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.
|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.