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Claim Editing Update Report: Third Quarter 2021

Code pair edits added to the Change Healthcare KnowledgePack Update.
 
Code pair edits closed from the Change Healthcare KnowledgePack Update.
 
Code pair edits changed from the Change Healthcare KnowledgePack Update.
 
Edits added in new version of CCI. Provides brief CCI policy for each edit.
 
Edits that were closed in new version of CCI.
 
Changes to modifier overrides (new override = 1 or no longer overrides = 0) for existing code pairs and changes to existing edits' effective and/or expiration date.
 
Edits that were deleted in new version of CCI.
 
Edits added in new version of OCE/CCI.
 
Edits that were closed in new version of OCE/CCI.
 
Changes to modifier overrides (new override = 1 or no longer overrides = 0) for existing code pairs and changes to existing edits' effective and/or expiration date.
 
Edits that were deleted in new version of OCE/CCI.
 
PLEASE REVIEW THE FOLLOWING IMPORTANT INFORMATION
The information contained in this report is intended to expedite review of Horizon BCBSNJ 2019 second quarter edit changes. Edits in the workbook are sorted first by denied code then by paid code in ascending numeric order. A '#' sign immediately preceding the code description denotes a deleted code. Edit source abbreviations are defined below.
CCI Edits: CCI code pair edits are code pairs that should not be reported together for a number of reasons explained in the “National Correct Coding Initiative Coding Policy Manual for Medicare Services”. The CCI Additions tab contains new edits added by CCI (with policy statement). The CCI Expirations tab contains edits expired by CCI. The CCI Deletions tab contains edits deleted by CCI. The CCI Changes tab contains edits modified by CCI. Changes can include 1) Modifier Override (CCI "GB Indicator") modifications represented with a 'Modified' record and an 'Added' record, or 2) edit effective or expiration date modifications represented in one 'Modified' record. NOTE: An indicator of "1" = a modifier indicated by CCI can be used to allow payment for both codes. "0" = No modifier can be used to bypass the edit pair.
 
OCE/CCI Edits: CCI edits incorporated into Outpatient Code Editor (OCE). The OCE/CCI Additions tab contains new edits added by OCE/CCI (with policy statement). The OCE/CCI Expirations tab contains edits expired by OCE/CCI. The CCI Deletions tab contains edits deleted by OCE/CCI. The OCE/CCI Changes tab contains edits modified by OCE/CCI. Changes can include 1) Modifier Override (OCE/CCI "GB Indicator") modifications represented with a 'Modified' record and an 'Added' record, or 2) edit effective or expiration date modifications represented in one 'Modified' record. NOTE: An indicator of "1" = a modifier indicated by OCE/CCI can be used to allow payment for both codes. "0" = No modifier can be used to bypass the edit pair.
 
Change Healthcare Corporation Code Pairs: This includes code pairs based on three of the rule types in the CXT UNBUN_PAIRS rule. These rule types are Incidental (INC), Mutually Exclusive (ME), and Parent/Child (ULT_PARENT) editing. An Edit Rationale number is provided with each Change Healthcare Code Pair addition, which can be used to refer to the Edit Report Rationale worksheet where they are listed in numeric order. This Edit Rationale number is specific to this report only.
 
General Modifier Information: Modifiers -25, -57, and -59 are intended to indicate that a service/procedure that would normally be included in payment for another service/procedure should, for specific reasons, not be denied when submitted with one of these modifiers.
By default, modifier -25 will override any edit within the Change Healthcare Code Pair Additions tab where the RULE_TYPE is ME.
By default, modifier -57 will override any edit described in the Change Healthcare Visits tab.
By default, modifier -59 will override any edit within the Change Healthcare Code Pair Additions tab where the RULE_TYPE is ME, INC, or ULT_PARENT.
 
Source Abbreviation/Name
AAOS - American Academy of Orothopaedic Surgeons
ACC - American College of Cardiology.
ACOG - American College of Obstetricians and Gynecologists.
ACR - American College of Radiology.
ACS - American College of Surgeons
AMA - CPT coding guidelines.
AMA RBRVS - AMA RBRVS Data Manager
ASA - American Society of Anesthesiologists.
ASM - American Society for Microbiology.
AUA - American Urological Association.
CCI - Correct Coding Initiative .
CCN - External physician consultants.
CMS - Centers for Medicare and Medicaid Services (CMS) coding guidelines.
DMEPOS - DME Prosthetic, Orthotic, Supplies Fee Schedule
HPP - Health Plan Policy
PPP - Internal physicians.
SMFM - Society for Maternal-Fetal Medicine.
STS - Society of Thoracic Surgeons.
 
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
 
The responsibility for the content of any "National Correct Coding Policy" included in this product is with the Centers for Medicare and Medicaid Services and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, nonuse or interpretation of information contained in this product.
 
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