Code Editing Software

In January 2015, Martin's Point implemented new software that more closely aligns our claims editing rules with correct coding and billing criteria established by the Centers for Medicare and Medicaid Services (CMS). The new claim editing rules apply to both institutional and professional claims (UB-04 and CMS-1500) claims processed on or after January 2, 2015, regardless of the service date. This includes claims submitted for reconsideration, reprocessing, or correction. 

There are some exceptions to our application of correct coding and billing criteria, based on our health plan benefit design. But overall, we adhere closely to Medicare claim editing practices. For example, we now apply more extensive claim editing rules for common billing and coding errors such as: 

Bundling: Items and services considered incidental to a physician service on the same date.

Unbundling: Determining whether two procedure codes are allowed to be billed for the same patient, on the same day, by the same provider.

Post -Op Surgery (Global Period): Surgical procedures rendered within pre-determined follow-up time periods for services by the same provider, department, and specialty, with the same diagnosis code.

Medical Visit on Same Day as Procedure without Modifier: An evaluation and management (E/M) code billed on the same day as a procedure without a modifier to indicate that the E/M service was performed and documented as a significant, separately identifiable service. 

We also apply Medicare Local Coverage Determination (LCD) rules to claims for services rendered to Generations Advantage members in Maine and New Hampshire. LCD rules do not apply to US Family Health Plan claims. For example:

Diagnosis to Support Medical Necessity Edits: Apply to certain procedures that require the use of specific diagnosis codes to support medical necessity for the service.

Primary/Secondary Diagnosis Code Edits: Apply when LCD rules indicate a specific diagnosis code is required in the primary or secondary position to support medical necessity and/or to more fully define the patient's condition.

Code Modifier Edits: Apply when LCD rules require use of specific modifiers to communicate additional information about a service.

Frequency Limit Edits: Apply to services that have limitations on how frequently they can be covered.

What is an LCD?
Under certain circumstances, Medicare fiscal intermediaries and carriers have the discretion to cover a particular service (i.e., determination that a service is reasonable and necessary). These coverage policies are issued in a document called a Local Coverage Determination (formerly, the Local Medical Review Policy). Local Coverage Determinations (LCDs) provide guidance that assists providers in submitting correct claims for payment. LCDs also outline how the contractor will review claims to ensure that the services provided meet Medicare coverage requirements. LCD rules can be found on the local carrier's website or by contacting them directly. Following are the local carriers for Maine and New Hampshire: 

Medicare Parts A & B: National Government Services, Inc. 

Medical Policy Center

Durable Medical Equipment (DME): NHIC, Corp.

For more information about Medicare coding and billing criteria, please visit https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/