Clinical edits listing

Ambulance During Inpatient Stay

Ambulance services are not separately payable when reported with a date of service within an admission and discharge date of an inpatient claim per PH payment policy. The service is considered bundled to the inpatient stay and will be denied. The edit will not apply if the service was provided on the day of admission or day of discharge of the inpatient stay. Ambulance services provided during an inpatient leave of absence (LOA) that have been denied with the edit may be reconsidered via the Reviews & Appeals process.

Ambulance Required Modifiers for Ambulance Service HCPCS Code Rule

Ambulance origin and destination modifiers should be appended to ambulance services. Ambulance codes that are missing origin and destination modifiers will be denied. Exception – an ambulance service will not be denied for missing origin and destination modifiers if modifier QL is appended to indicate the patient was pronounced dead after the ambulance was called.

Antepartum Care Codes Submitted in History Prior to OB Package Code

The maternity global package codes include routine antepartum care, delivery and postpartum care per CPT guidelines. Antepartum care only codes will be denied when reported by the same provider within 280 days prior to a global delivery code.

Anatomical Modifier Not Appropriate

Anatomical modifiers are used to designate the area or part of the body on which the procedure is performed. When an anatomical modifier is appended to a procedure code that doesn't match the anatomical site indicated by the modifier, the service will be denied.

Anatomical Modifiers Use Max Frequency

Claims will deny excess units when any provider bills more than one unit of service with an anatomical modifier E1-E4 (Eyes), FA-F9 (Fingers), and TA-T9 (Toes).
Anatomical modifiers of E1-E4, FA-F9, TA-T9 have a maximum allowable of one unit per anatomical site for a given date of service. Any service billed with an anatomical modifier for more than one unit of service will be adjusted accordingly.

Diagnosis Coding - Excludes1

ICD-10's Excludes1 criteria details diagnosis codes that shouldn’t be reported together because the two codes can’t occur at the same time. Reference the ICD-10 coding manual’s Excludes Notes section for more detail and examples.

Durable Medical Equipment Required Modifiers

Several DME, PO, and supplies HCPCS codes require the use of modifiers to identify that anatomical, laterality, functional, or support policy criteria is met. Claims reported without required modifiers will be denied. Those reported with modifiers that do not support medical necessity may be member liability. Please note that this does not replace the need for NU, RR, UE, etc. associated with DME items. For more detail, see DME authorizations and billing.

Inappropriate Use of Modifier 25

Refer to the Modifier 25, separate E&M service, same physician, same day page in the Provider Manual for information on appropriate use of modifier 25. E&M services billed with Modifier 25 will be denied if the only other service reported for the member for the same date of service is a major surgery.

Inappropriate Use of Modifier 57

Modifier 57 is appropriate for use when the E&M service has resulted in a decision to perform a major procedure. E&M services billed with modifier 57 will be denied if a major surgery isn't reported on the same date of service or one day after the E&M service.

Obstetric Services, Global Care

Claims will deny Evaluation and Management services (99202-99215) when billed with a diagnosis of post-partum care uncomplicated postpartum care (ICD-10 codes Z39-Z39.2), contraceptive management (ICD-10 codes Z30.011, Z30.013-Z30.09), or family planning advice when a delivery care only service (59409, 59514, 59612, 59620) has been billed in the past 42 days (6 weeks) by any provider.

AMA CPT manual instructs postpartum care cannot be reported as a separate E/M service during the postpartum period, whether performed by the same provider who performed the delivery or by a different provider. Postpartum care is correctly reported.

Online Digital E/M or Assessment Group Frequency

Online digital evaluation and management (E/M) services may be reported only once in a 7-day period by the same provider per CPT coding guidelines. Online digital evaluation and management (E/M) services reported more than once in a 7-day period by the same provider will be denied.

Principal or First-Listed Diagnosis Codes

ICD-10 coding guidelines require coding to the highest level of specificity. They’ve designated certain diagnosis codes to be principal or first-listed. As the description indicates, these diagnosis codes should be listed first on the claim. Details are available in the ICD-10-CM Guidelines – April 2022 update.

