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What’s the Code?

What’s the Code?


We want to be sure you are recognized for the quality of care you provide to your patients, our members.

Providing accurate quality of care information will increase your quality rating and reduce administrative burden in your claim submissions.

One of the most important things your practice can do is to code correctly.

The care you provide should be reflected in every code you submit. Coding correctly will improve your quality performance by helping to achieve specific HEDIS measures.

What is HEDIS?

The Healthcare Effectiveness Data and Information Set, or HEDIS, was developed by the National Committee for Quality Assurance.

HEDIS is a set of standardized performance measures used for improving quality in the United States.

HEDIS measures are impacted by the codes you submit.

First submit accurate claim data. Second, make sure your records match billed services. And third, submit corrected claims when necessary.

It is critical you submit accurate claim data for each and every service rendered.

Submit detailed information using the correct codes.

Modifiers may be used to report that the procedure has been altered by a specific circumstance.

Modifiers, when added to CPT or HCPCS codes, provide additional information about a service or procedure

You can find a complete list of codes in the Provider Tips for Optimizing HEDIS Results Booklet available on our website.

HEDIS data collection is a year-round process. HEDIS rates are measured by using either claims or medical records. Fulfilling HEDIS measures will help you close quality care gaps.

Another important point is to ensure medical record documentation reflects all services billed.

Let’s take a look at an example of a compliant medical record.

In this example, Dr. Penn saw Alexa Alexander on March 1, 2020 for a visit and completed Nutrition and Physical Activity Counseling.

Dr. Penn submitted a claim for the visit on April 17, 2020, and included the ICD 10 code Z71.3 and Z71.82 to reflect the rendered services of Nutrition and Physical Activity Counseling.

Accurate and timely submission of administrative data reduces the need for medical record review.

You can submit corrected claims to capture applicable coding requirements.

A corrected claim is a resubmission of a claim with specific changes that have been made, such as changes to CPT codes, diagnosis codes or billed amounts.

There are two ways to submit corrected claims to improve your quality performance.

You can submit electronically through the Electronic Data Exchange, or EDI.

The electronic corrected claim submission capability allows for faster processing, increased claims accuracy and a streamlined submission process.

You can also complete the CMS-1500 paper claim form.

All re-billed claims should show a $0 payment. Re-submitted claims will be denied, because it will be a duplicate claim.

For more information on claim submissions, EDI, modifiers, corrected claims and more, review the Provider Administrative Manual or the Physician and Other Health Care Professional Office Manual. You can view these tools on our website.

If you have questions about HEDIS or how to improve your score, contact the Quality Management Department via email or by phone at the Horizon Healthy Journey line.

Don’t forget to review the Provider Tips for Optimizing HEDIS Results Booklet for a complete list of codes and details on each HEDIS measure.

Looking to receive additional support for closing gaps in your HEDIS measures? Contact us for information about the Results & Recognition Program.

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