Updates to correct coding editing

Effective for Medicaid claims processed on or after February 1, 2025, we are updating our professional editing system to align with the Centers for Medicaid & Medicare Service (CMS) and the American Medical Association (AMA) CPT^® Manual:

• Appropriate billing of column one procedure codes with column two procedure codes:
• Column two codes are not eligible for reimbursement when billed with a column one code and a correct coding initiative modifier is appended to either code, and the use of the modifier was not justified.
• Appropriate billing of procedures classified as an add‑on procedure code:
• According to AMA CPT Manual and CMS Type I Add‑on code guidelines, add‑on code procedures are not allowed for reimbursement when billed as a standalone procedure separate from a primary procedure code. Add‑on procedure codes will not be allowed for reimbursement if the primary procedure code billed has been denied.
• Appropriate billing of procedures based on AMA CPT Manual coding guidelines:
• AMA CPT Manual coding guidelines provide instructions on the correct usage of procedures. These guidelines must be followed to align with correct coding. For example, see below:
• CPT 76377 — 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation. According to the AMA CPT manual, this procedure should only be billed in conjunction with the base imaging procedure code(s).
• CPT 90471 — Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) should not be billed with procedure code.
• CPT‑90473 — Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid).

Claim lines not billed in accordance with the correct coding guidance outlined above will not be approved for payment. If you disagree with a claim reimbursement decision, please follow the claim dispute process (including submission of such documentation with the dispute) as outlined in the Provider Manual.

If you have questions about this communication or need assistance with any other items, contact your provider relationship management representative.