Our health plan uses Lyric claim edits, Medicare's National Correct Coding Initiative (NCCI) and customized editing rules as the basis for clinical edits. Our claim adjudication systems are updated on a quarterly basis to recognize the most recent CPT© and HCPCS codes as well as changes from the relative value units (RVU) file. Please review your CPT and HCPCS coding publications for codes that have been added, deleted, or changed, and use only valid codes. Please append modifiers to HCPCS and CPT codes when appropriate.
When submitting claims, procedures should be reported with the CPT/HCPCS code that describes the services performed to the greatest specificity possible and only if all services described by that code are performed. CPT/HCPCS code definitions and rules are used in applying clinical edits. Unbundling occurs when multiple codes are used to report a procedure covered by a single comprehensive code.
- ClaimsXten – We use ClaimsXten™, a clinical code editing software developed by Lyric. ClaimsXten logic is based on a thorough physician review of current clinical practices, physician specialty society guidance, and industry standard coding and guidelines.
- ClaimsXten’s web-based tool Clear Claim Connection allows providers to model claim editing.
- Our health plan uses the code auditing edits included in Clear Claim Connection.
- Clinical edits – The clinical edits by code list applies to all commercial lines of business. It is sorted by code and contains all cosmetic, investigational, and non-reimbursable services, as well as the supporting documentation requirements for each.
- Bundling edits – We created additional code pair edits, found in our Correct Code Editor (CCE), to be used as a supplement to Centers for Medicare & Medicaid Services' (CMS') National Correct Coding Initiative (NCCI)
- OCE edits – Outpatient code editor (OCE) clinical editing is used in addition to our existing medical policy clinical edits and follow our reimbursement policies.
Other edits – View other coding guidelines:
- Secondary editor
- Add-on codes related to bundling edits code pairs
- NCCI bypass modifiers
- Maximum allows units for procedure codes
- Unlisted codes
- Codes without allowables
Use the tabs above to learn more about our edits.
We implement updates on National Coverage Determinations (NCDs)/Local Coverage Determinations (LCDs) within one month of receipt/delivery of edits from ClaimsXten Portfolio. NCD/LCD updates will be effective retro-active to the date specified by the Centers for Medicare & Medicaid Services (CMS) or Noridian. Claims received before our systems are updated will not be adjusted.
We provide claims processing information in an ANSI 835 Electronic Remittance Advance (835 ERA) format. We use Group Code "PI" (Payer Initiated Reductions) and do not use Group Code "OA" (Other Adjustment) except for the codes indicated on the Claim Adjustment Reason Code (CARC) list.
To understand why a claim was denied, view the external code lists on the wpc-edi website. View the Explanation Code (EXCD) ANSI code crosswalk document.
We use ClaimsXtenTM, a clinical code editing software developed by Lyric. ClaimsXten logic is based on a thorough physician review of current clinical practices, physician specialty society guidance, and industry standard coding and guidelines. These edits are proprietary to Lyric and, therefore, we cannot provide the editing detail.
ClaimsXten’s web-based tool Clear Claim Connection allows providers to model claim editing.
Our health plan uses the code auditing edits included in Clear Claim Connection.
- Does not display protected health information (PHI)
- Does not contain edits outside of ClaimsXten
- Requires services to be entered on the same claim for a single provider
- Does not guarantee final disposition due to specific variations within provider and group contracts
- Only provides correct coding information; it does not consider pre-authorization requirements, benefits or pricing
- We do not guarantee this tool will meet your requirements, or that your access or use of this tool will be uninterrupted, timely, secure or error-free
- Uses defaults
Should only be used for claim scenarios for professional services
To access the tool, sign into Availity Essentials. The tool is located in the main menu: Payer Spaces>Resources>Claims and Payment>Research Procedure Code Edits.
If you do not have an Availity Essentials account, register today.
Note: When using the Clear Claim Connection tool to model claims editing, the input of procedure codes must be on the same claim. If all procedure codes are submitted on the same claim, the Clear Claim Connection tool will provide information about how your claim would be processed.
The following is a list of the most common ClaimsXten rules that we have implemented. This list is subject to change and is not exhaustive; refer to our reimbursement policies for more detail.
