Insurer’s alignment with CMS coding initiative could result in denials

Anthem will soon begin a review of “medically unlikely” procedure code edits that could result in claims denials. Beginning Oct. 1, the insurance company will review medically unlikely edits with a medical adjudication indicator (MAI) of “3” based on the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI). The policy, intended to ensure Anthem aligns with CMS guidelines, is for all of the company’s commercial markets but has been delayed in California, Virginia, and Maine.

A medically unlikely edit (MUE) for a procedure code (HCPCS or CPT) is the maximum units of service that a single physician would report under most circumstances for a single patient on the same date of service. A MAI of “3” means there are per-day frequency limits based on clinical criteria, such as the nature of service or prescribing information, combined with data that indicates it would be medically highly unlikely that higher values would represent correctly reported medically necessary services.

Anthem will automatically deny any claim line where a code exceeds the per-day unit, even if submitted with appropriate modifiers. CMS guidance notes that Medicare Administrative Contractors (MACs) may pay for services that exceed the MUE value when services are provided, correctly coded, and medically necessary. If you believe a claim payment denial should be reviewed, follow the normal dispute process. Include documentation that demonstrates it was medically necessary to exceed the clinical benchmarks and indicate where that specific information can be found in the supporting medical record.

To view CPT code MAIs please visit CMS’s Medicare NCCI MUEs website and click “Practitioner Services Table.” (CMS updates these tables quarterly, be sure you are viewing the most up-to-date version.) For example, CPT code 11300 (removal of one epidermal or dermal lesion of 0.5cm diameter or less from the trunk, arms or legs) has an MUE value of five and the MAI is “3.” Therefore, if the same physician bills more than five units of 11300 for the same patient on a single date of service, all claim line(s) for this code will be denied. However, the physician can appeal the denials with appropriate documentation that reflects medical necessity.

Proactively sending medical records with the first claim submission can prevent denials. Visit the Medicare NCCI FAQ library for more information on billing and coding advice, NCCI modifiers, etc.

Anthem will also make the following updates to align payment policies with CMS and NCCI guidelines:

• Code and Clinical Editing – Professional: Add language stating the health plan will follow procedure to procedure edits, and add language stating the health plan will deny claim lines when a service unit exceeds a CMS MUE.
• Frequency Editing – Professional: Remove drug codes (J codes) from the policy. The removed codes will have limits based on the CMS MUEs.
• Unit Frequency Maximums for Drugs and Biologic Substances – Professional: Retire this policy. The codes outlined in the policy will align with CMS MUEs.

For specific policy details, visit Anthem’s Reimbursement Policies webpage.

If you have questions about this notification, contact your Anthem contract manager or provider relationship management account representative. To find a contact, select your state on this page, select the “Providers” tab at the top of the page, select “Contact Us” (under “Communications"), and select “Additional support.”

— Brennan Cantrell, AAFP Commercial Health Insurance Strategist

Posted on July 24, 2023