Five New Claimsxten™ Rules To Be Implemented April 2020

Revenue Codes Requiring Healthcare Common Procedure Coding System (HCPCS) Code

This rule recommends the denial of claim lines if they are:

• Submitted with a revenue code that requires a HCPCS code, and
• No HCPCS code is present.

If a claim is missing a HCPCS code, the claim line will be denied.

Modifier to  Procedure Validation Filter – Non-Payment Modifiers

For non-payment modifiers, this rule identifies claim lines with an invalid modifier to procedure code combination.

It recommends the denial of procedure codes when billed with any non-payment affecting modifier that is not likely or appropriate for the procedure code billed.

When multiple modifiers are submitted on a line, all are evaluated and if at least one is found invalid with the procedure code, the line is recommended for denial.

Bilateral Services for Professional Claims

This rule identifies claim lines where the submitted procedure code was already billed with a modifier –50 for the same date of service.

The same service performed bilaterally should not be billed twice when reimbursement guidelines require the code to be billed once with a bilateral modifier.

The rule denies the second submission.

Lifetime Event

This rule audits claims to determine if a procedure code has been submitted more than once or twice on the same date of service or across dates of service when it can only be performed once or twice in a lifetime for the same member.

The Lifetime Event is the total number of times that a procedure may be submitted in a lifetime.

This is the total number of times it is clinically possible or reasonable to perform a procedure on a single member. After reaching the maximum number of times, additional submissions of the procedure are not recommended for reimbursement.

Multiple Medical Same Day Visits

This outpatient facility rule identifies and recommends the denial of claims with multiple Evaluation & Management (E&M) codes and other visit codes that are:

• Submitted on the same date of service,
• Performed at the same facility,
• Submitted with the same revenue code, and
• Where the second and subsequent E&M code submitted lacks the required modifier –27.