Clinical Relationship Logic, or Code-to-Code Edits (e.g., Incidental,
Integral, Component, Mutually Exclusive, etc.), pertains to the edits used to
appropriately adjudicate claims in a claims processing system. As previously
communicated, Independence completed its transition to a new claims processing
platform.
On the new claims processing platform, procedure terminology-based
combinations and logic for similar codes are applied to claims submitted on the
CMS-1500 claim form or through the 837P transaction. In addition, Medicare?s
National Correct Coding Initiative (NCCI) edits are also applied.
Procedure terminology-based combinations
For information regarding procedure terminology-based combinations as well
as the specific procedure terminology-based combinations, please refer to the
recently updated
code-to-code list.
Logic for similar codes
When two or more procedure codes represent services that are considered to
be similar in nature to one another, the procedure codes are identified as
?similar codes? on the new platform. ?Similar codes? are defined as any code(s)
that should not be reported with or appended to another code by the same
provider on the same date of service when:
- The codes are clinically duplicative; OR
- There is an AMA CPT1 parenthetic note indicating, ?Do not report
(code) in addition to (code).?
Medicare?s NCCI edits
For information regarding NCCI edits, please visit the Centers for Medicare & Medicaid
Services
website.
For more information on Clinical Relationship Logic, visit our
website.
1AMA CPT ? American Medical
Association® Current Procedural Terminology®
CPT copyright 2014 American Medical Association. All
rights reserved. CPT is a registered trademark of the American Medical
Association.