First Health makes every attempt to utilize standard coding systems throughout the product. Coding systems utilized in the product include:

Transcription

1 First Health Bill Review Processing Edits The First Health Bill Review system employs a wide range of edit criteria which can be roughly grouped into five classes; field edits, file edits, duplicate detection, Texas Workers Compensation fee schedule rules, and clinical edits. The specific types of clinical edits are outlined in greater detail in the following paragraphs. The defined edit types are: Field edits values entered into each field, i.e. future dates, field mask File edits (Coding Edits) valid data entered into certain fields, i.e. valid diagnosis or procedure Duplicate Detection - identifies exact and potential duplicates based on client parameters. Clinical Edits including Incidental Procedures, Unbundled and Mutually Exclusive Procedures Fee Schedule rules and regulations based on the Texas Workers Compensation Fee Schedule Field Edits The First Health Bill Review system employs a number of field level edits which validate that all fields required for each form type, as specified by Texas Forms TWCC-67, TWCC-68 and TWCC-70. Specific instructions for completing these forms according to Texas guidelines can be found at the Texas Workers Compensation Commission website. Additionally, the system performs validation edits that verify the consistency of fields. Examples of this type of edit include checking for future dates, validating the Date of Service is after the Date of Injury, and that these required fields follow proper format requirements. For additional information on the field level billing requirements under the Texas Workers Compensation Commission fee schedules visit File Edits (Coding Edits) The First Health Bill Review system contains edits for identifying attribute level coding edits such as global procedures, modifier appropriateness (including assistant surgeons), and age and gender edits. Additionally, the bill review system contains tables that identify all valid modifiers based on valid procedure codes and dates of service according to the Texas Workers Compensation Fee Schedule and the American Medical Association Current Procedural Terminology. These edits identify inappropriate modifier use for co-surgeons, teams surgeons, technical and professional components, multiple or bilateral procedures and a number of other modifier related edits all based on the Texas Workers Compensation fee schedule. First Health makes every attempt to utilize standard coding systems throughout the product. Coding systems utilized in the product include: CPT (Current Procedural Terminology)

2 ICD-9-CM (Diagnoses and Procedures) DRG (Diagnostic Related Group) CMS Place of Service and Type of Service Codes CMS HCPCS Codes American Dental Association Dental codes The Centers for Medicare and Medicaid Services defines most coding systems with the exception of the CPT, which is maintained by the American Medical Association. For additional information on the Current Procedural Terminology coding guidelines, visit the American Medical Association at For information on the International Classification of Diseases 9 th Clinical Modification, Diagnostic Related Groups and Place of Service or Type of Service and HCPCS code data, visit the Centers For Medicare and Medicaid Services at Additional dental code information may be obtained from the American Dental Association at Duplicate Detection First Health Bill Review contains specific edits for detecting duplicate bills. At the header and service-line levels, our system identifies exact and line-level duplicates. At the service-line level, the system identifies potential duplicates. The system applies a service-line level analysis in detecting duplicates. Each service line is independently compared against all service lines in the history database for the same claimant. Based on the matching criteria, the system identifies the service as a potential (soft) or as an exact (hard) duplicate. If the system identifies a soft duplicate, the bill suspends for the bill processor to review the keyed information against the billed information in the history database. The system automatically presents both the billed service line and its related history to the examiner for resolution. If the system identifies a hard duplicate, the duplicate service line is automatically denied, and a message appears on the Explanation of Review (EOR) identifying a duplicate charge. Because a unique identifier is used to gather all history for a patient, duplicate detection can occur across multiple claims and client databases. The data elements used for matching service lines are as follows: Patient Gender Patient Date of Birth First Date of Service Last Date of Service Date Span Procedure Code Diagnostic Code Provider Charge Provider Tax ID Number Units of Service

