CMS Encounter Data Processing and Pricing System (EDPPPS) Proposed Edits EDPPPS Edit#

Transcription

1 CMS Encounter Data Processing and Pricing System () Proposed Edits Edit Edit Edit Error Message Validation Reject From Date of Service is Greater than TCN Date Validation Reject Modifier 51 Invalid Units Validation Informational Nasal Punctum/Nasolacrimal Duct Dilation & Probing with or without Irrigation Validation Informational Kidney Disease Patient Education Services Validation Informational Cardiac Computed Tomography (CCT) and Cardiac Computed Tomography Angiography (CCTA) Validation Reject To Date of Service after Date of Claim Receipt Validation Informational Dermal Injections for Treatment of Facial Lipdystrophy Syndrome Validation Informational NCD PRO Time Monitoring for Home Management Validation Informational NCD Arthroscopic Lavage Validation Informational Tetanus Immunization Validation Informational NCD - Infrared Therapy Validation Informational Telehealth Service Validation Informational Verteporfin Validation Informational Late Filing Validation Informational Drug Cap No Pay Modifier Validation Reject Adjustment or Void ICN Not Found in History Validation Informational Leuprolide Acetate Units Exceed More than Validation Informational Approved CAS Facilities for PTA Validation Informational Reproductive Medicine Procedures Validation Informational Human Papillomavirus Validation Informational Ophthalmic Ultrasound, Echography, Diagnostic; Corneal Pachymetry Validation Informational Lab Travel Validation Informational Service Payable Under Part A Validation Reject Codes Billed Together in Error Validation Informational Modifier GX Provider Informational Referring/Ordering Provider Not Allowed to Refer Provider Informational Referring/Ordering Provider Name Mismatch Provider Informational Performing Provider Name Mismatch Provider Informational Chirpractors Can Only Refer Consultation 12/8/2011 1

2 Edit Edit Edit Error Message Provider Informational Diagnostic Testing Provider Informational Ambulance Extra Charge Codes Provider Reject Invalid Procedure for Chiropractor Provider Reject Sanctioned Provider Provider Reject Rendering Provider Not Eligible for Date of Service Beneficiary Reject Invalid Beneficiary Last Name Beneficiary Reject Beneficiary Health Insurance Carrier Number (HICN) Not on File Beneficiary Reject Date of Service is After Beneficiary Date of Death Beneficiary Reject Beneficiary Gender Mismatch Beneficiary Reject Beneficiary Date of Birth Mismatch Beneficiary Reject Beneficiary Not Enrolled in Medicare Advantage Organization for Date of Service Beneficiary Reject Beneficiary Not Part A Eligible for Date of Service Beneficiary Reject Beneficiary Not Part C Eligible for Date of Service Reference Reject DOS Spans Procedure Code Effective/End Date Reference Informational Automatic Implantable Cardiac Defibrillator Q0 Modifier Requirement Reference Informational Diagnosis Not Covered for Reported Procedure Reference Informational Anesthesiologist vs CRNA Reference Informational NCD Allogeneic Hematopoietic Stem Cell Transplantation Reference Reject Invalid Modifier Reference Informational Smoking Cessation Required Diagnosis Reference Informational Chiropractic Manipulation Submitted with AT Modifier Reference Reject Invalid Recipient Age For Procedure Reference Informational Invalid Place of Service for Procedure Reference Informational Opthalmic Biometry Error Reference Informational Claim Detail Missing CLIA Certificate Reference Informational Claim Detail CLIA Numbers Not Matching Reference Reject Diagnosis Not Found on the Reference Table Reference Informational DME Billing Tracheo-Esphageal Voice Prosthesis Reference Informational Podiatry Without Last Date Seen Reference Informational Pancreas Transplant Facilities and Diagnosis Reference Informational NCD Lumbar Artificial Disc Replacement 12/8/2011 2

