CLINICAL EDITING

 

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 therapy.

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

4. Multiple 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.

 

5. 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.

6. 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.

7. 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 procedure

8. 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.

9. 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.

10. 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.

 

Rent to purchase - The total amount of the rental cost shall not exceed the total purchase price as established by MCO and vendor negotiations.

BWC 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.

 

Certain 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

BWC 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

It is common for injured workers to seek treatment for injury(s) that include performance and interpretation of x-rays in the emergency room. (ER)

Certain 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.

 

In 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.

 

In 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.

 

If an 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 physician.

 

15. Incidental Procedures

An 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 primary procedure.

 

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

• Frequency of service

 

17. Unlisted Procedures

Unlisted 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.