Q&A: Addressing edits for noncovered procedures

Q: How can we submit a claim that hits an edit for a noncovered procedure? Can we submit a claim for the covered procedures? Can we appeal if the provider believes the procedure should be covered?

A: If a claim is edited for a noncovered procedure, the claim cannot be submitted to CMS for appeal. Therefore, once the coding of the noncovered procedure is validated, the process to split the noncovered procedure onto a separate claim must be followed so that at least one claim can be submitted and processed. Then an appeal can be filed if the provider actually believes the procedure should be or is covered.

For more information, see The Chargemaster Essentials Toolkit, Second Edition.