Payment Policies for Outpatient Facility Claims - UB-04
This section contains background information for UB-04 billers.
National Correct Coding Initiative (NCCI)
To process outpatient facility services, Wellmark uses the National Correct Coding Initiative (NCCI) edits, a collection of bundling edits, created and sponsored by CMS (Centers for Medicare & Medicaid Services). The edits are separated into two major categories: The Comprehensive and Component procedure code edits, and the Mutually Exclusive procedure code edits.
Correct Coding Initiative edits are for services performed by the same facility on the same date of service only. Note that CCI edits applicable to outpatient hospital services are one version behind the CCI edits applicable to professional claims. More information may be obtained through the CMS Web site .
Revenue Codes Requiring Detailed Coding
Some revenue codes require detailed coding. You must include CPT or HCPCS codes for these revenue codes .
Maximum Unit Policy
Wellmark has assigned a maximum daily unit to each CPT/HCPCS code. Daily maximum units that have been exceeded can be identified with remittance advice message I512, a denial for maximum daily units or I563, a reduction in maximum daily units. Daily maximum units are guidelines that accommodate most "normal" services. For those services exceeding the maximum daily units, please submit a provider inquiry attaching the medical documentation to support the units of service.
Wellmark is now able to process modifiers for outpatient facility claims. We will process up to four modifiers per claim line. Please note that our process may change the order of the modifiers based on an established priority. Modifiers that affect payment will be listed first, with informational modifiers secondary. Providers receiving an electronic remittance advice will see up to four modifiers. Paper remittance advices do not include modifiers.
Inappropriate use of modifiers will cause a service to deny. For example, modifier 25 is appropriate for use with E/M codes services only. If billed with a surgical procedure, such as 52000, the surgery will deny as an inappropriately coded procedure. Additional information about specific modifiers follows:
Modifier 50 indicates a bilateral procedure. Claims containing the 50 modifier will process via the EAPG Grouper. It is no longer necessary to continue to report these on two lines with one unit of service per line.
Modifiers 52 (reduced services) and 73 (discontinued procedure prior to the administration of anesthesia) will be recognized in the EAPG Grouper.
You may request any modifier change using one of the following methods:
- Call a Provider/Customer Service representative.
- Send an electronic request by selecting the Provider Service e-mail line for your situation.
- Submit a Provider Inquiry form:
Claims corrections will appear on your remittance advice as an adjustment to the original claim number so you can easily track and reconcile corrections.
Recode or Deny
In some instances, iCAP will recode or deny the claim to avoid claim processing delays. For example, procedures submitted for an age that is inconsistent with the procedural description will be adjusted in one of the following ways:
- When a procedure code for a particular age is submitted that does not match the claim information, the procedure will be recoded to a more appropriate procedure for the patient's age. For example, we receive a claim for a newborn's circumcision: If submitted with code 54161 (circumcision, except newborn) the code would be changed to 54160 (circumcision, newborn).
- When a more appropriate procedure code does not exist for the patient's age, the procedure will be denied. For example, we receive the following code for a patient who is over 30 days of age: Code will deny if submitted for a patient over 30 days of age: 36510 (catheterization of umbilical vein; newborn).
Inpatient Only Procedures
If a service on the inpatient only list is provided in the outpatient setting, please submit a provider inquiry along with medical record documentation for payment consideration.
Download the Wellmark Inpatient Only List - #S-2317 .
In order to assist you with claim line messages, Wellmark has created a table listing the "I" message and the corresponding "G" message and the 835 ANSI message and Remark Code (where it applies).
Download the iCap Messages - #S-2318 .
Submitting Medical Records
Do not submit medical records when requesting a claim review if your claim needs a coding change. This includes CPT, HCPCS, ICD-9, modifier or date of service changes. Simply make the necessary change on a corrected claim and attach it to a Provider Inquiry form for Iowa or South Dakota . Wellmark will not add, change or delete codes or modifiers based upon a review of medical records.