Correct Coding Edits Coming to Claims Editor

Effective for claim processing dates on and after May 26, 2024, a series of “correct coding” edits will be implemented in the claims editor. These edits will enact the following coding criteria and guidelines:

• “EXCLUDES 1” notes:
  • As identified in the ICD-10 CM diagnosis coding guidelines, the EXCLUDES 1 code(s) should not be submitted/billed at the same time as the main code above the EXCLUDES 1 note.
  • Therefore, codes listed under EXCLUDES 1 note will be denied if submitted/billed with the codes above the EXCLUDES 1 note.
  • This editing will apply to professional claims only.
• The Place of Service (POS) code on professional surgical procedures should correctly reflect the location where the surgical procedure is performed, as indicated by the facility claim submission. For example:
  • If the facility claim represents an outpatient facility surgery, a professional claim should be billed with POS code 22-On Campus–Outpatient Hospital.
  • If the facility claim represents an inpatient surgical procedure, a professional claim should be billed with POS code 21–Inpatient Hospital.
• The Telephone Evaluation and Management (E&M) services (99441-99443), remote evaluation of video and/or images (G2012), or a brief check-in by MD/QHP (G2252) should not originate from a related E&M service (99202-99439, 99446-99499, 99091) billed on the same day or within the previous 7 days. Correct coding of these procedures should not lead to an E&M service or procedure within the next day based on the same primary diagnosis.
• Correct submission of surgical pathology procedure codes (88304-88309) should be based on the defined tissue specimens listed in the CPT Codebook, and the related primary diagnosis code associated with the procedure code categories.

Providers and their billing staff are encouraged to review the official ICD-10 CM diagnosis coding guidelines for diagnosis code EXCLUDES 1, and coding guidelines in the CPT codebook addressing the areas discussed above.