Outpatient facility claim update: Correct coding/code-editing

We want to make your day-to-day business as easy possible. With this in mind, we continually look for ways to make our claims processes more efficient and up to date.

Beginning May 23, 2021, Horizon NJ Health will change the way we process certain outpatient facility claims to help ensure that the codes submitted are processed in accordance with nationally recognized coding and code-editing guidelines. This includes guidelines implemented by the Centers for Medicare & Medicaid Services (CMS), National Correct Coding Initiative (NCCI), Outpatient Code Editor (OCE), American Medical Association (AMA) Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS) and the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM).

Beginning May 23, 2021, Horizon NJ Health will apply the following claim-editing guidelines to outpatient facility claims:

Add-on Code Policy
Guideline Action
Add-on Codes Deny an add-on code when the primary code is absent.
Bilateral Procedures Policy
Guideline Action
Modifier 52 or 73 with Bilateral Procedures Deny procedures without modifier 52 or 73 when billed and the same procedure code has been billed for the same date of service on the same claim with modifier 52 or 73. (CMS 1450)
Procedures that are Bilateral in Nature (Bilateral Indicator 2) Apply CMS Bilateral Indicator 2, Services billed with modifiers 50, LT or RT or with units greater than one may be adjusted as inappropriately coded procedures.
CMS Coverage Policies
Guideline Action
Pulmonary Rehabilitation Deny G0424 (Pulmonary rehabilitation) when billed with Bill Type 0130-013Z (Outpatient hospital) and the revenue code is not 0948 (Pulmonary rehabilitation).
Skin Substitute Procedures and Products Deny 15271-15278 (High-cost skin substitute application procedures) when billed with Bill Type 0120-012Z (Inpatient Hospital-Part B), 0130-013Z (Outpatient Hospital-Part B), or 0140-014Z (Outpatient Hospital-other) and a qualifying high-cost skin substitute product code has not been either paid or denied for the same date of service. (CMS 1450)
Device and Supply Policy
Guideline Action
Brachytherapy Source Deny brachytherapy sources when billed without an associated brachytherapy procedure.
Diagnosis Code Guideline Policy
Guideline Action
Manifestation Codes Deny all services received with a manifestation code billed as the only diagnosis on the claim.
Secondary Diagnosis Codes Deny procedures or services received with a secondary diagnosis code as the only diagnosis on the claim.
ICD-10-CM Sequela (7th character "S") Codes Deny any procedure or service received with a ICD-10-CM sequela (7th character "S") code billed as the only diagnosis on the claim.
Maximum Units Policy
Guideline Action
Maximum Units for Modifier 52 or 73 Adjust units and deny multiple lines of the same CPT code to allow only one unit of service for any procedure code billed with Bill Type 0120-012Z (Hospital-inpatient), 0130-013Z (Outpatient Hospital), 0140-014Z (Hospital-laboratory services provided to non-patients), or 0830-083Z (Ambulatory Surgical Center), and modifier 52 or 73 is appended.(CMS 1450)
Maximum Units Per Day for Outpatient Hospitals Deny excess units when any provider bills a certain number of units that exceed the daily assigned allowable unit(s) for that procedure for the same member.
Daily Max Units Regardless of Modifier Deny excess units when any provider bills more than one unit of service for certain procedures regardless of appended modifier and with the same revenue code.
Modifier Policy
Guideline Action
Anatomical Modifiers According to the AMA CPT Manual, the HCPCS Level II Manual and our policy, the anatomic-specific modifiers, such as FA, TA, and LC, designate the area or part of the body on which the procedure is performed. Deny a procedure defined as requiring an anatomical modifier when billed without an associated anatomical modifier.
Inappropriate Service Modifiers Deny services that are billed with inappropriate service modifiers.
Observation Services
Guideline Action
Bill Types Deny observation services if billed with a bill type other than 13X or 85X.
Place of Service
Guideline Action
Outpatient Radiology Services Deny 70010-79999 (Radiology services) when billed with Bill Type 0140-014Z (Hospital-laboratory services to non-patients).
Professional, Technical, and Global Services Policy
Guideline Action
Diagnostic/Therapeutic Tests & Radiology Services by a Facility Deny professional component procedures when billed by a facility and the revenue code is not 0960-0989 (Professional fees).
Revenue Code Policy
Guideline Action
Revenue Code Requires HCPCS Deny revenue codes that CMS indicates requires a HCPCS code when one of these revenue codes is billed without a HCPCS code.
Blood Products, Storage and Processing Deny P9010-P9040, P9043, P9044, P9048, P9051-P9060, P9070-P9071, P9073 (Blood product) when billed with Revenue Code 0380-0389 and the same blood product code has not been billed with Revenue Code 0390-0399.
Blood Products, Storage and Processing Separate Procedures Policy
Guideline Action
CPT Codes and Separate Procedures Deny separate procedures when billed with the associated major procedures.

The coding and code-editing guidelines to be implemented will impact claims submitted for services provided for all Horizon BCBSNJ, Horizon NJ Health (Medicaid and MLTSS) and Horizon NJ TotalCare (HMO D-SNP) members.

For more information on the implemented guidelines, review the Correct Coding/Code-Editing Guidelines. If the coding on claims submitted on and after May 23, 2021 is incorrect or submitted in error, please submit a corrected claim.

You also have the right to submit medical record documentation that validates your claim submission as part of an appeal of a specific claim payment determination. To do so, please complete a copy of the New Jersey Department of Banking and Insurance’s (DOBI) required form, Application to Appeal a Claims Determination. Mail the completed claim form, along with medical record information that supports your rationale for appeal, to:

  • Horizon Medical Appeals
  • PO Box 10194
  • Newark, NJ 07101-3129

If you have questions, please call Provider Services at 1-800-682-9091, weekdays, between 8 a.m. to 5 p.m., Eastern Time.

Published on: February 17, 2021, 13:57 PM ET
Last updated on: February 17, 2021, 15:36 PM ET