January 2010

Tools for Improving Claim Processing

CIGNA uses ClaimCheck^®, a code auditing software, to expedite accurate claim processing. The ClaimCheck 8.5 Knowledge Base Version 43 with National Correct Coding Initiative (NCCI) Version 15.2 was implemented on August 17, 2009.  The next update to Knowledge Base Version 44 with NCCI Version 15.3 is scheduled to occur on February 15, 2010.

You may view both ClaimCheck and NCCI code edits by using Clear Claim Connection^TM. This disclosure tool allows users to enter Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes and immediately view the code audit results prior to submitting a claim.  Clear Claim Connection shows NCCI edit definitions and the rationale behind a ClaimCheck edit. 

More information about ClaimCheck and Clear Claim Connection is available on the secure CIGNA for Health Care Professionals website at www.cignaforhcp.com > eServices > View Claim Coding Edits.

To learn more about code edits on claims associated with Great-West Healthcare ID cards or GWH-CIGNA ID cards, visit the Secured Provider Portal at www.greatwesthealthcare.com/providers (Tools & Resources > Clinical Edit Verification).

Note: Claim coding edit results are guidelines and are not a guarantee of claim payment.

ClaimCheck audits codes based on how services are reported on a professional claim form (CMS 1500).  The following examples are commonly billed to CIGNA:

• The CIGNA Modifier 26 Policy states to submit the code without a modifier (e.g., 26 or TC) when reporting the global value of a CPT or HCPCS code. If the code is submitted twice, (i.e., once with modifier 26 and once with modifier TC) ClaimCheck will only allow one and finds the other a duplicate service, which is not reimbursed. 

• Submitting for ambulatory surgical center (ASC) facility service fees by appending modifier SG to a code submitted more than once per date of service may lead to a duplicate edit.  If so, the second service will not be reimbursed. 

• As NCCI guidelines indicate, knee arthroscopies of the second and third compartments should be submitted using HCPCS add-on code G0289 [Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee] when performed with a primary knee arthroscopy procedure (CPT 29866-29889). CPT codes 29874 [Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)] and 29877 [Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)] should not be used to report the additional compartment procedures, and will not be reimbursed when reported with the other primary knee arthroscopy codes identified above.

• CIGNA supports physicians' efforts to treat participants in the office setting when appropriate rather than referring them to emergent or urgent care.  Accordingly, separate reimbursement is allowed for after-hours CPT codes 99050 and 99058 if submitted with office visits 99201-99205 or 99212-99215.  After-hours services represented by CPT codes 99051 – 99056 and 99060 do not support physicians’ treating patients in the office, therefore separate reimbursement is not allowed for these services.

Featured Articles
- New eCourses Available
- Laboratory Services
- CIGNA Cost of Care Estimator
- DME Transitioning to CareCentrix
- Tobacco Cessation
- Submitting H1N1 Claims

Great-West Healthcare Integration News
Transitioning to the CIGNA Brand
- Participant ID Cards
- Explanation of Payment Changes
- Electronic Transaction Changes

Administrative Updates
- Reference Guides Available Online
- Precertification of Coverage
- CIGNA Medicare Access®
- Submitting Information Changes
- Modifier and Payment Policies
- Go Green! Go Electronic!
- Use the Network
- Tools for Improving Claim Processing
- Access the Network News Archives!