October 5, 2023
During the upcoming fourth quarter of 2023, additional claim edits will be implemented in the first pass claims editor. The majority of these new edits enforce existing Premera payment policies as well as correct coding and billing industry guidelines.
These new edits include:
- OB/Maternity edits: Will identify when multiple global OB delivery codes are submitted for the same delivery or with components of the global (antepartum, postpartum, delivery only).
- Modifier 52-Reduced Services: Will deny delivery codes billed with modifier 52 to represent “labor management only” when a mother is transferred to another provider for the actual delivery of the baby.
- Multiple Deliveries/Births: Each second and subsequent birth after the initial birth will need to be billed on a separate claim line with an appropriate modifier, excluding initial cesarean section births.
- Home Birth Kit (S8415): Home birth kit is limited to 1 submission per pregnancy, billed on the mother’s claim only. Additionally, the billing of individual supplies that are included in the birth kit will be denied reimbursement if billed separately along with the birth kit code.
- Prolonged Services for Labor Management: Billing the prolonged services CPT codes to represent labor management will not be reimbursed.
- Multiple Anatomic Site Modifiers appended on same code: Identifies and denies a claim line billed with more than one anatomic site modifier.
- Laterality Match: Claim lines containing site modifiers (LT, RT) must match the diagnosis code laterality and vice versa (ICD-10-CM Diagnosis Coding Guidelines).
- Multiple E&M Visit Codes Billed on Facility Claims: Identifies multiple E&M and other visit codes submitted on the same date of service, by the same facility and the same Revenue Code where the second and subsequent E&M lacks modifier 27-Multiple Outpatient Hospital E&M Encounters on the same date (CPT Codebook Appendix A-Modifiers).
For more detailed information, for those upcoming edits that are based on a payment policy, a link to the associated policy is included above. For those edits based on an industry coding guidelines, the source is also noted.
If you have any questions, please contact your Provider Network Representative.