LPF
LCD Part B Profile
X
X
X
$X
Totals
Table Notes:
Occurrences
Billed $
The Occurrences column represents the number of times each edit appears in the
data.
The Billed $ column represents the submitted charge associated with each line that
elicits an edit.
The edits in Category IV are not factored into the return on investment.
Listed below are areas of interest identified for review.

The D59 edit (Documentation Needed with Modifier 59) occurs on claim lines where modifier
59 Distinct procedural service has been appended to the CPT code.

The IAP edit (Not a Frequent Diagnosis Code with Procedure) occurs when CPT/HCPCS codes
are submitted with ICD-9 diagnosis codes that are not commonly associated to be billed
together. Information from National Coverage Decisions (NCD), Local Coverage Decisions
(LCD), and provider specialty organizations are utilized to source commonly associated
relationships. Broad diagnostic relationships are assigned when procedure codes have no third
party industry source, historical use, policies, or guidelines to direct development of specific
relationships, including clinical development based on code descriptors. This edit will occur
when the CPT/HCPCS procedure code and the ICD-9 code are outside of the list of sourced,
commonly associated diagnosis to procedure relationships. Provider ID XXXXXXXXXX
accounted for X% of the occurrences.

The UNL edit (Unlisted Procedure Code) …

The DLP edit (Duplicate Line by Provider) …
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ClaimsManager
Medicare Claims
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Medicare Detailed Results
Category I – Non-billed Code Edits
Edit
mVP
Description
Occurrences
Medicare Venipuncture
Billed $
Non-billed
Occurrences
Non-billed
$
X
$X
X
$X
mMPN Medicare Pneumococcal Vaccine
Missing Administration
X
X
X
X
mMFL
Medicare Influenza Vaccine Missing
Administration
X
X
X
X
mSB
Medicare Add-On Procedure without
Primary Procedure
X
X
X
X
EST
Established Patient Code for New Patient
(X)
(X)
INJ
Injected Supplies
(X)
(X)
X
$X
X
$X
Totals
Table Notes:
Occurrences
The Occurrences column represents the number of times each edit appears in the
data.
Billed $
The Billed $ column represents the submitted charge associated with each line that
elicits an edit.
Non-billed Occurrences The Non-billed Occurrences is the number of occurrences in which the elicited edit
has the highest priority for the claim line. The mVP edit will occur on each lab
procedure and is only counted once per claim.
Non-billed $
Non-billed $ represents dollars associated with codes that may be appropriate but
do not appear in the data. Non-billed $ are portrayed as 100% of the Medicare
Physician Fee Schedule (adjusted for your locality) for ease of interpretation.
Category I results are factored into the return on investment.
Listed below are areas of interest identified for review.

The mVP edit (Medicare Venipuncture) occurs on claims where a code for a lab test that may
require a blood specimen was billed but there was no code on the claim for the actual blood
draw, for example 36415 Collection of venous blood by venipuncture. The 2014 clinical laboratory fee
schedule includes separately payable fees for certain specimen collection methods (CPT/HCPCS
codes 36415 Collection of venous blood by venipuncture, P9612 Catheterization for collection of specimen, single
patient, all places of service, and P9615 Catheterization for collection of specimen(s) (multiple patients).

The mMPN edit (Medicare Pneumococcal Vaccine Missing Administration) identifies
pneumococcal vaccine codes billed without the appropriate administration code per CMS
guidelines. CPT code 90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed
patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use
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accounted for X% of the occurrences. Provider ID XXXXXXXXXX accounted for X% of the
occurrences.

