Humana Correct Coding Update

June 2017 ~

Effective July 6, Humana will implement the following code changes:

  • Procedures that are Bilateral in Nature
  • Charges for a procedure performed bilaterally that is submitted with modifier LT (left) and modifier RT (right) will be denied.
    • Providers affected:
      • Inpatient/Outpatient Facilities
      • Physician/Health Care Providers
    • Impacted products
      • Medicaid – Illinois
  • ICD-10 Laterality Policy
  • The ICD-10-CM laterality policy is applied for diagnosis-to-modifier comparison. Services billed with an inappropriate combination of diagnosis code(s) and modifier(s) will not be reimbursed.
    • Providers affected:
      • Inpatient/Outpatient Facilities
      • Physician/Health Care Providers
    • Impacted products
      • Select self-funded* products
      • Commercial fully insured products
      • Medicare Advantage HMO products
      • Medicare Advantage PFFS products
      • Medicare Advantage PPO products
  • Corneal Tissue Processing, Preserving and Transporting
  • Processing, preserving and transporting corneal tissue is eligible for reimbursement only when billed with a corneal transplant procedure.
    • Providers affected:
      • Inpatient/Outpatient Facilities
      • Physician/Health Care Providers
    • Impacted products
      • Medicaid – Florida
      • Medicaid – Illinois
  • Factors Influencing Health Status and Contact with Health Services Diagnoses and Non-Routine Examination
  • With the exception of normal newborn care, Humana will not reimburse separately for evaluation and management (E/M) services billed with preventive medicine services (for example, CPT codes 99381 through 99429) when the only diagnosis reported on the claim is an ICD-10-CM Z-code.
    • Providers affected:
      • Inpatient/Outpatient Facilities
      • Physician/Health Care Providers
    • Impacted products
      • Medicaid – Florida
      • Medicaid – Illinois
  • Diagnosis and Procedure Consistency
  • Vestibular function tests and audiometry threshold testing will not be eligible for reimbursement for any of the following diagnoses:
  • Encounter for examination of ears and hearing without abnormal findings
  • Encounter for examination of ears and hearing with other abnormal findings
  • Encounter for fitting and adjustment of hearing aid
    • Providers affected:
      • Inpatient/Outpatient Facilities
      • Physician/Health Care Providers
    • Impacted products
      • Medicaid – Florida
  • Diagnosis and Procedure Consistency
  • Humana will not reimburse for pulmonary diagnostic testing submitted with any of these diagnoses:
  • Encounter for general adult medical examination without abnormal findings
  • Encounter for general adult medical examination with abnormal findings
  • Encounter for examination for normal comparison and control in clinical research program
  • Encounter for other general examination
  • Encounter for screening for malignant neoplasm of respiratory organs
  • Encounter for screening for respiratory disorder NEC
    • Providers affected:
      • Inpatient/Outpatient Facilities
      • Physician/Health Care Providers
    • Impacted products
      • Medicaid – Florida
      • Medicaid – Illinois
  • DMEPOS National Correct Coding Initiative (NCCI)
  • Unless submitted with an appropriate, applicable modifier, a Medicaid National Correct Coding Initiative (NCCI) Column II durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) HCPCS code is not eligible for separate reimbursement when a provider submits an associated Column I DMEPOS HCPCS code simultaneous with, or before, the Column II charge.
  • Also, a Medicaid NCCI Column I DMEPOS HCPCS code is not eligible for separate reimbursement when an associated Column II DMEPOS HCPCS code has previously been allowed for the same date of service, unless submitted with an appropriate, applicable modifier.
    • Providers affected:
      • Inpatient/Outpatient Facilities
      • Physician/Health Care Providers
    • Impacted products
      • Medicaid – Florida
      • Medicaid – Illinois
  • Diagnosis and Procedure Consistency
  • Injection, anesthetic agent; other peripheral nerve or branch will not be eligible for reimbursement when performed for the treatment of any of the following:
  • Multiple neuropathies
  • Peripheral neuropathies
  • Plantar fasciitis
  • Calcaneal spur
    • Providers affected:
      • Inpatient/Outpatient Facilities
      • Physician/Health Care Providers
    • Impacted products
      • Medicaid – Florida
      • Medicaid – Illinois
  • Urine Validity and Drug Testing
  • Urine validity testing is not eligible for separate reimbursement when performed at the same time as a toxicology procedure.
    • Providers affected:
      • Inpatient/Outpatient Facilities
      • Physician/Health Care Providers
    • Impacted products
      • Medicaid – Florida
      • Medicaid – Illinois

Humana reminder providers that claim edits do not supersede the necessity to obtain preauthorization. Preauthorization requirements are still applicable. Modifiers should be used when appropriate to accurately represent the services rendered. The use of modifiers may impact Humana’s application of these edits. For additional information, consult professional coding resources.

 

Source(s): Humana;

 

 

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