Edit name | Edit description |
|---|---|
Correct Coding Initiative | Edits claim lines for which the submitted procedure is not recommended for reimbursement when submitted with another procedure as defined by a code pair found in the National Correct Coding Initiative (NCCI). |
Incorrect Bilateral Surgical Billing | Bilateral billing means two claim lines are submitted on the same date of service with the same procedure code, and one line (or both lines) has been reported with modifier 50. Only one line with modifier 50 is allowed. When multiple bilateral units are billed on a single line, the system will split the units to create separate claim lines. The line with one unit will be allowed, and the line(s) with remaining units will be denied. |
Surgical Supplies Included with Surgery | Identifies inclusive supply codes that are reported by the same provider reporting a surgical or medical procedure for the same date of service. Surgical supplies and materials are not eligible for separate reimbursement when reported by the provider rendering the primary service. |
Unbundled Code Pairs | Occurs when two or more procedure codes are used to describe a service when a single, more comprehensive procedure code more accurately describes the complete service performed. These code pairs supplement NCCI. Incidental/Integral: "An incidental procedure is one that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure." A procedure determined to be incidental/integral to another procedure will not be eligible for reimbursement. Mutually Exclusive/Redundant: "Mutually exclusive edits consist of combinations of procedures that differ in technique or approach but lead to the same outcome. In some instances, the combination of procedures may be anatomically impossible. Procedures that represent overlapping services or accomplish the same result are considered mutually exclusive. In addition, reporting an initial service and subsequent service is considered mutually exclusive." A procedure determined to be mutually exclusive to another procedure will not be eligible for reimbursement. |
E&M Billed on Same Day as Surgery | Edits claim lines with evaluation & management (E&M) CPT codes billed on the same date of service as a procedure code with a global period established by the Centers for Medicare & Medicaid Services (CMS) or the plan. |
Pre-Operative Period E&M Denial | Edits claim lines containing E&M codes billed within the pre-operative period. |
Post Operative Period E&M Denial | Edits claim lines containing E&M codes billed within the post-operative period. |
CMS Fee Schedule T Status Bundling | Identifies claim lines containing T status procedure codes that are not payable when billed on the same date of service as any procedure payable under the physician reimbursement schedule for the same member and same provider. |
CMS Practitioner MUE | Identifies claim(s) where the total units of service of a HCPCS/CPT submitted on a single date of service for a member by the same provider exceed(s) the CMS practitioner medically unlikely edits (MUE) value. When multiple units are billed on a single line, the system will split the units to create separate claim lines. One line will be allowed with the appropriate number of units, and the line(s) with remaining units will be denied. |
CMS DME MUE | Identifies claim(s) where the total units of service of a durable medical equipment (DME) HCPCS code submitted on a single date of service for a member by the same provider exceed(s) the CMS DME MUE value. When multiple units are billed on a single line, the system will split the units to create separate claim lines. One line will be allowed with the appropriate number of units and the line(s) with remaining units will be denied. |
Inappropriate Frequency Billing | This rule identifies claim(s) where the total units of service of a HCPCS/CPT code submitted on a single date of service or within a date range for a member by the same provider exceed the units defined by ClaimsXten editing. When multiple units are billed on a single line, the system will split the units to create separate claim lines. One line will be allowed with the appropriate number of units and the line(s) with remaining units will be denied. |
Maternity Care Services | This rule audits potential overpayments for obstetric care. It will evaluate claim lines to determine whether any global obstetric (OB) care codes (defined as containing antepartum, delivery and postpartum services, e.g. CPT code 59400) were submitted with another global OB care code or a component code such as the antepartum care, postpartum care or delivery only services, during the average length of time of the typical pregnancy (and postpartum period, as applicable) 280 and 322 days respectively. This edit fires on the same provider or different providers. |
Component Billing - different provider | Identifies claim lines with procedure codes that have components (professional and technical) to prevent overpayment for either the professional or technical components or the global procedure. The rule also detects when duplicate submissions occurred for the total global procedure or its components across different providers. The claim line may be modified to add a Modifier 26/TC or remove Modifier 26/TC. |
