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Tag Archives: Processing

CR12377 Updates Coding in Medicare Claims Processing Manual

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Code updates prompted the release of Change Request (CR) 12377 by the Centers for Medicare & Medicaid Services (CMS) on Oct. 13. The updates to chapters 3, 18, and 32 of the Medicare Claims Processing Manual Pub. 100-04 are effective Nov. 17, 2021. CR12377 further clarifies that “Unless otherwise specified, the effective date is the […]

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AAPC Knowledge Center

Modifier 59 changes-New CMS Claims Processing Logic- Example

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The modification to the claims processing logic for modifiers 59, XE, XS, XP, and XU.
These modifiers were being processed only when applied to the Column 2 code in a bundled pair, per NCCI, with a modifier indicator “1.” This meant if the separate procedure modifier was appended on the Column 1 code, the modifier would not override the edit and the system would reject the code.
CMS carriers will now process the separate procedure modifier when it’s used on either the Column 1 procedure or the Column 2 procedure, effective July 1, 2019.
The NCCI bundling edit will be bypassed when modifier 59, XE, XS, XP, or XU is used on either the Column 1 code or Column 2 code.
Does this make a difference???
There were separate procedure modifier edit bypasses being ignored when appended to the Column 1 code. This required a corrected claim to be resubmitted for reprocessing and caused additional cost to both the provider and the carrier.
Why are separate procedure modifiers being put on Column 1 codes to get an edit bypassed?
This usually happens when the Column 1 code carries less RVUs than the Column 2 code, as described in the below example.
As a result, the Column 2 code appears before the Column 1 code on the claim because CPT codes are placed in RVU order to minimize the effects of multiple procedure discounts taken by the payer.
Placing a separate procedure modifier on the first of the two codes bundled on the claims appears awkward and, as a result, the biller tends to put modifier 59, XE, XS, XP, or XU on the bundled CPT appearing lower in the claim.
The new instruction allows a more billing-friendly approach for applying the separate procedure modifier.
Current NCCI Edits Example:
The otolaryngologist performs a rigid diagnostic nasal endoscopy for nasal complaints, and then pulls out the rigid endoscope and performs a flexible laryngoscopy to evaluate the patient’s complaints of coughing, throat clearing, and difficulty swallowing.
31231-XU            Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) (Column 2 codes but High RVU 5.69)
31575     Laryngoscopy, flexible; diagnostic) (Column 1 codes but Low RVU 3.31)
CPT 31231 is coded whether a rigid endoscope or a flexible endoscope is used, and it’s a Column 2 code of 31575. Interestingly, 31231 has more relative value units (RVUs) than 31575, but it should be listed first.
With this guidance, the mentioned above example should be billed on the claim as follows (consistent with the RVUs), Effective July 1,2019
 31231            Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure)
31575 – XU    Laryngoscopy, flexible; diagnostic)




Coding Ahead

Medical Billing Software Automated Bill Processing

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This software which is used for this process is commonly known as medical billing software. The billing software can check the eligibility of the patient for the services which the medical center is supposed to render. Earlier, prior to the usage of this software, the billing process require too many steps. There was an interaction between the heath care provider and the insurance company which used to pay the bills and the entire interaction was called a billing cycle which used to take may days or even weeks in processing and payment. To make this process easy, new medical billing software is being used which eases the entire process and provides many automated processes saving lots of time, effort and money.

Earlier the interaction used to start with the doctors visit to the patient and summarize his treatment summary and analyze the eligibility of the patient for the claim. The entire process was very complicated and time consuming but the medical billing software has made this very easy and time saving with every thing getting done automatically. The software has also brought down the rejection percentage considerably. The software also ensures a better quality control and provides an efficient, error free and smooth billing process.

In medical billing software the bills are submitted electronically, processed electronically, approved or declined electronically and the payment gets electronically remitted which ensures an error free transaction with better quality. The same software does every thing and nothing extra is required. Even the claim forms and other documents do not need to be downloaded. The consistency level of this software enhances the accuracy and reduces the work load of the staff. In case of any error while submitting, the system alerts the user automatically.

The medical billing software processes primary and secondary insurer bills which reduces the time taken in entering data twice. The claim bills are processed as per the order of submission and the second bill starts once the first gets processed.

Dick Weinberger is one of the famous personalities who generally write the content on those software companies which provide cutting edge solutions that serve various needs of the participants of the healthcare industry. Author also provides the information that helps the people increase the efficiency their business.For more information you can visit medical billing software.

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