Procedure Code Edits-Patient Billing Impact

The edits contained in the Claims Editing Tool are designed to provide appropriate coding, and to assist in processing claims accurately and consistently. The member is not responsible and should not be billed for any procedures for which payment has been denied or reduced as a result of column1/column2 and mutually exclusive edits.


Column1/Column2 and Mutually Exclusive Edits

Correct coding initiative (CCI) edits are pre-adjudication edits that prevent improper payment when incorrect code combinations are reported. Column1/ Column2 edits are code combinations that should not be reported together. Mutually exclusive procedures exist when a claim is submitted with two or more procedure codes that are not usually performed on the same patient, on the same date of service. These include combinations of procedures that may be anatomically impossible, represent overlapping and/or duplication of services, or are reported as both an initial and subsequent service.

One of the following denial reasons will be returned on the remittance advice depending on whether or not the code combination is allowed with or without a modifier:

• Mutually exclusive procedure

• Code 2 of a code pair not allowed

• Mutually exclusive procedure - Bill with appropriate mod.

• Secondary code not allowed - Bill with appropriate mod.


Medically Unlikely Edits (MUE)

A(medically unlikely edit (MUE) for a HCPCS/CPT code is an edit applied to ensure accurate coding of units reported for outpatient claims. Weuse Medical Coverage Guidelines (MCGs) to define the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. This edit is not applied to all HCPCS/CPT codes. At this time, the maximum units for outpatient HCPCS/CPT code billing do not vary from those documented and used by Medicare. We use the existing MUE units for commercial and Medicare Advantage outpatient claims.

Note: If your claim denies due to the number of units reported for a service, you may submit a claim payment appeal. Your appeal must be submitted in writing and accompanied by the necessary documentation to support the number of services provided and for appropriate pricing of the claim.

One of the following denial reasons will be returned on the remittance advice


• EXCEEDS DAILY MAXIMUM LIMITATIONS

Periodic Updates
The claims editing tool is updated quarterly to accommodate coding changes. Refer to CMS website for the latest Claims Editing Tool updates. All claims submitted after the implementation date, regardless of service date, will be processed according to the updated version.