Review Guidelines
The updated PT/OT RE-eval claim review guidelines.(9.1.24)
What is remove the edit if there are providers of different specialties or if you can tell that guidelines for a re-evaluation were met ( i.e., modifiers indicating a PT and OT. GP=Physical therapy, GO=Occupational therapy).
Never leave both RDS and RUPA edits on a claim line. One edit or both edits must be removed on claim review to allow appropriate reimbursement of at least one EM service. (9.9.24)
What is the rule for RDS and RUPA edits on a single claim line?
Use the Rendering Subspecialty. (9.9.24)
When there is a subspecialty listed under Billing Subspecialty & Rendering Subspecialty that are not the same, which one should be used?
Heparin J1642-J1644 is not allowed if being given as part of a procedure. (See JCODE- Heparin J1642 J1644.) (9.1.24)
What is updated RG, is heparin (J1642-J1644) always paid on appeal when the units reported are above 3,000?
The new GENOM Rationale (9.16.24)
What new rationale can be found for TERT Testing with Oncology Thyroid (Afirma) Testing 81345 w 81546?
The updated RG added for EM service unb to Endovenous Ablation 36473-36483? (9.12.24)
What is remove the edit on claim review if a diagnostic study such as a duplex scan is performed to the opposite leg as the ablation.
Per CTNSC client review guidelines: Please remove the BIL, MAX, and FRE edits to allow for bilateral procedure codes. Support for this would be one of the following:
(A) Reported on 2 lines with 1 unit on each line with a modifier 50 on one line and not on the other OR
(B) Reported on 2 lines with 1 unit on each line with a LT modifier on one line and a RT modifier on the other OR
(C) Reported on 1 line with 2 units and RT/LT modifiers. (9.1.24)
What is the CTNSC CIW & Review Guideline Update for Bilateral Procedure Codes 00100-V5364: BIL, FRE & MAX?
If there is additional information on the claim and in history that supports multiple providers that are from different group/specialty that saw the patient, we can pay. (9.12.24)
What bullet point was added to the CPD EM Flowchart?
OLOW OUPP- Multiple Fractures Treated w Same Cast Strap Splint bullet points at the beginning of the appeal rationale. (9.1.24)
Where can the guidelines be found to know when to use the OLOW OUPP- Multiple Fractures Treated w Same Cast Strap Splint rationale?
EMCRD. (9.12.24)
What new rationale has been created for an EM w Endovenous Ablation?
Do not simply pay for dx of plantar fascial fibromatosis/plantar fasciitis (9.23.24)
What is the RG for strapping (29540) with tendon injection (20550/20551) on claim review?
Separate spinal regions DO support separate sites for these codes. (9.1.24)
What are Trigger Point Injections (20552/20553) with Peripheral Nerve/Branch Injections (64450)?
Per Centene for laterality codes (i.e. hearing aids, insoles, custom molds, etc.) if diagnosis/modifiers support allow the appropriate units for each side. (9.12.24)
What is the update made to Centene FRE/FOT Corp CIW?
When reviewing a M25 appeal, evidence is needed that something beyond the reported procedure and its components is being assessed or treated. (9.1.24)
What update was made to the M25 appeal review guidelines?
If the documentation clearly supports the provider is managing labs, imaging, counseling etc. this would support the EM service. (9.23.24)
What is High Risk Medication Management
Support can be found in the provider narrative, MAR or Orders (with note the order was carried out) (9.23.24)
Where can support for admin codes be found in documentation?
The place where NDC look up information is given.(9.30.24)
What is JCODE UNL appeal rationale?
Counseling (9.23.24)
When first looking at a claim where Preventative Counseling is the denied code, what specific word are we looking for in the diagnoses in order to proceed?
VASC3 bullet point #5: If the kidneys and bladder were reviewed/documented, then this supports a complete ultrasound (76770), regardless of urinary pathology. (9.1.24)
What update was made to the Limited/Complete Retroperitoneal (Back Wall) US with Vascular Studies 76770, 76775 (deny) with 93975-93976, 93978, IU21/SIU21/RIU21,1 appeal rationale?
For what edits are a new patient EM and new preventive EM allowed when both are supported. (9.23.24)
What is a UNB or RDS Ninja Edit.
This is a new weekly high-level overview of notes that will be sent out with Weekly Education. (9.30.24)
What are the CVCAT notes?
DAILY DOUBLE (Everyone please buzz in)
the 13th person to buzz in will claim these points
Cotiviti is no longer making recommendations about FDA approval, you are only reviewing for whether or not there is a more appropriate CPT code (9.23.24)
What is the UNL Lab Rationale.
Deny timed therapy codes UNB with non-timed codes when the minimum of 8 minutes is not met. (9.9.24)
What has HCSC confirmed recently for PHMODS2 appeal rationales?
VASC1- Limited or Complete Vascular Study w Limited or Complete Pelvic US 93975 93976 w 76856 76857.docx (9.23.24)
Which rationale has been updated to note that listing the CM/SEC Ratio findings alone support spectral doppler?