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Clinical Editing
MMBA - Lansing
April 2013
Terri Brady, RN, BSN, CCM
Manager, Medical Policy Clinical Editing
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Clinical Editing Team
• Supervisor – Tracy Bunge
– 4 Clinical editing analysts
• Lead analyst
– System configuration
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Clinical editing overview
BCN is focused on accurate and fair payment
to providers for the covered services they
provide:
 The proper reporting of clinical services presents
challenges due to the significant volume and
complexity of codes, modifiers and combinations
that are used to define correct coding.
 Effective clinical editing management is required to
assure proper payment is made. The challenges
that apply to proper reporting also apply to clinical
editing.
 The largest national carriers contract with external
vendors for clinical editing expertise.
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Clinical editing overview
From
Claims
chapter of
BCN
Provider
Manual
4
Clinical editing overview
From
Claims
chapter of
BCN
Provider
Manual
5
Clinical editing appeals: The basics
Clinical Editing 101
 Appeals are processed in Grand Rapids and Southfield by
trained analysts.
 Appeals are scanned into the system within one week.
 Our goal is to make a determination within 30 days and
respond to the appeal within 40 to 50 days.
 If you have not received a determination in 30 days, please
status your appeal with Customer Service before resubmitting.
 Currently, determinations are being made under 30 days, with
responses sent within 30 days, in most cases.
 Our main focus is on correct coding.
 Not all clinical editing denials require an appeal.
 Submit appeals when appropriate.
 BCN does not use Clear Claim Connection (C3).
 Clinical editing denials are the provider’s liability; members
are to be held harmless.
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Clinical editing appeals: The basics
Clinical Editing 101
(continued)
Important things to know about the clinical
editing appeals process:
 There is only one level of appeal.
 Appeals must:
 Be received within 180 days of the original denial.
 Submitted with a completed Clinical Editing
Appeal Form.
 Submitted with appropriate clinical
documentation.
 Include all other relevant documentation, if
applicable.
 If further review is needed, the appeal will be sent to
the medical director for determination.
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Clinical editing appeals process
From Claims chapter
of BCN Provider
Manual
8
Clinical editing appeals process
From web-DENIS
Billing page
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Clinical editing appeals process
From web-DENIS
Billing page
10
Clinical editing appeals process
From
Claims
chapter
of BCN
Provider
Manual
11
Clinical editing denials
From
Claims
chapter of
BCN
Provider
Manual
12
Unbundling/rebundling
From Claims chapter of
BCN Provider Manual
13
Unbundling/rebundling
Example of procedure unbundling / rebundling
From
BCN
Provider
News,
Jan-Feb
2011
Note: *72192, 72193, 72194 and 74150, 74160, 74170 would be the individual component codes
.
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Unbundling/rebundling
Example of procedure unbundling / rebundling
(continued)
• *11750
• *11752
• If these codes are reported on the same claim
for the same toe or the same finger, pc 11750
would rebundle (or be considered incidental)
to pc 11752.
• If no modifiers are reported to distinguish
separate sites an edit will occur, as same sites
are assumed.
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Incidental edits
From Claims
chapter of BCN
Provider Manual
16
Incidental edits
Example of incidental procedure
• Examples:
– *19102
– *19301
• If a breast biopsy is done at the same time as a
mastectomy or a partial mastectomy, the biopsy will
deny incidental to the mastectomy.
• If the procedures were done on different breasts,
the edit can be avoided by the use of a site modifier.
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Repeat procedures
Using modifiers for repeat procedures
• Modifiers *76 and 77 are used to indicate repeat
radiology, EKG or surgical pathology procedures.
• Tips for using 76 and 77 include:
Note: Modifier 77 usage has been expanded to include
CPT code *59025.
From Appropriate
Modifier Usage
document on webDENIS Billing page
18
Repeat procedures
Using modifiers for repeat procedures
(continued)
• Modifiers *76 and 77 will not work in the
two-view and three-views scenarios. These
scenarios must be appealed.
