CONNECTIONS APPEALING A CODE DENIED BY CLINICAL EDIT

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1 APPEALING A CODE DENIED BY CLINICAL EDIT Providers may appeal denials of edited codes by submitting a clinical edit (CE) inquiry. The Clinical Edit Inquiry form may be found on ProvLink by clicking on Forms in the tool bar on the left side of the home page. Submit the completed form, along with all documentation for the date of service, to the dedicated inquiry fax number listed at the top of the form. Use Clinical Edit Inquiry fax form for the edits listed on page 5 of this newsletter. (These edits are also listed on the form.) To avoid delays, it is important to submit documentation supporting all services performed on the day in question, including documentation for codes that were paid. When a bundling edit (incidental or mutually exclusive edit) fires on a code pair, PHP needs to see documentation supporting both the paid code and the denied code. If a coding review determines that the edited code(s) may be paid for the case in question, the claim will be reprocessed and the denied charge(s) will be reconsidered. If the review finds that the edit was appropriate, a letter will be sent to the provider with PHP s rationale for upholding the edit. May-June 2013 In This Issue Appealing a Denied Code (NEW) Transitional Care Management (NEW) Unlisted Codes (NEW) Multiple Codes for Shoulder Surgery (NEW) Place of Service (POS) for Services or Supplies (NEW) CPT Code (NEW) PHP Clinical Editing Explanation Codes What To Do If You Have Questions Payment Rules Electronic Contract Delivery For additional information on clinical edits and the appeal process, see pages 5 and 6 of this newsletter. 1

2 TRANSITIONAL CARE MANAGEMENT PHP will allow payment for CPT codes and for transitional care management (TCM). Code is used to report TCM with medical decision making of at least moderate complexity during the service period and at least one face-to-face visit within fourteen calendar days of discharge. Code is used to report TCM with medical decision making of high complexity during the service period and at least one face-to-face visit within seven calendar days of discharge. These codes are used to report care management services by a physician or physician extender (see PHP Payment Policy 40.0) for a 30-day period following a patient s discharge from a hospital or care facility. Providers are cautioned to carefully read and follow the instructions given in the CPT book for reporting these codes. The 30-day period for TCM services begins on the day of discharge and continues for the next 29 days. The date of service reported on the claim should be the 30th day following discharge. Each of these codes includes at least one face-toface visit which should not be reported separately. The place of service for the TCM code should correspond to the place of service of the required face-to-face visit. Providers will need to submit an appeal with chart notes to support any evaluation and management (E/M) services billed within 30 days of a TCM code to show that the visits are separate from the visit included in the TCM code. If the patient is readmitted in the 30-day period following discharge, the TCM code may be reported as long as the services described by the code are furnished by the practitioner during the 30-day period, including the time following the second discharge. Alternatively, the practitioner may bill for TCM services following the second discharge for a full 30-day period as long as no other provider bills the service for the first discharge. CPT guidelines for TCM services state that only one individual may report TCM services and only once per patient within 30 days of discharge. Another TCM code may not be reported by the same individual or group for any subsequent discharge(s) within 30 days. Because the TCM codes are used to report a full 30 days of care, the codes should not be used in cases when the patient dies prior to the 30th day. In those cases, providers may use the appropriate E/M code to report any face-to-face visits that occurred. 2

3 DOCUMENTATION REQUIREMENTS FOR UNLISTED CODES PHP Payment Policy 27.0 (Exception Pricing for CPT or HCPCS Codes) gives the coding and documentation requirements for reporting unlisted codes to PHP. To avoid delay in payment, providers are encouraged to follow the guidelines in this policy when submitting claims with unlisted codes. Because unlisted and unspecified procedure codes do not describe a specific procedure or service, it is necessary for the provider to submit supporting documentation when filing the claim. The documentation should include: A clear description of the nature, extent, and need for the procedure or service. Time, effort, and/or equipment necessary to provide the service. In the procedure note, or in the notes section of the claim, indicate which CPT code may be considered most like the unlisted procedure performed. Underline the portion of the note that identifies the test or procedure that is being reported with the unlisted code. Any extenuating circumstances which may have complicated the service or procedure. MULTIPLE CODES FOR SHOULDER SURGERY The National Correct Coding Initiative (NCCI) policy manual has new guidance for reporting multiple procedures performed on the shoulder. The 2013 NCCI policy manual, Chapter IV, Section H-22, states, CMS considers the shoulder joint to be a single anatomic structure. An NCCI procedure to procedure edit code pair consisting of two codes describing two shoulder joint procedures should never be bypassed with an NCCI-associated modifier when performed on the ipsilateral shoulder joint. This type of edit may be bypassed only if the two procedures are performed on contralateral joints. Beginning with claims processed on or after June 1, 2013, modifier 59 will not be allowed to override any NCCI edit for surgical codes performed in the shoulder joint. Modifiers LT and RT may be reported as appropriate when performed on opposite (contralateral) shoulders. PHP will not allow modifiers to override NCCI edits for multiple procedures performed on the same (ipsilateral) shoulder. 3

