Fine-Tuning Excellence:

Unveiling OaRS’ Industry Standard Edit Administration

OaRS administers the following industry standard edits

The Duplicate Claim function reads through claim history seeking out records that can be considered duplicate billings. The duplicate search can be set to user defined criteria utilizing a dozen different fields such as Billed Charges, Place of Service, Modifiers and Billing Provider, as just an example.

The system has the ability to check service units to determine whether they exceed a pre-defined maximum frequency per day limitation. Utilizing CMS’s Medically Unlikely Edits (MUE), the system will compare the calculated units from one or more claims to the values contained in the MUE master file for the CPT or HCPC code being analyzed. The claim line will be flagged if the unit exceeds the daily maximum. 

Based upon user specified options, this feature can determine if maximum units have been exceeded based upon a single individual line item, as Medicare requires, or the sum of all similar procedure codes on the same day for the same patient and provider.

This function reports claims that have either been paid or flagged for payment when the patient had become ineligible for benefits after the service had already been rendered. Since eligibility reporting can be received several weeks after a member has actually been terminated, this feature allows the plan to identify those claims that had been finalized, allowing the claim expense to be taken back. 

The National Correct Coding Initiative (NCCI) edits are a series of rules developed by CMS to identify errors in two areas of procedure code submission. The Mutually Exclusive edits check for procedures that should not be performed during the same session (that is, same claim) based on standard medical practice, while the Comprehensive/Component edits look for codes that cannot be reasonably performed during the same session or day. 

The Medical Necessity Edit, also known as Local and National Coverage Determination (LCD/NCD), are published by CMS and are typically applied to Medicare claims in order  to determine whether CMS will pay for a service based upon the relationship between the diagnosis and procedure code. Medicare will cover items which it considers reasonable and necessary and deny any service in which a NCD policy is defined.

Procedure Rebundling occurs when two or more procedures codes can be replaced with a single, more comprehensive code. For example, if CPT code 27705 (Osteotomy, tibia) is reported on the same date of service as 27707 (Osteotomy, fibula), procedure 27709 (Osteotomy, tibia and fibula) would replace both codes.

This edit identifies separate procedures on the same date of service for the same provider which contain modifiers LT and RT. Depending on how the user sets up their environment, the system will recommend that the line items with LT and RT be denied and replaced with a single line containing modifier 50. The system also identifies procedures that are billed with modifiers LT, RT and 50 which are defined as bilateral and unilateral in nature, in addition to isolating line items containing more than one unit for modifiers LT, RT and 50.

The CMS definition of a Status Code B, T and P claim is one which contains a CPT code that is defined as being a service that is always bundled into another service on the same Date of Service for the same patient and provider. This edit identifies any line item which is defined as Status B, T or P and at least one other CPT code is billed for the same member and provider on the same Date of Service and that code is not also defined as Status B, T or P.

Add-on codes are defined as additional procedures associated with a primary procedure. A primary procedure must always be found on the same claim along with its associated add-on procedure. Add-on codes must never be submitted alone.

Our system also identifies ambulance claims submitted without transportation codes. For example, A0425 submitted without A0433 will be flagged as an error.

The Global Surgery Days feature identifies Evaluation and Management (E&M) services which were paid within the 0, 10 or 90 day global services period. Surgical procedures include preoperative, intra-operative and postoperative services. The preoperative period for major surgery is 1 day. The postoperative period for major surgery is 90 days while the postoperative period for minor surgery is either 0 or 10 days, depending on the procedure.

The system also administers the OB Care Package for professional maternity claims.

MPPR are those surgical CPT’s which are billed on the same Date of Service for the same provider as other procedures which qualify for reduced payment. This reduction in payment is administered by either recommending that modifier 51 be added to the claim or applying a tiering methodology which reduces payment by a predetermined percentage. If an existing line is billed with modifier 51 and the system finds that the line item is the primary procedure, a recommendation is made that modifier 51 be removed.

The system has the ability to determine whether this edit applies only to the current claim or all claims billed on the same Date of Service for the same Member and Provider.

