Original Effective Date:
06/01/2011
Current Effective Date:
01/01/2015
HMSA uses Optum’s Claims Editing System (CES) as a source of code editing.
CES editing is focused on standard coding guidelines. Examples of sources include:
- AMA CPT® guidelines
- The National Correct Coding Initiative (NCCI)
- Medical Society recommendations
Rules and Editing Currently In Use for QUEST Integration
| Rule | Edit | Source/Rationale |
|---|---|---|
| Inappropriate Gender for Procedure | Denies if a service code that is defined as a male or female procedure only is billed with the opposite gender | AMA CPT® Guidelines |
| Global Test Only Codes | Denies if a standalone code for which there are associated codes that describe the professional component of the test only and the technical component of the test only is billed with an inappropriate modifier | Medicare Physician Fee Schedule (MPFS) |
| Professional Component Only Codes | Denies if a service code that describes physician work is billed an inappropriate modifier | Medicare Physician Fee Schedule (MPFS) |
| Team Surgeons | Denies if a service code that is not applicable to team surgery is billed with an inappropriate modifier | Medicare Physician Fee Schedule (MPFS) |
| Surgical Procedure not on Ambulatory Surgical Center (ASC) Allowable List | Denies if a service code that is identified as not allowable in an ASC is billed by an ASC provider | CMS ASC Payment Rates – Addendum EE |
| Never Events | Denies if a service code is billed with a modifier that indicates that the service was rendered on the wrong body part, wrong patient or the wrong service was performed | CMS National Coverage Determinations (NCD) |
| Modifier GK With Upgrades | Denies if a service that is billed with modifier -GK is not billed with an additional modifier | Noridian Upgrade Billing Guidelines |
| Laboratory Interpretation in the Hospital | Denies if a laboratory service that represents the physician interpretation is billed in the hospital. | Medicare Physician Fee Schedule (MPFS) |
Future Rules and Editing
Over the next several months, HMSA will be turning on additional claims processing edits. Please see below for further information.
Effective June 1, 2021 we will edit with these additional rules.
| Rule | Edit | Source/Rationale |
|---|---|---|
| Repeat Radiology Service Modifier | Denies if a repeat radiology service is billed without a repeat modifier | CPT® Professional Edition |
| Repeat Laboratory Service Modifier | Denies if a repeat laboratory service is billed without a repeat modifier | CPT® Professional Edition |
| Inappropriate Use of Modifier -91 with Laboratory Services | Denies if a laboratory service that has not been repeated is billed inappropriately with a repeat modifier | CPT® Professional Edition |
Customizations to Claims Editing Software
The following revisions have been made to our commercial claims editing software products to be consistent with HMSA QUEST Integration established reimbursement policies.
| Category of Service | CPT/HCPCS Codes | Processing Action |
|---|---|---|
| Procedures considered integral to the primary procedure |
34839, 99490, 99491, 99439 Effective May 1, 2015: 61781, 61782, 61783 Effective June 1, 2011, the following codes will be classified as integral to the primary procedure: 20930, 20936, 22841, 38204, 90885, 90887, 91123, 92352, 92353, 92354, 92355, 92358, 92371, 92531, 92532, 92533, 92534, 92605, 92606, 93740, 93770, 94005, 94150, 96902, 97010, 97602, 98960, 98961, 98962, 99002, 99024, 99051, 99058, 99070, 99071, 99078, 99090, 99091, 99288, 99339, 99340, 99363, 99364, 99366, 99367, 99368, 99374, 99377, 99379, 99380, A4262, A4270, A4300, A4550, G0269, Q3031, R0076 Effective June 08, 2021: M0201 Effective January 1, 2024: G0019, G0022, G0023, G0024, G0136, G0140, G0146 |
These codes continue to deny as integral to the associated primary procedure. |
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform.
|