Avoid Claim Edits and Denials with These Helpful Tips

  • September 2, 2021

    As previously communicated, Premera is expanding clinical editing in October 2021. This information can help you understand the edits. This isn’t a definitive list.

    Modifier Edits

    • Pay attention to anatomic modifiers. 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. Modifier 25 should be used 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.

    Coding Validation Edits

    Coding validation edits identify claims with potential incorrect coding for review by clinical analysts (registered nurses and coders). Using information on the flagged claims and 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) unbundling edits
    • Cross provider duplicates to identify multiple providers billing the same procedure code on the same date

    ICD-10 Diagnostic Coding Edits

    • All diagnosis codes on the claim need to be valid, complete, and coded to the highest level of specificity. If at least one of the codes on the claim line (professional claim) or a claim header (facility claim) isn’t meeting these standards, the claim line on the professional claim or the entire facility claim will be denied.
    • Ensure that primary/principal diagnosis code is appropriate for that position. If a claim has a secondary, manifestation or sequela code in a primary/principal position, a claim will be denied.

    Correct Place of Service (POS) Edits

    • Professional services rendered in an inpatient setting must be reported with the inpatient hospital POS code 21 irrespective of the setting where the patient receives the face-to-face encounter. If a professional claim has a wrong POS, it will be denied.
    • If an independent laboratory bills for a test on a sample drawn in an inpatient or outpatient setting of a hospital, 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 a wrong POS, it will be denied.

    If you have questions, visit the payment policy page for updates or attend a Provider Workshop on September 15. Sign up today!

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