10 Colo. Code Regs. § 2505-10-8.041
Current through Register Vol. 47, No. 16, August 25, 2024
Section 10 CCR 2505-10-8.041 - Claims Editing8.041.1DEFINITIONSCurrent Procedural Terminology (CPT) means the common medical procedure codes used for the purpose of billing medical services as defined by the American Medical Association (AMA).
Fiscal Agent means a vendor who is contracted by the Department to process and maintain the Medicaid Management Information System (MMIS) for purpose of processing claims.
Healthcare Common Procedural Coding System (HCPCS) means an alpha numeric code set as defined by CMS used for the purpose of billing services that are not identified under CPT.
Medically Unlikely Edits (MUE) means units of service edits. This edit restricts the maximum units of services per claim line that may be billed for a procedure code.
National Correct Coding Initiative (NCCI) means a set of claim edits developed by the Centers of Medicare and Medicaid Services (CMS) to promote NCCI methodologies and control improper coding leading to improper Medicaid payments.
Procedure to Procedure edit means the prevention of certain procedure codes from being billed with other procedure codes for the same patient by the same practitioner on the same date of service.
Remittance Statement means the electronic or hard copy statement sent by the Medicaid fiscal agent to advise a provider of claims reimbursement or claims status.
8.041.2AUTHORITY8.041.2.A Pursuant to Colorado Revised Statute § 25.5-4-300.7 the Department is authorized to implement and maintain a system for reducing medical services coding errors in Medicaid claims submitted to the state department for reimbursement. The system shall include automatic, prepayment review of Medicaid claims through the use of nationally recognized correct coding methods in MMIS.8.041.2.B The Department will utilize a claims editing program to automatically review claims prior to payment to identify and correct improper coding for professional and outpatient services claims pursuant to Colorado Revised Statute § 25.5-4-422(3). The claims editing program will recommend that the Department approve for payment, deny, or modify providers' submitted claims. The claims editing program will utilize a nationally recognized standardized method of processing claims for professional and outpatient services using clinical logic based on the most Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD), American Medical Association (AMA), Centers for Medicare and Medicaid Services (CMS), and nationally recognized specialty practice guidelines.8.041.3NCCI PAYMENT METHODOLOGIES8.041.3.A All providers shall report services performed on and rendered to clients by submitting claims using the HCPCS/ CPT codes designated by the Department. The use of these codes will be limited to providers who submit claims that are reimbursed based on the CPT code. Claim forms containing these codes are submitted to the Fiscal Agent for payment. NCCI methodologies include a set of edits, a definition of the type of claims subject to the edits, and rules regarding the application of the edits and provider appeals of denied payments. Claims submitted by providers shall be edited according to the six NCCI methodologies defined within the rule:1. NCCI procedure to procedure edits for practitioners and Ambulatory Surgical Centers (ASC) services.2. NCCI procedure to procedure edits for out-patient hospital services reimbursed based on CPT codes.3. NCCI procedure to procedure edits for Durable Medical Equipment (DME) claims.4. MUE units of service edits for practitioner and ASC services.5. MUE units of service edits for out-patient hospital services reimbursed based on CPT codes.6. MUE units of service edits for provider claims for Durable Medical Equipment (DME).8.041.3.B The Department shall apply the following types of NCCI edits for services performed by the same provider for the same client on the same date of service. 1. Procedure-to-procedure edits (also known as Column I/Column II define pairs of HCPCS/ CPT codes) that should not be reported together.2. MUEs (also known as units-of-service edits) define for each HCPCS/CPT code the maximum number of units of service allowable for each (e.g., claims for excision of more than one gallbladder or more than one pancreas).3. Providers' services shall be denied by line item for the HCPCS/CPT code that is rejected by one of the NCCI edits in the above methodology.8.041.4PROVIDER APPEALS8.041.4.A Providers may submit an appeal for denied line items due to NCCI edits in accordance with 10 CCR 2505-10 Sections 8.049 and 8.050.8.041.5REMITTANCE STATEMENTS8.041.5.A A system of electronic remittance statements shall be used by the Department's Fiscal Agent to advise all Medicaid providers of claims reimbursement or claims status unless hard copy remittance statements are specifically authorized by the Department.