19
Mutually exclusive edits
From
Claims
chapter of
BCN
Provider
Manual
20
Mutually exclusive edits
Example of mutually exclusive codes
• Examples:
– *58152
– *58140
– Removal of fibroid tumors would be considered mutually
exclusive when performed at the time of a hysterectomy.
• An assumption is made when codes are submitted on
a claim – same site and same session
• Mutually exclusive edits consist of:
– Procedure combinations that reach the same outcome,
but typically via a different approach or technique
– Overlapping services
– Initial and subsequent services
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Duplicate edits
From
Claims
chapter of
BCN
Provider
Manual
22
Duplicate edits
Example of duplicate procedures
• Example: BCN will pay for only one radiology
report. The following example is for a patient
receiving X-ray services during a surgical
procedure:
– If the orthopedic surgeon bills for professional
radiology services rendered during the surgery, and
the radiologist also reports for the same services,
here’s what will happen:
• The claim that is presented to BCN first will get paid.
• The second claim will receive the edit.
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Frequency edits
Example of frequency edits
• Example: a screening mammogram
– A member’s benefits allow one for every 12 months.
• Identified provider issue: verification of prior
mammogram
– Have member bring the prior report or film.
– Contact the prior provider for the report.
– Contact BCN Customer Service for the member’s last
documented screening mammogram.
• Screening and diagnostic mammograms can be done
and reported on the same day, if medically indicated.
• Diagnostic mammograms do NOT count against the
frequency limit.
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Procedure code/modifier edits
From
Claims
chapter of
BCN
Provider
Manual
25
Add-on code edits
Add-on codes
• Add-on codes must be reported with an
appropriate primary procedure in order to be
paid.
• An add-on procedure should never be reported
as a stand-alone service, and if done so, will
most likely result in a clinical editing denial.
• Add-on codes are not subject to multiplesurgery reduction, as this is taken into
consideration in the code configuration.
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Add-on code edits
Add-on codes
(continued)
• Example: Billing with the add-on code *58110 (a
biopsy code for a colposcopy) without billing an
appropriate primary procedure code will result in a
denial.
• Many times there is more than one appropriate
primary code. For PC *58110, the CPT manual
indicates to code first *57420-57421, 5745257461).
• To correct this type of clinical editing denial,
submit a corrected claim or the Status Claim
Review Form (available via the web-DENIS Billing
page).
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Modifier 59 usage
Information on modifier *59
From BCN Provider News, Mar-Apr 2011
28
Modifier 59 usage
Information on modifier *59 (continued)
From BCN Provider News, Mar-Apr 2011
29
Modifier 59 usage
From web-DENIS
Billing page
30
Modifier 59 usage
31
Modifier 59 usage
32
Unlisted edits
33
Unlisted edits
More about NOC codes
From Care
Management
chapter of
BCN
Provider
Manual
34
Unlisted edits
NOC codes
(continued)
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Limit edits
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Limit edits
Example of limit rules
• When a provider reports a number of units
that exceeds the allowed number of units
for that procedure, here’s what happens:
– The total number of units is adjusted to the
allowed amount assigned to that procedure.
– The excess units are denied.
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Limit edits
Example of limit rules
• For an injection into the eye, typically the
procedure code of *67028 is reported:
– The system is set up to allow a maximum of
two injections
– The limit is one per eye, RT and LT
Note: Limits may also be applied to the drug(s) administered via the injection and are administered
separately from the injection code(s), if applicable. Drug codes are not to be reported with site
modifiers.
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Investigational edits
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Investigational edits
Example of an investigational procedure
•
•
•
•
*61640
*61641
*61642
BCN medical policy states:
“The effectiveness of percutaneous transluminal angioplasty for the
treatment of cerebral vasospasm following subarachnoid
hemorrhage has not been established, therefore, it is considered
experimental and investigational.”
