November 3, 2022
Last year, Premera expanded clinical editing to help avoid claims edits and denials. Professional and facility claims use enhanced edits to promote correct coding and billing practices. This includes coding validation edits reviewed by registered nurses and certified coders. This level of claim review considers past claims experience to see if the claim was coded correctly.
Modifiers Matter: Tips to Avoid Denials
If a procedure code doesn’t match the anatomic site of the modifier, the procedure code will be denied. Missing anatomic modifiers when billed with another procedure with a modifier may result in a denial or a bundle of the procedure code.
If a diagnosis code that has laterality included in its description doesn’t match with an anatomic modifier appended to the procedure code, a claim/claim line will be denied.
If multiple evaluation and management (E&M) encounters occur on the same date, make sure you append a correct modifier. Use modifier 25 for professional services and modifier 27 for outpatient hospitals (emergency room and ambulatory surgery center). If a modifier is incorrect, the claim will be denied. Documentation in the patient’s record must support a separate and distinct E&M service when appending modifier 25.
Coding Validation Edits
Coding validation edits identify claims with potential incorrect coding that needs further review by clinical analysts (registered nurses and coders). Using information on the flagged claims and the patient’s claim history, the coding accuracy is validated.
Some situations addressed by coding validation:
- Correct coding initiative (CCI) edits with modifier override allowed and an override modifier is on the line
- E&M on same day as a procedure and an override modifier is on the line
- American Medical Association (AMA) and National Correct Coding Initiative (NCCI) unbundling edits
- Cross provider duplicates to identify multiple providers billing the same procedure code on the same date
Physical Medicine and Rehabilitation Therapy Service Modifiers
Physical medicine/rehabilitation services, including physical, occupational, speech and massage therapy services, when submitted by any provider and any specialty, must be submitted with an appropriate plan of care modifier. A link to the applicable therapy codes has been added to the policy.
The plan of care modifiers are as follows:
- GN – Services delivered under an outpatient speech-language pathology plan of care
- GO – Service delivered under an outpatient therapy plan of care
- GP – Service delivered under an outpatient physical therapy plan of care
Correct Place of Service (POS) Edits
Professional services provided in an inpatient setting must be reported with the inpatient hospital POS code 21 no matter the setting where the patient receives the face-to-face encounter. If a professional claim has an incorrect POS, it will be denied.
If an independent laboratory bills for a test on a sample drawn in an inpatient or outpatient hospital setting, it must use the place of service code for the inpatient (POS code 21), off-campus outpatient hospital (POS code 19), or on-campus outpatient hospital (POS code 22), respectively. If an independent lab claim has an incorrect POS, it will be denied.
A full list of the POS codes can be found in the policy.