Coding Edits

The Alliance applies industry standard edits to provide consistency in reimbursement by the benefit plan. The Alliance addresses coding relationships through code pair edits from the Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) as published by OPTUM’s Resource Based Relative Value System (RBRVS).

Providers must report services correctly, according to CMS’s NCCI. Medical and surgical procedures are to be reported with the Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes that most comprehensively describe the services performed.

When the same provider submits two or more procedure codes for the same member on the same date of service, the codes will be compared. If any of the codes is considered to be a component of or mutually exclusive of the other code, only the most comprehensive procedure code will be reimbursed.

These edits are based on CMS’s NCCI (or CCI) code pair edits, which are intended to promote consistent and correct coding and reduce inappropriate reimbursement.

Under certain circumstances, codes may be reimbursed when appended with the proper modifier if the criteria are met as indicated by OPTUM’s Resource Based Relative Value System (RBRVS).

Modifiers include (when appropriately indicated):

Modifier 25 Significant, Separately Identifiable Evaluation and Management (E/M) Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.
Modifier 59 Distinct Procedural Service.
Modifier XE Separate Encounter. A service that is distinct because it occurred during a separate encounter.
Modifier XP Separate Practitioner. A service that is distinct because it was performed by a different practitioner.
Modifier XS Separate Structure. A service that is distinct because it was performed on a separate organ/structure.
Modifier XU Unusual Non-overlapping Service. The use of a service that is distinct because it does not overlap usual components of the main service.

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