New and Updated Payment Policies - Effective September 1, 2023

Prepay Edit

Interim Claims

Based on CMS guidelines, bill type ending in XX2 or XX3 will be denied when discharge status 30 is not present on the claim.

Medicare

Prepay Edit

Inappropriate Primary Diagnosis

Deny or limit diagnosis codes based upon correct coding guidelines that are supported by CMS and ICD-10. Based on these guidelines, claims will deny when billed with unacceptable primary/principal diagnosis, manifestation diagnosis, and sequela diagnosis in outpatient or inpatient facilities.

Medicaid
Medicare

CC.PP.074

High Dollar IV Hydration

Requesting medical records to determine if documentation supports services billed and that those services were in accordance with policies and regulations related to IV hydration therapy.

Medicaid

CC.PP.074

Custom Fitted or Custom Fabricated Prosthetics or Orthotics

Requesting medical records to verify documentation supports high-dollar custom DME codes billed by the provider

Medicaid

Prepay Edit

Optum CPI AMISYS – Phase 2

To identify surgical claims that have a 10- or 90-day global period, and no modifier 54 present, which were performed in a POS 23 (emergency room), where follow up would not typically occur. Patients are typically referred to their PCP for follow up. Review will take place to ensure that the entire surgical package was performed by the billing provider.

Medicaid

Prepay Edit

Professional Claims for Select Surgical Procedures

Pre-payment medical record review for inappropriate billing of services not documented in the physician clinical notes. There is no medical necessity decision making involved.

Medicaid
Medicare

Prepay Edit

Facility NCCI Modifier Override

The algorithm identifies instances in which providers submit claims that utilize the NCCI bypass modifiers with CPT codes that are not allowed to be billed together for the same recipient, on same date of service, based on Medicare NCCI OCE edits.

Medicaid
Medicare