3 Place of Service Type of Service Case Number Client ID Number Hard and soft duplicate detection criteria against the above fields are table-maintained. The rules are defined at the client level. Soft duplicate detection is based on a best-of-series process combined with minimum required fields. For example, a soft duplicate sets if four of seven fields match. However, two of the matches must be procedure code and date. Clinical Edits The First Health Bill Review system includes clinical edits that are used during the adjudication process to reject, suspend, or recommend payment of the bill. The clinical edits and supporting clinical logic within the bill review system were developed by and are proprietary to First Health. There is a documented rationale statement for each clinical edit that describes the reason(s) First Health is recommending a change in payment. First Health Medical Directors develop the clinical rationale for the clinical edits. The primary bases for the clinical edits are the National Correct Coding Policy Manual (NCCPM), CPT, and the American Academy of Orthopedic Surgeons. The clinical edits are reviewed on a constant basis to verify interaction of these edits with changes to Texas state fee schedules. The edits undergo a thorough review each quarter as updates are released for the NCCPM. Updates to the clinical edits are generally performed annually, as changes to the CPT coding system are released. The major edit classes are outlined below. Unbundled procedure codes are identified, according to Texas state-specific guidelines and medical policies. Procedure unbundling occurs when a code is billed that is generally considered part of a more comprehensive service billed on the same day. When this occurs, the more comprehensive service will be paid and the included code will be automatically denied. Incidental procedures that are commonly performed as a part of a larger procedure are edited in the system. For example, if an injection procedure is billed in conjunction with a tendon repair, the system identifies the injection procedure as an incidental procedure and denies the charge. Mutually exclusive procedures are those procedures that should not be performed during the same visit. The system automatically identifies mutually exclusive procedures and recommends payment only for the most clinically intensive procedure performed. Fragmented procedures are also identified by our bill review system. A fragmented bill is a bill which the provider submits only a portion of the services. The secondary billing includes additional services on the same or different date of service. Our bill review system performs edits and audits on a line-by-line basis and uses other service lines on the bill and in the history database to determine appropriate adjudication. Procedure to diagnosis relationship edits examines diagnosis codes that are not related to the procedures with which they are billed. A series of edits alert the processor of billing

4 inconsistencies in the areas of radiology and surgeries involving the musculo-skeletal system. These edits can be assigned a severity to disallow services or suspend bills for manual review. Additional information on the National Correct Coding Initiative Policy Manual can be obtained from the National Technical Information Service (NTIS) at Additional information on the American Academy of Orthopedic Surgeons coding guidelines can be obtained from the Academy at Additional information on the Current Procedural Terminology guidelines can be obtained from the American Medical Association at Fee Schedule Rules and Regulations The system uses both table-driven and hard coded edits to assess the unique attributes of a bill and apply Texas ground rules. Texas fee schedule rules can include several key edit types including, but not limited to: Modifier Validation Code Attribute Checks (gender, age, validity) Modifier Pricing (multiple procedure, assistant surgeon, etc.) Utilization (Physical medicine services) Procedure to Diagnosis validation Work/injury related Diagnosis Global Surgical period Updates of the latest hospital and medical fee schedule changes are continually loaded into the bill review system to ensure compliance with the Texas Workers Compensation Commission fee schedules. Once all clinical and state fee schedule edits have been applied to a bill, the system will perform pricing functions on the bill. These functions will include repricing to the Texas Workers Compensation Commission fee schedule fees or fair and reasonable values if a fee schedule fee does not exist, calculating modifier reductions such as assistant surgeon or multiple surgery reductions. The bill review system assigns a three-digit area plan to each state or jurisdiction. All repricing is tied to the area plan for that state or jurisdiction. Fee schedule rules and regulations are also connected to the area plan, which prevents state or fee schedule specific edits from setting inappropriately. For valid services not defined under the Texas Workers Compensation Commission fee schedule, First Health maintains fair and reasonable fee files utilizing data supplied by Ingenix, formally known as Medicode (MDR). Fair and reasonable information is updated quarterly and is integrated into the bill review system. The data purchased is Ingenix s proprietary data that we contract fair use in the bill review system.

5 For additional information on the Texas Workers Compensation Commission fee schedules visit For additional information on the fair and reasonable fee database used in The First Health Bill Review system visit PPO Repricing Our system applies our negotiated rates to bills generated by providers in The First Health Network for Workers Compensation. Provider specific contract rates are available to appropriate parties upon request from First Health. An overview of the basic pricing methodology is outlined below. Most contracts are based on a negotiated reduction from the Texas Workers Compensation Commission fee schedule is the most common pricing mechanism. The negotiated reductions are typically percent reductions from the fixed state fee schedule but may include case rates, per diems or other reimbursement mechanisms.