Enhanced Claim Editor Program: Coding Validator review and the reporting of manual therapy and CMT

February 22, 2021

​AmeriHealth has a variety of programs in place dedicated to ensuring claims are billed accurately and in accordance with industry standard coding principles, including:

  • Centers for Medicare & Medicaid Services (CMS) standards such as the National Correct Coding Initiative (NCCI), modifier usage, and global surgery guidelines
  • American Medical Association (AMA) Current Procedural Terminology (CPT®) coding guidelines
  • CMS HCPCS LEVEL II Manual coding guidelines ​​
  • ICD-10 Instruction Manual coding guidelines​

In order to verify all providers are adhering to AmeriHealth claim payment policies and the industry standard source guidelines listed above, as of February 1, 2021, the AmeriHealth Enhanced Claim Editor Program includes coding validation performed by a team of Registered Nurses and Certified Professional Coders that will review select professional and outpatient facility claims in conjunction with patient claim history. 

Area of focus: Manual therapy reported with chiropractic manipulative treatment (CMT) and proper use of modifiers and diagnosis pointers

NCCI claim edits bundle manual therapy (97140) to chiropractic adjustment codes (98940 – 98942) when performed in the same anatomic region. However, manual therapy reported on the same date of service as CMT for the same member is eligible for separate reimbursement when reported for separate anatomic body regions. When the two procedures are performed in separate regions, the claim lines should have the proper diagnosis code pointers representing the condition treated in each area and be appended with the appropriate modifier to indicate separate regions.

Example: A patient receives a spinal adjustment of the lumbar region and manual therapy on the right shoulder. The patient's diagnoses are lumbar degenerative disc disease (M51.36) and “frozen" right shoulder (adhesive capsulitis) (M75.01). The diagnosis pointers must correctly point the manual therapy 97410 to the adhesive capsulitis diagnosis code M75.01 and the CMT 98940 to the lumbar disc disease code M51.36. Additionally, the manual therapy should be appended with Modifier XS to signify that the therapy was performed on a separate structure from the CMT.

With the implementation of coding validation, claim lines found to be submitted with inappropriate coding may be denied. Providers will be notified via the Provider Explanation of Benefits (EOB) (professional) or Provider Remittance (facility), which will include a reason code for the claim line denial. This program should have little or no affect to billing practices for submission of claims that are in accordance with the guidelines listed above and national industry-accepted coding standards.

Identifying claims that went through the coding validator process

If your claim was affected by one of the Coding Validation reviews, the edit explanation will be displayed on your electronic remittance report (835) and/or paper Provider EOB or Provider Remittance. Unique alpha-numeric codes and messages have been created that begin with E819X. Should your claim line contain an E819X code/message, it means it was affected by the Coding Validation review. You can also find the E819X codes/messages on the Claim Status Inquiry Detail screen on the NaviNet® web portal (NaviNet Open) and on the PEAR portal.* To view, hover your mouse over the service line and select View Additional Detail. If you see an E819X code/message the further detail in the Rationale and Description section will state Per Coding Validation review. Only E8XXX codes/messages are part of the enhanced claim editor, which will include coding validation as of February 1, 2021. All other codes/messages are unrelated to the enhanced claim editor.

​Request for coding validator claim review

While you may use NaviNet Open or the PEAR portal* to view detailed information on a Coding Validator E819X denial, clinical information is needed in order to dispute the denial. Please ensure that all applicable medical records, notes, and tests are submitted along with a cover letter explaining the reason for the dispute.

To facilitate a review, submit the documents listed above via:

  • Mail:

   Claim Coding Validation
   1901 Market Street
   Philadelphia, PA 19103

*If your organization has transitioned to use PEAR Practice Management on the Provider Engagement, Analytics & Reporting (PEAR) portal, you can use the Claim Search transaction to view this information. Additional information and self-service training materials are available in the PEAR ​Help Center.

For more information

For questions about the claim editing process, please review our Claim edit enhancements: Frequently asked questions ​(FAQ). Note: The FAQ will be updated as more information becomes available.

If you still have questions after reviewing the FAQ, please send an email to ahclaimeditquestions@amerihealth.com.

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