New ClaimsXten Edits - Effective August 14, 2016

Date Issued: 6/30/2016

Effective August 14, 2016, EmblemHealth will add the following new billing and reimbursement edits for all EmblemHealth benefit plans, both in- and out-of-network. These edits reflect recent updates to the ClaimsXten® software utilized by EmblemHealth. EmblemHealth follows the policies of the Centers for Medicare & Medicaid Services, the American Medical Association, and its own medical policy regarding the correct coding of claims.

A complete list of edits, including updates and additions, is available here.

Rule Description
Bilateral Procedures Identifies the same code billed twice for the same date of service, where the first code has the bilateral -50 modifier appended. The rule denies the second submission regardless if it is submitted with or without a bilateral modifier.
Bundled Service Identifies claim lines containing procedure codes indicated by CMS as always bundled when billed with any other procedure for the same member for the same provider ID for the same date of service. The rule allows bundled codes to pay if billed alone or if billed with only other procedure codes indicated as always bundled.
New Patient Procedures Identifies claim lines containing a new patient E&M code when another claim line containing any E&M code was billed within a three year period by the same provider.
Pay Percent - Multiple Cardiology Identifies claim lines that are eligible for a Multiple Procedure Payment Reduction- Technical Component (TC) of Diagnostic Cardiovascular Procedures. Assigns appropriate pay percentage to the eligible line(s), including adjustments for multiple procedures, as well as bilateral, multiple quantity, and additional payment modifiers.
Pay Percent - Multiple Ophthalmology Identifies claim lines that are eligible for a Multiple Procedure Payment Reduction- Technical Component (TC) of Diagnostic Ophthalmology Procedures. Assigns appropriate pay percentage to the eligible line(s), including adjustments for multiple procedure, as well as bilateral, multiple quantity, and additional payment modifiers
Co-Surgeon (CO_SURGEON_MADV) Identifies claim lines containing procedure codes, submitted with co-surgery modifier –62 in any of the four modifier positions, where there is a payment restriction for co-surgery according to the CMS Medicare Physician Fee Schedule.
CPAP BIPAP Supply Frequency Identifies supply codes associated with the Continuous Positive Airway Pressure or Bi-level Positive Airway Pressure (CPAP/BIPAP) therapy that are being submitted at a rate that exceeds the usual or customary rate. This rule will also identify those supply codes submitted without modifier –KX (Requirements specified in the medical policy have been met). This rule recommends the denial of claim lines containing CPAP/BIPAP supply codes submitted with modifier –KX prior to the determined renewal interval. This rule identifies quantities of supplies greater than the usual maximum amounts.

Additionally, this rule identifies claim lines containing CPAP/BIPAP supply codes submitted with modifiers –EY, –GA, or –GZ. If a claim is submitted without modifier –KX, this line will also be denied.