Clinical editing, a critical part of identifying and
eliminating inappropriate payments, is a process of reviewing bills for
appropriate coding and reimbursement and restricts how a procedure can be reimbursed.
Components of clinical editing may go beyond those noted in the MCO’s medical
bill editing criteria package below. For example, medical necessity should
determine reimbursement eligibility for the physical medicine treatments or
modalities, not the number of the modalities. Three modalities might be
medically necessary for one injured worker, but only one for another. The
provider reports what was done and the MCO determines if reimbursement is
appropriate for the allowed conditions in the claim.
Should the MCO receive an appeal to an edit, follow the steps
contained within the established Grievance process.
MCOs are not required to follow The Centers for Medicare and
Medicaid Services (CMS) medical editing criteria guidelines. However, all MCOs
are required to have a nationally recognized, medical bill editing criteria
package and shall supply the rationale behind the editing to the provider and
identify the software vendor. MCOs must update their clinical editing software
yearly to include CPT additions, changes and deletions The MCO’s clinical
editing shall contain but is not limited to the following:
1. Valid provider type: The MCO
shall be able to identify that the provider of the services has reported codes
that are valid for that provider type and within his/her scope of practice. Example:
An ambulance provider should not bill codes for performing physical
2. Correct provider coding: The
MCO shall be able to discern patterns that a provider has reported codes that
do not accurately describe the procedure performed or service provided. Example:
A provider frequently bills a high level evaluation and management code, or
frequently bills both an evaluation and management service and one or more
Chiropractic or Osteopathic manipulation treatment codes, on the same date of
service. Provider documentation shall support the codes that are billed.
3. Modifiers: Modifiers are 2
digits (letters or numbers) used with CPT codes to identify special services or
circumstances. Modifiers indicate that the services or procedures performed
have been altered by specific circumstances. MCOs shall apply EOBs to prohibit
payment of an incorrect modifier. Example: Modifier -50 bilateral
procedure is appended to a code that could not be performed bilaterally
procedure pricing: MCOs shall follow the following criteria for use of
Modifier -51 multiple procedure pricing shall be based on the determination of
the primary, secondary, third, fourth and fifth procedures. The primary
procedure is the one that has the highest relative value unit or highest paid
amount per unit, not the procedure with the highest billed amount. The primary
procedure will be priced at 100 percent of the allowed amount. The second,
third, fourth and fifth procedures will be priced at 50 percent of the allowed
amount. The sixth procedure and beyond will be priced at 25% of the fee. Reimbursement will not automatically be made
for more than five procedures. Any exception shall be determined to be
reimbursable by the MCO. Modifier –51 may be applied to all CPT codes except
E/M codes and those listed in CPT Appendix D (Add On Codes) & E (Exempt
from Modifier –51 codes). Add on and exempt from modifier -51 codes shall be
priced at 100 percent, in addition to the primary procedure; however, are
counted in the number of procedures reimbursed.
Units of Service The MCO shall review
whether units of service billed are appropriate for the allowed conditions and
meet the Miller Criteria. The Centers for Medicare and Medicaid Services’ (CMS)
Medically Unlikely Edits, which pertain to procedures, DME, etc., and Maximum
Allowable Units for medication dosage guidelines are used as for determining
standard units billed for a given service.
Follow-up days - also called
global period: The BWC shall be able to determine the period of time when
medical services are considered to be part of the surgical procedure and are
not reimbursed in addition to the surgical procedure. Example: The
surgical procedure includes post-op care of 10 days for a minor procedure
and 60 days for a major procedure. During that time period, office visits
to the same provider or another provider rendering post operative care are
considered as part of the original surgical fee.
Unbundling - also called
fragmenting or down-coding: The MCO shall be able to determine that a
provider has reported multiple codes when all services should be included in
one code. The MCO shall be able to detect the unbundling, re-bundle using the
appropriate code(s) and price at the re-bundled procedure fee. Example: Billing
separately for services which are a necessary part of the surgical or other
Mutually exclusive procedures - The
MCO shall be able to determine procedures that, by definition, cannot be billed
together at the same time. Example: Two codes are billed for the same
date of service, one for osteopathic manipulation to one to two body regions
and one for three to four body regions.