• Therefore, without prior authorization of an
experimental/investigational procedure, it is not payable to
providers and members are not responsible.
Source: BCN medical policy Percutaneous Transluminal Angioplasty (PTA) for the Treatment of Cerebral Vasospasm effective 05/01/12.
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Drug & biological edits
• Implementation of Drugs & Biologicals editing began in
April of 2010
• Edits are related to select drugs & biologicals;
information has been published in the provider
newsletter
• Types of edits that may be seen with the d&b may
vary with the agent, but may include the following:
–
–
–
–
–
–
Diagnosis
Dose interval
Dose quantity
Dose frequency
Age
Other
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Drug & biological list - sample
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Drug & biologicals: additional info
• Drugs & Biological Editing
J9300 is the procedure code for Gemtuzumab
– PC J9300 will receive an edit when a diagnosis of
acute myeloid leukemia is not reported on the
claim for this injectable
– PC J9300 will also receive an edit when it is
reported more frequently than once every two
weeks by any provider, regardless of the diagnosis
• D & B Edits
– Identified on remittance advice by an explanation
code of QPB – QPL
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Additional reasons for denials
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Q&A
QUESTION:
How should an EMG be reported if it is done along with
NCS?
ANSWER:
In 2012, the codes for EMGs were updated to include three
add-on codes, *95886-95887. If NCS are done at the same
time as an EMG, the appropriate add-on code should be
reported, as opposed to a stand-alone EMG code (eg, 95860,
95861, 95870, etc.)
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Q&A
QUESTION:
I am receiving a denial for the administration of drugs I get
through the specialty pharmacy. This does not seem right.
How can I get paid?
ANSWER:
The administration code for many drugs requires
documentation as to which drug was provided. The solution,
other than submitting an appeal, is to document the drug on
the claim with the appropriate HCPCS code and a charge of
$0.01. This will allow the drug to be recognized and the
administration to go through and be paid.
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Q&A
QUESTION:
Why do we have to appeal so much?
ANSWER:
BCN is focused on correct coding and documentation
supporting the correct reporting of services provided. Appeals
provide information that supports this effort and may result in the
modification of clinical edits.
A recent example of an edit modification is with PC 93306. This had
been receiving an edit with E&M codes, especially noted in the IP
setting. Upon review it was noted that the providers were typically
performing the full study and doing a complete E&M. Therefore, it
was determined to break this edit.
NOTE: To facilitate the processing of appeals, please mark sections or comments specific to
the procedure service being appealed. Highlighting may not work as it may obscure notes or
become invisible as appeals are scanned.
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Q&A
QUESTION:
What documentation do I need to submit for an appeal?
ANSWER:
It depends….on the service provided, the reason for the edit and what is
being appealed. Typically for a an office visit – office visit notes are needed;
for surgery – the operative report is a must; for radiology – the x-ray report is
required.
But, the reason for the denial must be considered in what documentation to
send. For example, additional documentation may be required, including that
of paid services, in many instances:
•Duplicate denials, such as with radiology (both reports are needed)
•Office visit/office procedures may require documentation of the procedures, not just the
visit
•Global edits may require the records from prior visits/services
Documentation from the CPT book is not needed. Do not send copies of other
payers or Medicare RAs or EOBs. If, though, you have information from
professional societies or recent changes in Medicare payment rules (eg,
transmittals), those may assist in the review.
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Resources
Links
•
•
•
Transmittals http://www.cms.hhs.gov/Transmittals/
NCDs
http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd
LCDs
http://www.cms.hhs.gov/DeterminationProcess/04_LCDs.asp
Resources
• BCN Provider Servicing: 1-866-299-4667
• BCN Clinical Editing – submit appeals to:
Clinical Editing Appeals – Mail Code G820
Blue Care Network
611 Cascade West Parkway, SE – Grand Rapids, MI 49546-2143
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