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Important 2025 claims processing updates
Community Health Options updates its claims processing system regularly to stay in line with the latest American Medical Association Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS), and International Classification of Diseases (ICD) code sets. Additionally, we ensure our system complies with other key sources, including CMS guidelines, correct-coding initiatives, policy requirements, national benchmarks and industry standards.
These updates also include additions and updates to edit rules and logic that were not previously implemented but are represented in current published policies. Effective January 1, 2025, the following edit logic will be live in our claims processing system and will apply to all claims processed on or after January 1, 2025.
Add-on Codes:
Add-on codes are only those codes designated by CPT and identified by a specified descriptor that includes the phrase “each additional” or “list separately in addition to the primary procedure."
Diagnosis code level of specificity:
Services will be allowed only when all diagnosis codes submitted on the claim are coded to the highest level of specificity.
Frequency:
A procedure or service billed for a single member, on a single date of service by the same provider and/or provider group up to the maximum number of units allowed.
Incidental Procedures:
Procedures performed at the same time as a primary procedure are considered incidental if clinical practice standards indicate they are normally included as part of the primary procedure. Incidental procedures are not reimbursed separately.
Incidental:
An incidental procedure is a service that is performed at the same time as a primary procedure but is not essential to the primary procedure and is not separately billable.
Mutually Exclusive Procedures:
Two or more procedures are considered mutually exclusive if they cannot reasonably be performed at the same anatomic site or patient encounter. These coding combinations are deemed submitted in error and only the primary service is considered for reimbursement.
Bundling:
Bundling is when multiple services are linked together under one code. This is often done when one service is performed as a result of another.
Unbundling:
Unbundling occurs when two or more procedures are reported separately when a single, comprehensive code exists that accurately describes the service performed.
Modifiers:
Modifiers allow for the reporting of a service or procedure that has been adjusted by a specific circumstance without altering the procedure code itself. They enhance accuracy in compensation, ensure coding consistency, assist in editing, and help capture precise payment data.
DME Modifiers:
New, rented or used durable medical equipment appended with the appropriate modifier. DME modifiers are considered reimbursement modifiers and must be billed in the primary or first modifier field to determine appropriate reimbursement.
Global Surgical Period:
Supplies and services typically associated with a surgical procedure will not be separately reimbursed when submitted on the same date of service or within the allotted global period (0, 10 or 90 days).
Prior Approval updates
Effective Oct. 1, 2024, the follow services no longer require prior approval:
- Abortion codes
- TENS units (DME), Codes E0720 and E0730
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