Review Guidelines
What is done to the ASM edit when the denied procedure is not a surgical service? 08.05.24
Remove the ASM edit as the modifier was appended in error.
How many calendar days are counted for a code denied with the FOT edit when the DOS are 10/1/2024 to 10/5/2024? 08.05.24
5 days! Use the date calculator or count dates beginning with the denied DOS.
When can the PC of x-ray be paid on appeal if intent of the x-ray is to check for completeness or complication from a procedure? 08.19.24
Pay if the documentation for x-ray reading includes other pathologies unrelated to the procedure being addressed. See Comparative Imaging Studies update.
T/F EMRC: We can give 'high' on the risk component regardless of why the patient is being admitted? 08.29.24
True. Admission to the hospital will always be 'high' risk. (See EMRC FAQ - Risk of Complications & MDM: EM Audit Tool & FAQ 20231)
Where is Errata and CPT corrections found? 08.26.24
Errata and corrections are found in the Resources folder and contain updates made quarterly to the CPT codebook.
When can an EM service UNB to Principal Care Management (99424-99427) be paid on claim review? 08.05.2024.
Principal Care Management can be paid when PCM has not been reported prior to the claim DOS and M25 guidelines have been met.
What is the Nucleus Subspecialty List resource used for? 08.12.24
The Nucleus Subspecialty List resource is used to determine the subspecialty of a provider from the code listed in Nucleus.
Which appeal rationale should be used if the denied code is also a trigger code on another line? 08.19.24
The appeal rationale: Denied Codes Hitting as The Trigger Code on Appeal.
Pay or Deny: EMIM appeal with documentation that includes a list of diagnoses but no indication the dx are assessed or treated.
Deny! Documentation must indicate diagnoses are assessed or treated; simply being listed out does not support the EM service.
Who do you send a Teams message to if you find an incorrect appeal rationale attached in Nucleus? 08.0524
Please message Penny Barney.
How often is an EM allowed with footcare procedures? 08.30.24
An EM is allowed 60-days for patients with At-Risk diagnoses. See EM unbundling to Footcare (99202-99215 UNB 11719-11721).
What previous studies will indicate an angiography is NOT a diagnostic study? 08.26.24
A prior CTA or MRA of the area of interest will indicate an angiography is NOT a diagnostic study. See REVAS- Angiography w Vascular Interventions.