3 Edit Edit Edit Error Message Reference Informational Modifier Invalid with Procedure Reference Informational Modifier 26 Invalid for Specialty Reference Informational Optometrist Service Billed Without Modifier Reference Informational Corneal Pachymetry not Supported by Diagnosis Reference Reject Collagen Implant Billed Reference Informational Assistant At Surgery Services Reference Informational Health and Behavior Assessment-Intervention Reference Informational Cardiac Event Detection Reference Informational Mammography Screening Not Allowed Reference Informational Ambulatory Blood Pressure Monitoring Reference Informational MR Service Audit on Reference Reject III CPT Codes Reference Informational MR Service Audit on Reference Informational Review Botox Surgery Codes Reference Informational Review Botox Injection Codes Reference Informational Vertebroplasy and Kphoplasty Reference Informational Medical Nutrition Therapy Codes Reference Informational High Sensitivity C-Reactive Testing Code Limit Informational Procedure Limit Exceeded Limit Informational Ophthalmic A & B Scans 8 per Year Limit Informational Pacemaker Transtelephonic Monitoring Exceeds One Unit in 90 days Limit Informational Services Allowed Twice Per Day Limit Informational Excessive Initial Visits Limit Informational Non-Invasive Vascular Allowed Once Per Day Limit Informational Darbepoetin Alfa Services Allowed Once Per Day Limit Informational Bilateral Indicator of 2 Limit of 1 per Day Limit Informational Services Allowed Once Per Day Limit Reject Initial Visit Limit Exceeded Limit Informational Hemorrhoid Treatment Limit Exceeded (2 Year) Limit Informational Hemorrhoid Treatment Limit Exceeded (90 Day) Limit Informational CPO Limit Exceeded Limit Informational SCF Initial Visit vs Subsequent Visit 12/8/2011 3

4 Edit Edit Edit Error Message Limit Informational Footcare 60 Day Limit Limit Informational Dialysis 30 Limit Exceeded Limit Informational MCP Monthly Limit Exceeded (Same Code) Limit Informational MCP Monthly Limit Exceeded (Different Code) Limit Informational Smoking Cessation Counseling Limit Exceeded Limit Informational Services that Exceed 2 Units on the Same Date of Service Limit Informational Services that Exceed 6 Units on the Same Day Limit Informational Care Plan Oversight Limit Exceeded Limit Reject Lifetime Limit Exceeded Conflict Informational Sleep Studies Procedure Conflict Conflict Reject ESRD Monthly vs Daily Billing Conflict Reject Dialysis Treatment Conflicts with E&M Codes Conflict Informational Infusion Encounter Conflict Conflict Informational Kidney Disease Service Conflict Conflict Informational Dialysis Service Conflict Conflict Informational ASC Code Must be Billed with a Surgery Procedure Conflict Reject Portable X-Ray Billed without X-Ray Conflict Informational Q2043 Sipueleucel-T (Provenge ) without supporting diagnosis Conflict Reject J1250 Present on Claim without 93015, 93017, or Conflict Informational Annual Wellness Visit Billed with E&M and no Modifier 25 is Present Conflict Informational Smoking Cessation Billed with E&M and no Modifier 25 is Present Conflict Informational Dialysis vs E/M Visits with Modifier Conflict Informational Thermal Intradiscal Procedures Conflict Informational Add-On A4648 or A Conflict Informational Outpatient or Other Concurrent Care Conflict Conflict Informational Discharge Management Billed Same Day as Observation Codes Conflict Informational Visit vs. Visit Conflict Conflict Informational Status T Code Denial when Billed with a Physician s Service Conflict Informational Breast Imaging Mammography-Breast Echography (Sonography) Breast-MRI Ductography Conflict Reject Critical Care Service Provided by Same Specialty Conflict Informational Nonvascular Extremity Ultrasound 12/8/2011 4

5 Edit Edit Edit Error Message Conflict Reject Global 90 (90 Days Post Op) Conflict Informational Corneal Pachymetry Global Surgery Conflict Conflict Reject Opthal Biometry Global-Technical Conflict Reject Global 90 (1 Day Pre Op) Conflict Reject Visit Same Day as Major Surgery Conflict Reject Global Same Day (Same Day Visit 000 and 010) Conflict Reject Global 010 (10 Days Post Op) Conflict Reject Surgery in Post-Op of Another Surgery Conflict Reject Surgery in Post-Op of Another Surgery Same Provider Conflict Informational Global vs. Modifier Conflict Conflict Reject Admission Conflict with E&M Service Conflict Informational New Technology Intraocular Lens Conflict on Claim Pricing Informational No Rate on File for Service Line Pricing Informational Service Line Amount Adjusted for Multiple Technical Procedure Pricing Reject ASC Non-Approved Codes NCCI Informational Correct Code Initiative Error NCCI Informational Medically Unlikely Error Duplicate Reject Claim is an Exact Duplicate of a Previously Priced Claim Duplicate Anesthesia and Surgical Services by Same Provider Duplicate Informational Post Op vs Pre Op Conflict Duplicate Informational Surgeon vs Assistant Surgeon Conflict Duplicate Informational Non DME Duplicate Duplicate Informational Administration Code with Non-Covered Injection Duplicate Informational Prolonged Care without E&M Billed Duplicate Informational Bariatric Surgery Billing Conflict Duplicate Informational NCD Bone Mass Measurement Duplicate Reject Multiple Claims for Surgery Duplicate Reject Anesthesia vs Anesthesia Different Code Duplicate Reject Anesthesia vs Anesthesia Same Code 12/8/2011 5