Behavioral Health Correct Coding Claim Processing Edits
Date: 10/02/20
Superior HealthPlan periodically reviews its Payer claim edits and associated system configuration to validate full compliance with all correct coding edits, to include all local, state and national billing and reimbursement standards. As result of a recent audit, Superior identified several correct coding edits that were in effect for physical health claims, but not appropriately configured in the behavioral health claims platform.
To ensure that Medicaid benefits are being appropriately administered, and all correct coding obligations are fully met, applicable configuration updates are scheduled for revision in Superior’s claims system effective for service dates on and after November 1, 2020.
To ensure all provider claims billing systems are up-to-date to comply with the applicable coding requirements, details of the scheduled system updates for November 1, 2020 implementation are included in the table below.
Superior appreciates the provider cooperation with all claims billing requirements, and appreciates the continued participation in our network. For any questions about this communication, please contact your Account Manager.
| Claim Edit Description | Claim Edit Function | Claim Remittance Denial Descriptions | Claim Remittance Explanation (EX) Denial Code | Edit Source |
|---|---|---|---|---|
| Procedure code inconsistent with patient age or gender (AGED) edit | If the age or gender of the patient is inconsistent with the procedure or service code limitations, the claim will be denied as inappropriate billing. | INCORRECT PROCEDURE CODE FOR MEMBER AGE OR GENDER PER CMS/AMA/PLAN | yt | Superior Policy CP.PP.011 - Code Editing Overview |
| New patient Evaluation and Management (E/M) service billed for existing patient (NPT) edit | If a new patient E&M service is billed, but the provider has billed other services for the same patient within the past 3 years, the claims will be denied as inappropriate billing. | NEW PATIENT E/M INAPPROPRIATE PER AMA GUIDELINES | w4 | Current Procedural Terminology (CPT) Coding Guidelines |
| Denial of add-on code if primary procedure is disallowed (AOM) edit | If the primary procedure code is disallowed, the add on code is also disallowed. | PRIMARY SERVICE IS DENIED, THEREFORE,ADD-ON SERVICE IS DENIED PER AMA | w5 | Superior Policy CC.PP.030 - Add-on Code Billed Without Primary Code |
| Duplicate billing Edits | If the service has already been billed by another provider for the same patient and date of service (CPD), the service is disallowed. | DUPLICATE CLAIMS OR MULTIPLE PROVIDERS BILLING SAME/SIMILAR CODE(S) | yq | Superior Policy CP.PP.011 - Code Editing Overview |
| If the service has already been billed by same provider for the same patient and date of service (DUP), the service is disallowed. | ||||
| If the service has been billed by more than one provider in the same procedure code range (RDS), the service is disallowed. | ||||
| Miscellaneous Procedure Code | If the service is billed with a non-specific procedure code (UNL), the service is denied as inappropriate billing. | INCORRECT CPT/HCPCS/REV/MOD OR UNLISTED CODE BASED ON CPT/CMS GUIDELINES | yu | Current Procedural Terminology (CPT) Coding Guidelines |