4 PLACE OF SERVICE (POS) FOR SERVICES OR SUPPLIES PHP follows CMS guidelines for place of service (POS) coding. With two exceptions, the POS code for all services for professional charges should be the setting in which the patient received the face-to-face service. If a splint or other supply is dispensed in the physician s office, report POS 11 (office), even though the patient will be taking the supplies home. The physician would not use POS 12 (home) for the splint or supplies because the physician did not provide a face-to-face service in the patient s home. In cases where the physician or practitioner provides the interpretation of a diagnostic test from a distant site, the provider should assign the POS code that corresponds to the setting in which the patient received the technical component (TC) of the service. For example, a patient receives an x-ray in the outpatient department of a hospital and the physician performs an interpretation of the study at his/ her office. POS 22 (outpatient hospital) would be used on the physician s service to indicate that the patient received the face-to-face (TC) portion of the x-ray at the outpatient hospital. The only two exceptions to the face-to-face rule apply when the patient is admitted to a facility as an inpatient or an outpatient. In those two cases, the POS is the setting where the patient is admitted/registered, regardless of where the face-toface service occurred. In other words, if the patient is admitted as an inpatient and is transferred to an outpatient facility for a procedure or test, the POS for the interpretation of that test is 21 (inpatient hospital), even though the technical component of the test is in an outpatient setting. CPT CODE CPT code is used to report de-clotting of an implanted vascular access device or catheter. After a clot has been confirmed by an angiographic procedure, a thrombolytic agent (streptokinase or urokinase) is slowly infused directly into the device or catheter. After a few minutes, the access port is then flushed with heparinized saline. Code should not be used to report flushing of an intravenous (IV) line following IV therapy. Per CPT guidelines, flushing of an IV line following IV therapy is included in the infusion codes and should not be reported separately. 4

5 PHP CLINICAL EDITING EXPLANATION CODES EX Code CDD a01 a02 a03 a04 a05 a10 a11 a13 a14 a29 b01 b02 d01 d02 N01 N02 N04 N05 N06 N14 N15 N51 N52 N54 N55 N58 N58 N91 N92 N93 N94 Explanation Duplicate claim Add-on codes billed without an appropriate parent code Co or team surgeons not appropriate for code Charges are included in global OB payment Postoperative visit included in global surgery payment New patient visit frequency exceeded per CPT guidelines Pharmacy codes currently invalid Lifetime maximum for procedure exceeded Bundled/global services, services are never paid separately Chemo admin code not allowed with this drug Clinical daily maximum exceeded for this service Experimental/investigational procedures not covered Cosmetic procedures not covered Services not allowed from this provider specialty Services not allowed at this place of service Procedure is incidental to another procedure Procedure is mutually exclusive to another procedure Postoperative care is included in global surgical payment Preoperative care is included in global surgical payment Assistant surgeon not allowed for this procedure Invalid gender for procedure Age does not fit within range described by procedure Rebundle edit occurred with a claim in history Duplicate unilateral or bilateral procedure Daily maximum for this procedure has been exceeded Procedure(s) on current claim combined with procedure(s) on claim in history exceed daily maximum Mutually exclusive edit with claim in history Incidental edit with claim in history CCI edit, procedure is incidental to another procedure CCI, current claim denied as incidental to claim in history CCI edit, procedure mutually exclusive to another procedure CCI, current claim denied as mutually exclusive to claim in history 5

6 WHAT TO DO IF YOU HAVE QUESTIONS Inquiry Locate the Clinical Edit Fax Inquiry form on ProvLink. (Click on Forms in the tool bar on the left side of the home page.) Complete the form and send all required documentation as indicated on the form to our dedicated inquiry fax line (s). Note: This form is used only for clinical edits as listed on the previous page of this newsletter. A review of the coding applications will be initiated. Service may be allowed and the claim reprocessed. Service denial may be upheld and an explanation of the rationale for the edit will be forwarded to you. Appeal If you do not agree with the edit or payment rule logic, a formal appeal may be submitted in writing. If you are familiar with the edit logic or payment rule and still wish a formal appeal, indicate this to your Provider Relations Representative. Our Medical Coding Administration Department and/or Medical Department will review the appeal and will reply by letter if the denial is upheld. Edit Reviews When there is a high volume of inquiries or appeals about a specific edit combination, PHP Medical Directors will review the edit combination. If the decision is made to reverse the edit, PHP will implement within 7 days. If the decision is made to uphold the edit, we will publish the information in Newsletter. If an edit combination is upheld, we will ask that you not continue to submit individual claims for review unless there is a clear and distinct exception clearly documented. 6

7 PAYMENT RULES Payment Rules are located on ProvLink. Please review these, as they may explain many of the payment applications that affect your claims payment. It is our policy to notify providers via Connections newsletter prior to implementing new payment rules. ELECTRONIC CONTRACT DELIVERY Providence Health Plan offers secure electronic contract delivery. If you have not already done so, please provide your Providence Health Plan Provider Relations Representative with an address for the person in your organization who should receive contract negotiation and contract update information. Please note that if the contracting contact in your organization changes, it will be important to communicate the new name and to your Providence Health Plan Provider Relations Representative. 7