November 18, 2021
Professional and Facility claims will use enhanced edits to promote correct coding and billing practices including coding validation edits which are reviewed by registered nurses and certified coders. This level of claim review takes into consideration
historical claims experience to determine if the claim was coded correctly.
Additional coding and billing guidelines from the following sources are included as part of this claim edit expansion:
- Premera’s payment and medical policies
- CMS coding policies
- CPT and ICD-10 coding guidelines
- Nationally recognized academy and society guidelines
- National Uniform Claim Committee billing guidelines (CMS-1500)
- National Uniform Billing Committee Official UB-04 Data Specifications Manual
Some of the enhanced edits include but aren’t limited to the following:
- Additional National Correct Coding Initiative edits
- Global surgical periods
- Co-surgeon and assistant surgeon billing guidelines
- Multiple procedure reductions
- Correct modifier usage
- Correct place of service coding
- Correct add-on and primary code usage
- Unit limitations
- Medically unlikely (MUE) edits
- Appropriate coding on UB-04 claims including revenue codes, bill types, condition codes, value codes, etc.
- Device and supply criteria expansion
Review the prior articles published in the Provider News announcing these edit enhancements: