Clarifying edits with patient financial services
Q: We are having difficulty getting our patient financial services group to route claims back to us that hit edits for lack of a medically necessary diagnosis. We have found one procedure-to-diagnosis pairing that is faulty because it is a crossover from a local coverage determination (LCD) that has multiple procedure codes related to a procedure. One of the procedure codes happens to be on this claim, but as a standalone procedure and not as part of the service described by the LCD. How do we get them to understand that the edit is not always correct for the individual situation?
A: It is important for edits to be reviewed for many reasons, but one of the most compelling is the one that you present – the edit is not always correct for an individual situation. For example, one that has been noted in the past is for a stress test. The stress portion (CPT® code 93017) was reported alone with an appropriate diagnosis code to support the service.
However, this claim hit an edit because of a stress echocardiogram LCD. The diagnosis was not on the list of covered diagnoses for a stress echocardiogram. The edit should have been triggered with the stress echocardiogram but not with the “regular” cardiac stress test. This required communication with the MAC to show them the LCD and the intent of the edit. The edit was adjusted and then claims processed as they should. This is most often noted just after a software update to the claims processing systems, when parameters are changed.
It has become very, very important for providers to monitor the edits. One MAC just announced “automated LCD editing.” They are going to deny claims as an error if a payable diagnosis code is not reported on the claim. This is an effort to exclude payment for services that are not reasonable and necessary. This is for Part A coverage policies. They also note they will perform “mass adjustments” to identify claims that either denied in error with payable diagnosis present and claims that paid in error with a “non-payable diagnosis” present. They will publish further information on the mass adjustments.
Please share this information with your patient financial services department and other departments that need to know – this is something that must be monitored to ensure that the appropriate scenarios are identified and not when there is an incorrect programming.
Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.