Component Billing - same provider | Identifies when a professional or technical component of a procedure is submitted and the same global procedure was previously submitted by the same provider ID for the same member for the same date of service. |
Ineligible Co-Surgeon | Identifies claim lines containing procedure codes billed with a co-surgery modifier that typically do not require co-surgeons according to CMS. |
Established Patient Billed as New Patient | Identifies new patient E&M procedure codes that are submitted for established patients. According to the American Medical Association (AMA): "A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the last three years." If our editing system detects a new or established E&M code reported within the last three years by the same provider, the new patient E&M code will be replaced with a comparable established patient code. |
Missing Professional Component Modifier 26 | Identifies claim lines where modifier 26, denoting professional component, should have been reported for the procedure performed at the noted place of service (POS). The claim line will be modified to add modifier 26. |
National and Local Coverage Determination - NCD/LCD (Medicare Advantage only) | These rules identify claim lines for certain procedure codes associated with diagnoses, frequencies and ages where the procedure is not considered medically necessary, is not payable or has payment constraints according to NCDs or LCDs. Appropriate coding of ICD-10 diagnoses is essential for accurate payment. |
Inappropriate Procedure for Age | Edits claim lines containing procedure codes inconsistent with the member's age. |
Replacement of Procedure for Age | Identifies claim lines containing procedure codes that are inconsistent with the member's age. The code will be replaced by a more appropriate code. |
Modifier to Procedure Validation | Edits procedure codes when billed with any payment-affecting modifier that is not likely or appropriate for the procedure code billed. |
Positive Airway Pressure Supplies | Identifies supply codes associated with the continuous positive airway pressure or bi-level positive airway pressure (CPAP/BiPAP) therapy that are being submitted at a rate that exceeds the usual or customary rate. Frequency limitations outlined in the associated reimbursement policy are applied per member. Supply maximums are based on member accumulation; this edit reviews across providers. |
Diabetic Monitors and Supplies | Identifies codes associated with glucose monitors that are being submitted at a rate that exceeds the usual or customary rate. Frequency limitations outlined in the associated reimbursement policy are applied per member. Supply maximums are based on member accumulation; this edit reviews across providers. |
Custom Oral Appliances | Identifies when custom oral appliances are billed by specialists other than dentists. Identifies claim lines containing associated services within the post-service period. |
Allergy Immunotherapy | Identifies claim lines when a provider bills allergy immunotherapy in excess of the frequency limitations outlined in the associated reimbursement policy. |
DME Rental and Purchase Limitations | These rules count the number of rental months allowed to convert to a purchase. The rules do not allow the rental or purchase of an item when ownership of the same item is documented within the time specified in the associated reimbursement policy. |
Services Out of Scope | This rule identifies services considered out of scope of the billing provider’s license. |
Missing Reduced Services Modifier 52 | Identifies claim lines where modifier 52, denoting reduced services, should have been reported for procedure performed. The claim lines will be modified to add modifier 52. |
Missing Surgical Care Only Modifier 54 | Identifies claim lines where a modifier 54, denoting surgical care only, should have been reported for the procedure performed at the noted POS. |
Chronic Care | Identifies claim lines when a provider bills chronic care management codes in excess of the frequency limitations outlined in the associated reimbursement policy. |
Bilateral Procedure Invalid | Edits procedure codes when a reduced or discontinued service is submitted with a modifier 50. |
Virtual Care | Occurs when appropriate modifier, procedure and/or place of service is missing or billed incorrectly per reimbursement policy. We will edit on professional and facility claims that do not meet reimbursement policy criteria. |
Modifier to Place of Service Validation | Edits procedure codes billed with a modifier 90 that are not appropriate for the POS billed. |
Intermittent Catheter Supplies | Identifies intermittent catheter supply codes that are being submitted at a rate that exceeds the usual or customary rate. Frequency limitations outlined in the associated reimbursement policy are applied per member. Supply maximums are based on member accumulation; this edit reviews across providers. |
We post updated lists on a monthly basis.
The following lists are organized by line of business and are based on our medical and reimbursement policies.
Note: Codes for all services and supplies that require pre-authorization can be found on our pre-authorization list.
The clinical edits by code list is sorted by code and contains all cosmetic, investigational and non-reimbursable services, as well as the supporting documentation requirements for each.
Updated November 1, 2024
View past lists in the Clinical edits by code archive.