Surgical Supplies

Claims will deny when surgical dressings A6010-A6011, A6021-A6025, A6196-A6224, A6228-A6248, A6250-A6262, A6266, A6402-A6404, A6407, A6413, A6441-A6456 are billed in the provider's office (POS 11). According to CMS policy, when a physician applies surgical dressings as part of a professional service, the surgical dressings are considered incident to the professional services of the health care practitioner and are not separately payable

Vaccines and Administration

Claims will deny immunization administration (90460-90461, 90471-90474) when billed without a vaccine/toxoid code (90476-90750, 90756, 90758, 90759, J3530, Q2034-Q2039) by any provider on the same date of service. AMA CPT Manual and the HCPCS Level II Manual, immunization administration for vaccines and toxoids (90460-90461, 90471-90474) must be reported in addition to the vaccine and toxoid codes (90476-90750, 90756, 90758, 90759, J3530, Q2034-Q2039).

For Priority Health Medicaid, vaccines should be reported with a zero allowed amount for vaccines supplied though the State as part of the Vaccine for Children (VFC) program. See page 20 of Michigan VFC Provider Manual for additional detail.

Multiple Gestation Delivery

Diagnosis codes for multiple gestation and outcome of delivery should be reported when billing multiple vaginal or cesarean procedure codes for the delivery of multiple gestations. Multiple vaginal or cesarean procedure codes reported without a multiple gestation diagnosis code and an outcome of delivery code will be denied.

Modifier 57 and planned major surgeries

Claim will deny the Evaluation and management (E/M) services with modifier 57 when billed with planned major surgical services. You shouldn't bill modifier 57 which allows the Evaluation and Management (E/M) services to be paid with a surgery that has been planned in advance.

The intended use of modifier 57 (Decision for surgery) is to represent that the decision to perform major surgery has occurred on the date of, or the date prior to the surgery.

Exception: This edit will exclude office consultation codes, CPT codes 99241-99245 with place of service (POS) 11; office consultations, CPT codes 99221-99223 (Initial hospital care) and 99251-99255 (Inpatient consultation) with POS 21 and E/M codes billed within the emergency room setting with POS 23.

Ambulance Required Modifiers for Ambulance Service HCPCS Code Rule

Ambulance origin and destination modifiers should be appended to ambulance services. A modifier indicating whether the service was provided under arrangement or directly should also be appended. Ambulance codes that are missing origin and destination modifiers and/or a modifier to indicate whether the service was provided under arrangement or directly will be denied. Please refer to the Ambulance services page in the Provider Manual for exceptions and further information.

Covid-19 Lab Add-On Code Reported Without Required Primary Procedure

Procedure code U0005 is reported in addition to either HCPCS code U0003 or U0004 per HCPCS guidelines. Procedure code U0005 reported without U0003 or U0004 for the same date of service will be denied.

Critical Access Hospital (CAH) Bilateral Procedures Rule

Modifiers LT (left side) and RT (right side) should not be reported when modifier 50 (bilateral procedure) is applicable. A CAH bilateral service will be denied when it is reported with the same service date on two separate claim lines, once with modifier LT and again with modifier RT. A CAH bilateral service will also be denied when it is reported on a single claim line with both modifier LT and RT.

Device-Intensive Procedures Requiring Device HCPCS Code

Claims submitted for device-intensive procedures require the reporting of the device HCPCS code on the same date of service. Claims submitted without the device HCPCS code will be denied. Discontinued procedures would be excluded from editing (identified by modifiers 73,74) as well as revision procedures (identified by CG modifier).

Diagnosis Coding - Excludes1

ICD-10's Excludes1 criteria details diagnosis codes that shouldn’t be reported together because the two codes can’t occur at the same time. Reference the ICD-10 coding manual’s Excludes Notes section for more detail and examples.

Durable Medical Equipment Required Modifiers

Several DME, PO, and supplies HCPCS codes require the use of modifiers to identify that anatomical, laterality, functional, or support policy criteria is met. Claims reported without required modifiers will be denied. Those reported with modifiers that do not support medical necessity may be member liability. Please note that this does not replace the need for NU, RR, UE, etc. associated with DME items. For more detail, see DME authorizations and billing.