The mMFL edit (Medicare Influenza Vaccine Missing Administration) …

The mSB edit (Medicare Add-On Procedure without Primary Procedure) …

The EST edit (Established Patient Code for New Patient) …

The INJ edit (Injected Supplies) …
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Category II – Resubmission/Review Edits
Edit
Description
Occurrences
Billed $
Resubmit $
NPD
Not a Primary Diagnosis Code
X
$X
$X
mMOD
Medicare Modifier Not Typical for Procedure
Code
X
X
X
mM51
Medicare Modifier 51 Required
X
X
X
mPV
Medicare Preventive Vaccines
X
X
X
LBI
LCD Part B Missing or Invalid Diagnosis
X
X
X
LDY
LCD Part B Deny
X
X
X
mUO
Medicare Unbundle - Modifier Override
X
X
X
LPR
Repeat Lab Procedure Requires Modifier
X
X
X
mEV
Medicare Multiple E/M Codes
X
X
X
mUM
Medicare Other Unbundle - Modifier Override
X
X
X
LBS
LCD Part B Missing Required Secondary
Diagnosis
X
X
X
mEH
Medicare E/M and Surgery without Modifier History
X
X
X
LNM
Inappropriate Use of Repeat Modifier
X
X
X
LBM
LCD Part B Missing Required Modifier
X
X
X
mSP
Medicare Post-Op Surgery by Provider
X
X
X
mDP
Medicare Post-Op Unrelated Service
X
X
X
RDL
Repeat Radiology Requires Repeat Modifier
X
X
X
mFP24
Medicare Postoperative Unrelated Service by
Provider
X
X
X
BSP
LCD Part B Missing or Invalid Provider Specialty
X
X
X
CPT
Invalid Procedure Code
X
X
X
mDT
Medicare Diagnostic Testing in Hospital Setting
X
X
X
IDX
Nonspecific Diagnosis Code
X
X
X
mN51
Medicare Modifier 51 Inappropriate
X
X
X
IAG
Diagnosis Not Typical with Patient Age
X
X
X
mTH
Medicare Telehealth Services
X
X
X
mFL
Medicare Influenza Vaccine Missing Diagnosis
X
X
X
mEM
Medicare E/M and Surgery without Modifier
X
X
X
mPN
Medicare Pneumococcal Vaccine Missing
Diagnosis
X
X
X
mMUE
Medicare Medically Unlikely Edits
X
X
X
mSPh
Medicare Post-Op Related Surgery by Provider History
X
X
X
mPS
Medicare Physician Service Code
X
X
X
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Edit
Description
Occurrences
mEPG
Medicare Eval Code without Functional G Codes
X
X
X
mUMh
Medicare Other Unbundle - Modifier Override in
History
X
X
X
mHB
Medicare Hepatitis B Vaccine Missing Diagnosis
X
X
X
mDPh
Medicare Post-Op Unrelated Service - History
X
X
X
NPT
New Patient Code Billed for Established Patient
Totals
Table Notes:
Occurrences
Billed $
Resubmit $
Billed $
Resubmit $
(X)
(X)
X
$X
$X
The Occurrences column represents the number of times each edit appears in the
data.
The Billed $ column represents the submitted charge associated with each line that
elicits an edit.
Resubmit costs are based on the number of times an edit appears in the data (X)
divided by the average number of lines per claim (X), multiplied by the estimated
typical cost to resubmit a claim ($25).
Category II results are factored into the return on investment.
Listed below are areas of interest identified for review.

The NPD edit (Not a Primary Diagnosis Code) occurs on lines where the primary ICD-9 code is
not allowed for reporting alone or as a primary diagnosis (i.e., sequenced first). ICD-9-CM
guidelines indicate to ‘code first underlying disease’ or ‘nature of the condition’ and use the E or
V code for detailed analysis. ICD-9 code V58.69 Long-term (current) use of other medications
accounted for X% of the occurrences. ICD-9 code V42.0 Kidney replaced by transplant accounted
for X% of the occurrences. ICD-9 code V43.1 Lens replaced by other means accounted for X% of
the occurrences. Overall, V codes accounted for X% of the occurrences. Provider IDs
XXXXXXXXXX and XXXXXXXXXX accounted for X% and X% of the occurrences,
respectively.

The mMOD edit (Medicare Modifier Code Not Typical for Procedure Code) …

The mM51 edit (Medicare Modifier 51 Required) …

The mPV edit (Medicare Preventive Vaccines) …

The LBI edit (LCD Part B Missing Diagnosis) …

The LDY edit (LCD Part B Deny) …

The mUO edit (Medicare Unbundle – Modifier Override) …

The mUM and mUMh edits (Medicare Other Unbundle, Modifier Allowed and Medicare Other
Unbundle, Modifier Allowed – History ) …

The mMUE edit (Medicare Medically Unlikely) …
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Category III – Potential Denial Edits
Edit
Description
Occurrences
Billed $
mSM
Medicare Measurement Code
X
$X
mSX
Medicare Statutory Exclusion Service
X
X
mNV
Medicare Not Valid for Payment
X
X
mSE
Medicare Excluded from Physician Fee Schedule
X
X
mBC
Medicare Bundled Code
X
X
mBI
Medicare Bundled Item or Service
X
X
mTF
Medicare Timely Filing
X
X
mAP
Medicare Review Add-On Procedure
X
X
mFSQ
Medicare Nonpayable Function-Related G Codes
X
X
mMGY
Medicare Modifier GY
X
X
mNS
Medicare Non Covered Service
X
X
mIN
Medicare Injection Service
X
X
mSR
Medicare Restricted Coverage
X
X
mUN
Medicare Unbundle
X
X
mAS
Medicare No Payment for Assistant Surgeons
X
X
mUH
Medicare Unbundle - History
X
X
X
$X
Totals
Table Notes:
Occurrences
Billed $
The Occurrences column represents the number of times each edit appears in the
data.
The Billed $ column represents the submitted charge associated with each line that
elicits an edit.
The edits in Category III are not factored into the return on investment.
Listed below are areas of interest identified for review.