Updated November 1, 2024
View past lists in the Individual plan edits archive.
Note: We will not routinely require submission of clinical information in connection with adjudication of claims except for unlisted codes, codes without allowables, claims to which a modifier 22 is appended, facility claims containing revenue code 0624, or other limited categories of claims included on the clinical edits by code list.
We use the Centers for Medicare & Medicaid Services' (CMS') National Correct Coding Initiative (NCCI) as the basis for clinical edits. NCCI identifies pairs of services that normally should not be billed by the same physician for the same patient on the same day. NCCI also promotes uniformity among the contractors that process Medicare claims in interpreting CMS' payment policies.
We have created additional code pair edits, found in our Correct Code Editor (CCE), to be used as a supplement to CMS' NCCI. These code pair edits were developed using nationally accepted, logical and predictable coding principles based on the following:
- CMS
- CPT Assistant
- HCPCS manual
- Medicare Part B News
- The CMS Federal Register
CPT manual, including code definitions and associated text
Our CCE is updated quarterly (January, April, July and October). Updates are labeled with the corresponding numbered version of CMS' NCCI:
- January—supplement to NCCI version XX
- April—supplement to NCCI version XX.1
- July—supplement to NCCI version XX.2
October—supplement to NCCI version XX.3
For dates of service beginning October 1, 2024:
View past lists in the CCE archive.
ClaimsXten code pairs supplement the NCCI code pairs. They are developed by our vendor partner, Lyric. All code pairs are incidental or mutually exclusive.
The following outpatient code editor (OCE) clinical editing is used in addition to our existing medical policy clinical edits and follow our reimbursement policies. These edits are modeled after the Centers for Medicare & Medicaid Services' (CMS') Integrated Outpatient Code Editor (I/OCE). All OCE edits follow CMS. Refer to OPPS (APC) and non-OPPS (non-APC) columns for the edits that are being applied.
New edits published by CMS take effect on CMS's published effective date; we follow our existing process to post updates on a monthly basis.
2024
2024-10 Outpatient code editor clinical edits list (PDF)
2024-10 Outpatient code editor clinical edits list (Microsoft Excel)
2024-05 Outpatient code editor clinical edits list (PDF)
2024-05 Outpatient code editor clinical edits list (Microsoft Excel)
2024-02 Outpatient code editor clinical edits list (PDF)
2024-02 Outpatient code editor clinical edits list (Microsoft Excel)
2023
2023-07 Outpatient code editor clinical edits list (PDF)
2023-07 Outpatient code editor clinical edits list (Microsoft Excel)
2023-05 Outpatient code editor clinical edits list (PDF)
2023-05 Outpatient code editor clinical edits list (Microsoft Excel)
2022
2022-08 Outpatient code editor clinical edits list (PDF)
2022-08 Outpatient code editor clinical edits list (Microsoft Excel)
2022-05 Outpatient code editor clinical edits list (PDF)
2022-05 Outpatient code editor clinical edits list (Microsoft Excel)
We use MultiPlan’s payment integrity service as a secondary editor supporting our existing claims edits. MultiPlan applies edits in line with our medical and reimbursement policies and correct coding guidelines.
Between analysis and payment, MultiPlan adds a level of human expertise to examine claims, when appropriate, combining automation with expert clinical review. This complements MultiPlan’s robust analytical programs by targeting such complex issues as contradictory or overlapping services and suspect billing patterns that are generally not addressed by other software.
Some services are reported as add-on codes, which describe work done in addition to primary procedures. Add-on codes are not stand-alone codes and must always be reported with primary procedures. We will deny reimbursement for an add-on code as a Correct Code Editor (CCE) edit when its primary code is denied as part of an NCCI or CCE code pair. When correct coding indicates the use of a modifier is appropriate for the primary code, that modifier must be appended to both the primary code and add-on code.
NCCI bypass modifiers, as defined by CMS, will be processed in accordance with the current CMS superscript rules except for the published list of service or procedure code combinations that we have determined are not appropriately reported together.
View our code pair edits that do not bypass with any modifier on the Bundling edits tab on this page.
Our health plan has established a maximum allowed edit for the presumptive CPTs 0007U, 80305, 80306 and 80307 and the definitive HCPCS G0480, G0481 and G0659.
