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Medicaid/Marketplace and Marketplace Policy Updates effective January 1, 2022

 

Policy Number

Policy Name

Policy Description

Lines of Business

CC.PP.071

Evaluation and Management Services Billed with Treatment Rooms

Disallows E&M services in treatment rooms as this does not represent a treatment type of service.

Marketplace

CP.MP.209

Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing

Restricts reimbursement of GI pathogen panels with 12+ targets to only inpatient settings, including inpatient, ED, and outpatient hospitals.

Medicaid, Marketplace

Payment Policies effective December 1, 2021

Policy Number

Policy Name

Policy Description

Lines of Business

N/A

Cotiviti 8

The purpose of this policy is to serve as a reference guide for general coding and claims editing information. Cotiviti 8 is a correct coding edit of ICD-10 diagnosis codes. Source: ICD-10 CM Diagnosis Code Manual 

Medicaid
Medicare Marketplace

N/A

WCG Integration Value Capture - Correct Coding Batch 2 (Cotiviti 8)

The purpose of this policy is to serve as a reference guide for general coding and claims editing information. Cotiviti 8 is a correct coding edit of ICD-10 diagnosis codes. Source: ICD-10 CM Diagnosis Code Manual 

Medicaid
Medicare Marketplace

N/A

Procedure Modifier Revenue Necessary (PMRN) - Correct Coding Batch #3

The PMRN edit will deny procedures that require an associated modifier and also identify situations where a correct modifier and revenue code are required. The edit applies to both professional (HCFA) and outpatient facility (UB-04) claims.
• Per CMS and AMA, procedures that can be performed on different sides of the body, separate anatomical areas, or separate patient encounters, require the use of modifiers whenever appropriate.
• Additionally, on professional claims, each code designated as “always therapy” must always be furnished under an SLP, OT, or PT plan of care and as such must always be accompanied by one of the therapy modifiers.
• Medicare recognizes the services furnished under the OPT service benefit as either “always” or “sometimes” therapy. “Always therapy” codes require modifier GN, GO, or GP appended to the therapy CPT code.
• CMS approved “sometimes therapy” codes require the appropriate modifier and revenue code combination when furnished by a therapist.

Medicaid
Medicare Marketplace

New 'Hospital Acquired Conditions' Policy - Effective January 1, 2022

Buckeye continually reviews and updates our payment and utilization policies to ensure that they comply with industry standards, while delivering the best patient experience to our members. We want to inform you of a new policy Buckeye Community Health Plan will be implementing effective January 1, 2022.

Beginning January 1, 2022, Buckeye Community Health Plan’s adjudication of claims that include Hospital Acquired Conditions will follow current industry practice and align with CMS guidelines.

Upon implementation, Buckeye may deny or reduce reimbursement for claims that include these conditions in accordance with current CMS regulations. You can see the full policy details on CMS. Note: the CMS policy is subject to update and change.

OH Enhanced (NCDs) Guidelines Claims Xten Provider Notification

Buckeye Community Health Plan is committed to continuously improving its claims review and payment processes. Effective 10/01/2021, for Medicare, we will enhance several correct coding edits based on industry standards and coding rules. 

Enhanced NCD Guidelines Claims Xten

OH Correct Coding Guidelines Flexible Prov Matching Provider Notification

Buckeye Community Health Plan is committed to continuously improving its claims review and payment processes. Effective 10/01/2021 for Medicaid, Marketplace and Medicare lines of business, we will enhance several correct coding edits based on industry standards and coding rules. 

Correct Coding Guidelines Flexible Prov Matching