The mSM edit (Medicare Measurement Code) identifies services that Medicare considers a
measurement code and is used for informational purposes only. CPT Category II code 3016F
Patient screened for unhealthy alcohol use using a systematic screening method (PV) (DSP) accounted for X%
of the occurrences. Provider ID XXXXXXXXXX accounted for X% of the occurrences.

The mSX edit (Medicare Statutory Exclusion Service) …

The mNV edit (Not Valid for Medicare) …

The mSE edit (Medicare Excluded from Physician Fee Schedule) …

The CCI unbundle edits mUN and mUH (Medicare Unbundle Code on the Same Claim and
Medicare Unbundle Code, Separate Claim) …
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Category IV – Informational Edits
Edit
Description
Occurrences
Billed $
LPF
LCD Part B Profile
X
$X
D59
Documentation Needed with Modifier 59
X
X
mB2
Medicare Bilateral Adjustment Does Not Apply
X
X
mTR
Medicare Multiple Therapy Reduction
X
X
mDR
Medicare Diagnostic Radiology Reduction
X
X
mPD
Medicare Professional Diagnostic Radiology Reduction
X
X
m52
Medicare Reduced Services
X
X
mBP
Medicare Bilateral Procedure Reduction
X
X
LRD
LCD Part B Review/Request Documents
X
X
UNL
Unlisted Procedure Code
X
X
m53
Medicare Modifier 53
X
X
mMP
Medicare Multiple Procedure Reduction
X
X
mM78
Medicare Return to Operating Room Reduction
X
X
mER
Medicare Multiple Endoscopy Reduction
X
X
mD1
Medicare Document Assistant Surgeon
X
X
DLP
Duplicate Line by Provider
X
X
mERh
Medicare Multiple Endoscopy Reduction - History
X
X
mMPh
Medicare Multiple Procedure Reduction - History
X
X
mTRh
Medicare Multiple Therapy Reduction - History
X
X
X
$X
Totals
Table Notes:
Occurrences
Billed $
The Occurrences column represents the number of times each edit appears in the
data.
The Billed $ column represents the submitted charge associated with each line that
elicits an edit.
The edits in Category IV are not factored into the return on investment.
Listed below are areas of interest identified for review.

The LPF edit (LCD Part B Profile) occurs if the claim line meets an LCD or NCD requirement.
The claim line pays and the claim information is profiled. Further review of the policy may be
performed at your discretion to determine the circumstances identified in the policy; for example,
there may be specific recommendations regarding how often tests can be performed within a
timeframe. Within LCD policy LXXXXX Removal of Benign Skin Lesions, CPT code 17000
Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions
(eg, actinic keratoses); first lesion accounted for X% of the occurrences. Within LCD policy
LXXXXX Transthoracic Echocardiography (TTE), CPT code 93306 Echocardiography, transthoracic, realtime with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler
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echocardiography, and with color flow Doppler echocardiography accounted for X% of the occurrences.
Overall, LCD policies accounted for X% of the occurrences. Provider ID XXXXXXXXXX
accounted for X% of the occurrences.