View the reimbursement policy.
Services billed using an unlisted procedure code will not be separately reimbursed when considered incidental to a comprehensive procedure billed on the same date of service.
Similarly, if a procedure or service is determined to be incidental to a more comprehensive procedure described by an unlisted code, separate reimbursement will not be allowed.
We may require the submission of clinical information to price CPT and HCPCS codes for which an allowed amount has not been established. Refer to our Pricing Codes Without RVUs (relative value units) reimbursement policies for more information:
Our health plan considers CPT 0038U and 82306 to be medically necessary only when billed with the following ICD-10 diagnosis codes:
Our health plan considers CPT 0038U and 82306 to be medically necessary only when billed with the following ICD-10 diagnosis codes:
A31.2, B20, B97.33, B97.34, B97.35, C46.0, C46.1, C46.2, C46.3, C46.4, C46.50, C46.51, C46.52, C46.7, C46.9, D71, E20.0-E21.3, E43-E46, E55.0, E64.0, E64.3, E67.3, E83.30-E83.39, E83.50-E83.59, E84.19, E84.8, E84.9, E89.2, K50.00-K50.919, K51.00-K51.919, K70.0-K70.9, K72.10-K75.0, K75.4, K75.81, K76.0, K76.89-K76.9, K83.1, K85.00-K85.92, K90.0-K90.49, K90.89-K90.9, K91.2, M80-M80.8AXS, M81.0-M83.9, M85.80, M85.831-M85.839, M85.851-M85.859, M85.88, M85.89, M85.9, M897.0, M89.9, N18.1-N18.9, N20.0-N20.2, O98.711, O98.712, O98.713, O98.719, O98.72, O98.73, P71.0-P71.9, Q44.2-Q44.3, Q78.0, Q78.2, T86.01, T86.02, T86.03, T86.20, T86.21, T86.22, T86.23, T86.33, T86.298, T86.810, T86.811, T86.819, Z11.4, Z20.6, Z21, Z48.21, Z79.52, Z79.811, Z94.0, Z94.1, Z94.2, Z94.3, Z94.4, Z94.5, Z94.6, Z94.7, Z94.82, Z94.81, Z94.83, Z94.84.
Our health plan considers CPT 82652 to be medically necessary only when billed with the following ICD-10 diagnosis codes:
D86.0-D86.9, E20.0-E21.3, E55.0, E64.3, E720.0-E720.9, E83.30-E83.39, E83.50-E83.59, E89.2, M83.0-M83.9, N20.0-N20.9, N22, N25.81, P71.0-P71.9.
The rationale for these edits is detailed in our Vitamin D Testing (#LAB52) medical policy.
Our health plan considers 82746 to be medically necessary when billed with following ICD-10 diagnosis codes:
D51.0, D51.1, D51.2, D51.3, D51.8, D51.9, D52.0, D52.1, D52.8, D52.9, D53.1, D53.9, D53.8, D55.9, F01.50, F01.511, F01.518, F01.52, F01.53, F01.54. F01.A0. F01.A11, F01.A18, F01.A2, F01.A3, F01.A4, F01.B11, F01.B18, F01.B2, F01.B3, F01.B4, F01.C0, F01.C11, F01.C18, F03.C2, F03.C3, F03.C4, G30.0, G30.1, G30.8, G30.9, G31.0, G31.1, G31.2. G93.32, K50.00, K50.011, K50.012, K50.013, K50.014, K50.018, K50.019, K50.111, K50.112, K50.113, K50.114, K50.118, K50.119, K50.80, K50.811, K50.812, K50.813, K50.814, K50.818, K50.819, K50.90, K50.911, K50.912, K50.913, K50.914, K50.918, K50.919, K90.0, K90.1, K90.2, K90.3, K90.49, K90.81, K90.89, K90.9, K91.2, Z98.84
The rationale for these edits is detailed in our Folate Testing (#LAB79) medical policy.
This edit applies to virtual care services, as defined in our Virtual Care (Administrative #132) reimbursement policy. The edit includes criteria between providers as well as between providers and members regarding telehealth and telemedicine.
Recent implementation dates | Quarterly implementation dates archive |
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