Duplicative Laboratory Professional and Facility Procedures

The professional component of a laboratory service should only be reported by either the practitioner or facility; likewise, the technical component of a laboratory service should only be reported by either the practitioner or facility. The laboratory service will be denied when the same laboratory service component has been reported for the same date of service on a professional claim.

Multiple Facility E/M Services on the Same Date

When multiple E/M services (including clinic visits) are performed by the same facility on the same date of service, modifier 27 and condition code G0 should be appended to the facility claim to indicate visits were considered distinct and independent from one another. These modifiers and condition codes should be reported on the second claim (and additional) submitted for the date of service. Claims submitted without the appropriate modifier and condition code will be denied.

Principal or First-Listed Diagnosis Codes

ICD-10 coding guidelines require coding to the highest level of specificity. They’ve designated certain diagnosis codes to be principal or first-listed. As the description indicates, these diagnosis codes should be listed first on the claim. Details are available in the ICD-10-CM Guidelines – April 2022 update.

Revenue Code Requires HCPCS

There are certain revenue codes that require the reporting of a HCPCS code. Claims submitted with revenue codes that are missing the required HCPCS will be denied. This edit will impact claim lines with charges, a revenue code that requires an HCPCS code (not packaged), with no HCPCS codes. The logic Medicare Claims Manual, Section 20.1 General states: “The HCPCS codes are required for all outpatient hospital services unless specifically defined as an exception in manual instructions. This means that codes are required on surgery, radiology, other diagnostic procedures, clinical diagnostic laboratory, durable medical equipment, orthotic-prosthetic devices, take-home surgical dressings, therapies, preventative services, immunosuppressive drugs, other covered drugs, and most other services.''

Resubmissions for Adjusted Claim Type of Bills and Change Reason Codes

For accurate identification of facility claim corrections, facilities should report the appropriate adjustment indicator for a corrected or voided/canceled claim along with the claim change reason code. To accurately identify these, report with one of the following bill types:

• Bill type xx7 should be reported to request an adjustment based on the corrected claim submission along with the appropriate claim change reason code (equal to condition codes D0-D4, D7, D8, D9*, or E0)
• Bill type xx8 should be reported to request the claim be voided or cancelled along with the appropriate claim change reason code (equal to condition codes D5 and D6)

Claims reported without this bill type and correct claim change reason code (see below) will be denied.

Claim change reason codes

D0 - Changes to service dates
D1 - Changes in charges
D2 - Changes in revenue code/HCPC
D3 - Second or subsequent interim PPS bill
D4 - Change in Grouper input (DRG)
D5 - Cancel only to correct a patient's Medicare ID number or provider number
D6 - Cancel only - duplicate payment, outpatient to inpatient overlap, OIG overpayment
D7 - Change to make Medicare secondary payer
D8 - Change to make Medicare primary payer
D9 - Any other changes (should be used only when no other change reason is applicable)

Use of condition code D9 should also include a remark to mirror bold criteria below on the second line of remarks:

• Patient control nbr - changing or adding a patient control number
• Admission hour - changing or adding the admission hour
• Admission type - changing or adding the admission type
• Admission source - changing or adding the admission source
• Medical record number - changing or adding the medical record number
• Condition code - changing or adding a condition code
• Occ codes - changing or adding an occurrence code
• Occ span codes - changing or adding an occurrence span code
• Value codes - changing or adding a value code
• Modifier - changing or adding a modifier
• Date of service - changing a date of service on a line or changing the statement from and to dates, use a D0
• Units - changing units
• Recalculation - claim recalculated for a different payment
• Multiple changes - Please enter your changes
• DX code - changing a diagnosis code on an outpatient claim, inpatient claims would use a D4
• POA - changing, adding, or removing a Present on Admission (POA) indicator, unless you are changing an N to a Y and/or if it affects reimbursement then you would use a D4
• Removed non - removing non-covered charges
• Other - Place this information on the second line of the claim only. On the third line of claim include a brief description of why the claim is being adjusted

Unspecified Code

Diagnosis codes should be reported to the highest level of specificity. Certain unspecified diagnoses codes designated as either a Complication or Comorbidity (CC) or Major Complication or Comorbidity (MCC) will be denied when reported on an inpatient claim.