The D59 edit (Documentation Needed with Modifier 59) …

The mB2 edit (Medicare Bilateral Adjustment Does Not Apply) …
Medicare Reduction Edits …
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Category V – Medicare Edits
Edit
Description
Occurrences
Billed $
mSM
Medicare Measurement Code
X
$X
mSX
Medicare Statutory Exclusion Service
X
X
mVP
Medicare Venipuncture
X
X
mNV
Medicare Not Valid for Payment
X
X
mSE
Medicare Excluded from Physician Fee Schedule
X
X
LPF
LCD Part B Profile
X
X
mMOD
Medicare Modifier Not Typical for Procedure Code
X
X
mBC
Medicare Bundled Code
X
X
mBI
Medicare Bundled Item or Service
X
X
mM51
Medicare Modifier 51 Required
X
X
mB2
Medicare Bilateral Adjustment Does Not Apply
X
X
mTR
Medicare Multiple Therapy Reduction
X
X
mPV
Medicare Preventive Vaccines
X
X
mTF
Medicare Timely Filing
X
X
LBI
LCD Part B Missing or Invalid Diagnosis
X
X
LDY
LCD Part B Deny
X
X
mAP
Medicare Review Add-On Procedure
X
X
mUO
Medicare Unbundle - Modifier Override
X
X
mFSQ
Medicare Nonpayable Function-Related G Codes
X
X
mDR
Medicare Diagnostic Radiology Reduction
X
X
mPD
Medicare Professional Diagnostic Radiology Reduction
X
X
mMGY
Medicare Modifier GY
X
X
mEV
Medicare Multiple E/M Codes
X
X
mUM
Medicare Other Unbundle - Modifier Override
X
X
m52
Medicare Reduced Services
X
X
LBS
LCD Part B Missing Required Secondary Diagnosis
X
X
mNS
Medicare Non Covered Service
X
X
mIN
Medicare Injection Service
X
X
mSR
Medicare Restricted Coverage
X
X
mEH
Medicare E/M and Surgery without Modifier - History
X
X
mBP
Medicare Bilateral Procedure Reduction
X
X
LBM
LCD Part B Missing Required Modifier
X
X
mSP
Medicare Post-Op Surgery by Provider
X
X
mUN
Medicare Unbundle
X
X
mDP
Medicare Post-Op Unrelated Service
X
X
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Edit
Description
Occurrences
Billed $
mMPN
Medicare Pneumococcal Vaccine Missing Administration
X
X
mSB
Medicare Add-On Procedure without Primary Procedure
X
X
mFP24
Medicare Postoperative Unrelated Service by Provider
X
X
LRD
LCD Part B Review/Request Documents
X
X
mMFL
Medicare Influenza Vaccine Missing Administration
X
X
m53
Medicare Modifier 53
X
X
mMP
Medicare Multiple Procedure Reduction
X
X
BSP
LCD Part B Missing or Invalid Provider Specialty
X
X
mM78
Medicare Return to Operating Room Reduction
X
X
mER
Medicare Multiple Endoscopy Reduction
X
X
mD1
Medicare Document Assistant Surgeon
X
X
mDT
Medicare Diagnostic Testing in Hospital Setting
X
X
mN51
Medicare Modifier 51 Inappropriate
X
X
mTH
Medicare Telehealth Services
X
X
mFL
Medicare Influenza Vaccine Missing Diagnosis
X
X
mEM
Medicare E/M and Surgery without Modifier
X
X
mPN
Medicare Pneumococcal Vaccine Missing Diagnosis
X
X
mERh
Medicare Multiple Endoscopy Reduction - History
X
X
mMUE
Medicare Medically Unlikely Edits
X
X
mSPh
Medicare Post-Op Related Surgery by Provider - History
X
X
mPS
Medicare Physician Service Code
X
X
mMPh
Medicare Multiple Procedure Reduction - History
X
X
mAS
Medicare No Payment for Assistant Surgeons
X
X
mUH
Medicare Unbundle - History
X
X
mEPG
Medicare Eval Code without Functional G-Codes
X
X
mUMh
Medicare Other Unbundle - Modifier Override in History
X
X
mHB
Medicare Hepatitis B Vaccine Missing Diagnosis
X
X
mDPh
Medicare Post-Op Unrelated Service - History
X
X
mTRh
Medicare Multiple Therapy Reduction - History
X
X
X
$X
Totals
Table Notes:
Occurrences
Billed $
The Occurrences column represents the number of times each edit appears in the
data.
The Billed $ column represents the submitted charge associated with each line that
elicits an edit.
The edits in Category V are not factored into the return on investment.
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Appendix A – Data Validation
Prior to analyzing claims data through the ClaimsManager application, Optum evaluated the data through
a data validation process. Below we have listed the results of that process and listed the data elements
that were removed from the data.
Data Errors Excluded from Study
% Errors
Description
X%
Multiple DOB by Patient
X%
Multiple Gender by Patient
X%
Duplicate Claim and Line
X%
Zero Dollar Claim
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Appendix B – CERT Error Rates
As part of its Improper Payments Information Act (IPIA) of 2002 compliance efforts, and to help all
Medicare FFS contractors better focus review and education, CMS established the Comprehensive Error
Rate Testing (CERT) program to randomly sample and review claims submitted to Medicare. CERT
Error rates are calculated and reported in DHHS Agency Financial Report, CMS Financial Report, and
semi-annual Improper Payment Reports.
<Client>
Source: CMS Improper Medicare FFS Payments Reports (Nov. 2011 for National MAC/Carrier rate). Client rate
based on number of distinct claims that received Optum Category II edits divided by the total number of claims in
the Medicare sample provided.
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Appendix C – Contact Information
Optum Regional Sales Representative for <Client>
XXXXXXX XXXXXX
Phone:
(XXX) XXX-XXXX
E-mail:
[email protected]
Corporate Headquarters
Optum
12125 Technology Drive
Eden Prairie, MN 55344
(953) 833-7100
www.Optum.com
Prepared by XXXXX XXXXXXX, CPC
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