New ClaimsXten® Edits for Facility-Based Services

Date Issued: 8/21/2015

EmblemHealth plans to implement the following new facility billing and reimbursement edits in November/December 2015. These will be effective for EmblemHealth’s GHI, GHI HMO and HIP commercial and government programs and applies to claims submitted both in-and out-of-network. These edits reflect recent updates to the ClaimsXten® software utilized by EmblemHealth.

The new edits and descriptions are summarized below.

Rule Description
MUE Multiple Lines Facility This edit identifies claim lines where the MUE (Medically Unlikely Edit) has been exceeded for a CPT/HCPCS code, reported by the same provider, for the same member, on the same date of service. MUE was developed by CMS and is updated quarterly.
Multiple Medical Same Day Visits This edit identifies claim lines for subsequent submissions of E&M services where the subsequent visit codes lack applicable modifiers as required by CMS. This edit also identifies claim lines where E&M visit codes are submitted with a quantity greater than one (1) without applicable modifiers.
Procedures Not Covered, Facility This edit identifies claim lines on facility claims containing Procedure Codes with a Payment Status Indicator of E in the Integrated Outpatient Code Editor (I/OCE) HCPCS Data File published by CMS.
Revenue Code Validation This edit identifies claim lines containing invalid revenue codes.
Unbundled Pairs Outpatient This edit detects surgical code pairs where either one code is a component of the other code, or the codes represent services that would not reasonably be performed together on the same date of service.
External Diagnosis Codes This edit identifies claims submitted with E diagnosis codes as the principal diagnosis. E codes identified by CMS’s Integrated Outpatient Code Editor (I/OCE) HCPCS Data File are intended to provide data for injury research and evaluation of injury prevention strategies.
Revenue Codes that Require HCPCS Codes This edit identifies revenue codes for which the CMS Outpatient Prospective Payment System (OPPS) Integrated Outpatient Code Editor (I/OCE) requires submission with accompanying HCPCS codes.