Gender - Most CPT codes are
appropriate for male or female but some are specific to one gender. The MCO
shall be able to identify procedures appropriate to only one sex.
Place of Service - The MCO shall be
able to identify where the services were performed and reimburse the provider
according to the correct two digit place of service. Example: Non-Facility
and/or Facility fee.
11. Procedure appropriate for diagnosis - This is unique to workers’ compensation and affects
prior authorization more than the clinical editing; however, MCOs shall be able
to identify procedures appropriate for the allowed conditions in the claim. Example:
A CPT code for performing a craniotomy would not be allowed if the allowed
diagnosis is knee sprain.
to purchase - The total amount of the
rental cost shall not exceed the total purchase price as established by MCO and
considers DME to be purchased when rental has reached the purchase fee that was
effective at the time the equipment was initially rented. BWC does not accept a
provider’s percentage reduction from the rental fees already paid which result
in BWC payment of additional monies for the purchase of the equipment beyond
the BWC purchase fee.
items of DME listed on the professional provider fee schedule are rented only
(RR modifier) and may not be purchased. These items do not have an NU modifier
identified with the HCPCS code. For further explanation, refer to the preamble
of the current professional provider fee schedule.
12. Codes that are valid for the date of service: Codes are added and deleted yearly; therefore
providers shall report codes that are valid for the date of service. MCOs shall
be able to identify appropriate valid and invalid dates for each code
13. Reimbursement of splint
and casting supplies
follows CPT® guidelines for the musculoskeletal system for fractures and
dislocations as provided in the surgery section of the CPT® book. The
instructions state fracture and dislocation care includes the application and
removal of the initial cast. BWC will reimburse HCPCS level II casting supply
codes (Q codes) when supplies are indicated while providing reapplication of
casts or splints. Q codes will only be separately reimbursed if used for
subsequent replacement for the treatment of fractures and dislocations. The
HCPCS Level II casting supply codes (A codes) will become non-covered codes.
14. Reimbursement for
Interpretation of Emergency Room X-rays
common for injured workers to seek treatment for injury(s) that include
performance and interpretation of x-rays in the emergency room. (ER)
procedures such as x-rays are a combination of the procedure being performed
(technical component (TC) and a physician interpretation component, identified
by a modifier-26.) Reimbursement of the technical component of an x-ray will be
made to only one provider.
situations where more than one physician provides interpretation of the same
emergency room x-ray for the same IW, for the same or different dates of service,
the MCOs shall reimburse the radiologist.
addition, the MCOs shall reimburse the ER physician for the x-ray
interpretation when the interpretation results in treatment of the injured
worker. Examples include:
• ER physician orders X-ray that result in diagnosis
of fracture. ER physician applies cast.
• ER physician orders x-ray. No fracture is visible on
x-ray. ER physician diagnoses strain/sprain and orders non-steroidal
anti-inflammatory medication for pain.
ER physician orders an x-ray, does not treat the injured worker based on
results of the x-ray and refers the IW to a physician specialist for the
interpretation and treatment, BWC will not reimburse the ER physician for the
interpretation of the x-ray since it did not result in treatment by the ER
15. Incidental Procedures
incidental procedure is performed at the same time as a more complex primary
procedure. However, the incidental procedure requires little additional
physician resources and/or is clinically integral to the performance of the
16. Utilization Parameters
Coding multiple new patient E&M codes • Coding multiple consult codes
Coding multiple E&M codes on same date of service
Preventive counseling codes
17. Unlisted Procedures
procedures are those that identify CPT and Level II HCPCS services that do not
have a more specific code. Any use of an unlisted code will require a report
which describes the service or procedure.
18. Observation Days
For the purposes of
Rule 4123-6-01 relating to hospitals, “outpatient” means: The injured worker is
not receiving inpatient care, as “inpatient” is defined in paragraph (CC)(1) of
this rule, but receives outpatient services at a hospital. An outpatient
encounter cannot exceed seventy-two hours of uninterrupted duration.