Review Guidelines
DAILY DOUBLE (Everyone please buzz in)
The 13th person to buzz in will claim these points!!
CV FAB - Feedback Anonymous Box
Which form should be used for suggestions or feedback? (The Training requests box is for other things like requesting new a rationale or rationale updates, training resource updates/creation, claim review guideline notes new or updates, analyst training requests, etc.) 08.26.24
CTNIA, CTNMP and CTNMO Maternity Billing Rationales.
Which CTN clients have a new or updated Maternity Billing rationale? 08.26.24 and 08.19.24
Sweeping for debris in a separate duct from the one that is dilated.
When is 43277(ERCP w dilation, including sphincterotomy, each duct) separately reportable with 43264 ((ERCP with removal of calculi-debris from biliary-pancreatic duct(s).)
See GIUPP- ERCP Dilation w Other ERCP Proc 43277 w 43264, 43265 43274 43276. 08.26.24
Found in the Resources folder and contain updates made quarterly to the CPT codebook.
What is Errata and CPT corrections? 08.26.24
96160 or 96161 is supported by a separate and specific condition without potential overlap.
What is updated RG for 96110 unb to 96160-96161?See RG: RG: To remove the edit, you need to clearly be able to see that the Developmental Screening was used for a specific developmental screen test based on diagnosis and the procedure reported (trigger code) was used for another separate and specific condition/health risk assessment, without potential overlap. 08.26.24
Follow the NPI Look Up rules if the subspecialty code is not found here.
What is the Nucleus Subspecialty List resource? 08.12.24
The documentation for x-ray reading includes other pathologies unrelated to the procedure being addressed.
When can a professional component of x-ray be paid when intent is to check for completeness or complication from a procedure?
See Comparative Imaging Studies Appeal Rationale updated to match the CHERA/CHERA2 Appeal Category Training. 08.19.24
EMRC – admission to the hospital will always be high risk.
If there is hospital admission or elevation to hospital level care, can we give high on the risk for that regardless of why the patient is being admitted?
(See EMRC FAQ - Risk of Complications & MDM: EM Audit Tool & FAQ 20231) 08.29.24 question #4
If you find an incorrect appeal rationale text this person.
Who is Penny Barney. 08.0524
Remove the ASM edit as the modifier was appended in error.
What is done to the ASM edit when the denied service is not a surgical service? 08.05.24
The M25 flow chart.
What tool or resource should be used when reviewing a M25 claim? 08.26.24
CPD- Cross Provider Duplicate and ERRAD EREKG- Default Xray’s & EKGs in ER rationales.
What rationales have been updated and include: The CPD rationale has been updated for ER provider reporting EKG/X-ray with CPD for another ER provider reporting EKG/X-ray. The ERRAD EREKG bullets updated to further clarify when to pay and deny if the trigger provider is not specialty of radiology or cardiology. 08.12.24
An EMIM appeal with documentation including a list of diagnoses without indication the dx are assessed or treated.
When is an EMIM appeal denied? 08.26.24
A prior CTA or MRA of the area of interest.
What will indicate an angiography is NOT a diagnostic study? See REVAS- Angiography w Vascular Interventions. 08.26.24
Principal Care Management has not been reported prior to the claim DOS and M25 guidelines have been met.
When can an EM service UNB to Principal Care Management (99424-99427) be paid on claim review? See 08.05.2024.
60-days for patients with At-Risk diagnoses.
How often is an EM allowed with footcare procedures? See EM unbundling to Footcare (99202-99215 UNB 11719-11721). 08.30.24
EMRC EYE Appeal Training.
Which EMRC appeal training was updated with a new video clarifying initiation and continuation of treatments and diagnostic services?08.26.24
Documentation including Asthma Control Test will support 96160-96161 unb to allergy testing and immunotherapy procedures.
What is new information in the “What am I looking for” section of the COUNS- Health Risk Assessment 96160 96161 rationale. 08.05.24
Pericapsular nerve group block (PENG block).
What procedure may be reported with 64999? 08.12.24
AETNA ASM edit review guideline instructions when the primary surgeon has a CORE edit on their code.
What has Aetna clarified and now RG note says: If the primary surgeon has a CORE edit on the code, you can disregard the CORE edit and remove the edit if the assistant surgeon is billing the same CPT code and the assistant surgeon paid amount still appears reduced. 08.14.24
Using the date calculator or counting dates beginning with the denied DOS.
What is how to accurately count calendar days for a code denied with the FOT edit? 08.05.24
The appeal rationale: Denied Codes Hitting as The Trigger Code on Appeal.
Which appeal rationale should be used if the denied code is also a trigger code on another line?
08.19.24
This rationale covers a large range of eye procedure codes with general concepts. You will find a few details about a few common eye conditions.
What is the new EMEYE Eye EM with Eye Procedures 92012, 92014 w 66700-68770 appeal rationale? 08.05.24
CV205 Part 1 FOT edit.
Which updated training indicates that a rolling time frame is from the date the services were reported? 08.26.24