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New claims edits to go into effect in September

08/03/2016

Effective Sept. 27, the following claims edits will go into effect for both commercial and Medicare plans:

  • Global Surgery – Midlevel Providers: Evaluation and Management services are not separately payable when:
    • billed by midlevel providers with the same group Tax ID;
    • for a date of service within a paid 90- or 10-day global surgery; and
    • having an associated primary diagnosis, complication of surgical and medical care or an after-care diagnosis.

Exceptions will apply for modifiers 78, 79, 80, 81, 82 and AS.

  • Non-Invasive Vascular Diagnostic Studies: Extremity Arterial Studies CPT codes 93922-93931 are not separately payable when billed with Venous Studies CPT codes 93965-93971, unless a supporting diagnosis is present for each type of study based on Medicare LCD criteria.
  • New Patient Visits – Midlevel Providers: Midlevel providers are included in the new patient visit policy. If a new patient visit has been paid to any provider in the same Tax ID group and same specialty in the prior three years, it will be denied. An established patient visit may be billed instead.
  • Midlevel Providers as Assistant MD: Midlevel providers may be reimbursed only as assistant MD for surgical procedures with 90-day global periods as long as an assistant MD modifier is used as required.
  • Microvolt T-Wave Alternans (MTWA) Testing: CPT code 93025 is payable when billed with a supporting diagnosis code based on CMS National Coverage Determinations criteria.