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Code-to-Code Edits

Claims processed on the new platform (i.e., for migrated AmeriHealth Pennsylvania members)

Procedure terminology-based combinations and logic for similar codes are applied to claims that are processed on the new claim processing platform when submitted on the CMS-1500 claim form or through the 837P transaction.

In addition, as of January 1, 2015, Medicare’s National Correct Coding Initiative (NCCI) Edits are also applied.

Procedure Terminology-Based Combinations

For information regarding procedure terminology-based combinations as well as the specific procedure terminology-based combinations, please refer to the document below.

Logic for Similar Codes

When two or more procedure codes represent services that are considered to be similar in nature to one another, the procedure codes are identified as “similar codes” on the new platform. “Similar codes” are defined as any code(s) that should not be reported with or appended to another code by the same provider on the same date of service when 1) the codes are clinically duplicative or 2) when there is an AMA CPT1 parenthetic note indicating, “Do not report (code) in addition to (code).”

Medicare’s National Correct Coding Initiative (NCCI) Edits

For information regarding NCCI edits, please visit the Centers for Medicare & Medicaid Services.

1 AMA CPT — American Medical Association® Current Procedural Terminology® CPT copyright 2016 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.