Outpatient Facility Edit Implementation*

Beginning with claims processed on and after April, 26, 2020, we will be enhancing our outpatient facility edits for revenue codes, Current Procedure Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) and modifiers. Enhanced edits include appropriate use of various code combinations which can include, but are not limited to:

• Procedure code to revenue code
• HCPCS to revenue code
• Type of bill to procedure code
• Type of bill to HCPCS code
• Procedure code to modifier
• HCPCS to modifier

 

These edits are based on national correct coding guidelines and principles. The following coding resources are excellent resources to use for guidance; (CPT) codebook, (HCPCS) codebook, National Uniform Billing Committee (NUBC) and the Uniform Billing (UB) Editor codebook. Additionally, Anthem will begin adoption of the National Correct Coding Initiatives (NCCI) for Outpatient Facilities to include industry-standard column one and column two procedure-to-procedure (PTP) codes.

 

^{* Notice of Material Changes/Amendments to Contract and Changes to Prior Authorization Requirements may apply for new or updated reimbursement policies, medical policies, or prior authorization requirements.}