This edit administers price reductions for Radiology, Multiple Therapy, Cardiology and Opthamology Technical Component. It also has the ability to identify the primary endoscopic procedure, resulting in the recommendation to reduce all of the codes found to be contained in the same “family” of codes.

Seeks to find claims that were billed using the global code as well as modifiers 26 (professional component) and TC (technical component). If the global code was paid first, then the system will recommend denial of those claims containing modifiers 26/TC. Conversely, if claims were paid containing modifiers 26 and TC, then the recommendation would be for the global code to be denied.

This edit checks to see whether the age and gender of the patient is appropriate for the CPT code presented on the claim.

This edit checks to see whether the age and gender of the patient is appropriate for all of the ICD-9 or ICD-10 diagnosis codes present on the claim. When an error is reported, the actual diagnosis code is reported.

The Procedure by Place of Service edit will check to see if the Place of Service code is appropriate for the Procedure code.

This edit verifies that all of the modifiers attached to the CPT on a particular claim are associated with the procedure code.

Also included is the ability to identify facility claims which contain procedures defined with CMS’ PC/TC Indicator that are not billed with modifier 26.

Optionally, procedures that contain Assistant Surgeon modifiers (AS and 80) that are found to be inappropriate can also be identified based upon definitions contained in the CMS Physicians Fee Schedule.

The New Patient Frequency edit will check to see if a CPT code in the range 99202 through 99209 has been billed more than once for the same patient and provider within a three year period.

The Lifetime Maximum edit checks if certain procedures, which can be performed only once in a lifetime, have been billed more than once. An example of this would be an appendectomy, CPT 44950.

Identifies surgical CPT codes which contain modifier 76 (Repeat Procedure) and were billed within three days of the initial procedure for the same patient and provider. Alternatively, the system can be setup to identify those claims with a standalone modifier 76. This edit is used to determine whether the provider billed for a medically necessary procedure or whether correcting their own error.

̌An Obsolete Procedure is a CPT code which is no longer in use based on the Date of Service which was billed. The system has the capability to replace the obsolete procedure with a more appropriate code if defined.

The Assistant/co-surgeon edit verifies that procedures billed with modifiers AS, 80, 81, 82 and 62 are appropriate for the CPT code based upon the CMS Medicare Fee Schedule.

Lab Rebundling attempts to identify multiple laboratory procedures contained on a single claim and recommends replacement with a single, more appropriate “panel” code.

As an example, CPT codes 80053, 85025 and 84443 can all be replaced with the single, more appropriate code, 80050.

CMS defines Hospital Acquired Condition (HAC) as an undesirable situation or condition that affects a patient and arises during a stay in a hospital or medical facility. Their directive to Medicare Advantage health plans is to deny these claims because the condition was avoidable with proper care. This edit makes heavy use of the Present on Admission (POA) indicators that are associated with each diagnosis code.

The Medicare Code Edits are a series of rules based upon the Medicare Code Editor (MCE) system. Currently, OaRS administers these edits on facility claims based upon the current MCE version.

Used in conjunction with the Medicare Hospice Election file, the Hospice Billing edit will search for claims which were billed for Medicare patients who officially elected hospice care. During this period, all financial responsibility for patient care is assumed by the MAC. This edit identifies claims which the health plan is not responsible for, with the exception of the basic benefits package, and were paid in error.

For those claims containing Place of Service 21 through 25, the system will check the number of critical care codes billed on a single date of service and deny those claims which exceed a user definable count, which is typically one.

This edit triggers when multiple providers are billing hospital medical care codes with the same diagnosis for the same patient on the same date of service.

This edit identifies high level E&M codes billed by the same provider for the same member more than 4 times (user definable) per 12 month rolling calendar year (previous 365 days). Any claim billing a high level visit that exceeds the frequency limit of 4 (which is parameterized) for the same provider will trigger the edit.

This edit finds claims for inappropriately billed initial admission/discharge facility visit codes based on claims with Place of Service code 21 or 22.