4. Individual Consideration
On rare occasions, a procedure performed by a provider might not be adequately defined according to CPT-4 coding methodology. Individual consideration will be appropriate in these situations.

Claims involving individual consideration are referred to the DMC Care Medical Director. When a claim is submitted which requires individual consideration, the Medical Director may request and the provider will furnish certain medical records, such as operative notes, in order for the Medical Director to appropriately review the claim. Based upon the Medical Director’s review, DMC Care will calculate the appropriate claim payment and forward the claim to the Third–Party Administrator. Because of this review, normal claim processing time is delayed.

5. Incomplete Claim Forms

If the claim form is not completed properly, the Third-Party Administrator will request the missing information from the provider. This will delay claims processing.

6. Late Claims

Claims should be submitted within 30 days of the date services were provided. If claims are not submitted in a timely manner, additional research may be necessary before the claim can be processed.

Claims not submitted within one year from the date of service will be denied and the member shall be held harmless.

7. “Members not on file”

DMC Care will no longer be returning hard copy claims for “members not on file.” Instead, these claims will be entered into the claim system as a “Member Not on File,” and therefore a denial code of member not on file will be included on the EOP.

This change will allow for easier claim inquiry and reprocessing. As always, for member eligibility and verification, please call a Customer Service Representative toll-free at 1-800-543-0161.

8. Anesthesia Claims

In order to standardize the payment of Anesthesia Claims, DMC Care will require providers to bill anesthesia claims with the ASA procedure codes 00100-01999 along with the industry standard modifiers.

D. CodeReview

DMC Care TPA service has implemented code auditing software called CodeReview®. CodeReview is an expert system that assists the claims processor in evaluating the accuracy of submitted CPT/HCPCS codes. CodeReview uses a clinical knowledge base that results in one of three types of medically based recommendations to the claims processor:

• To accept the code(s) as submitted
• To consider changing the submitted code(s) to comply with generally accepted coding practices that are consistent with the AMA’s CPT Manual, HCFA’s HCPCS Level II Codes Manual, CMS guidelines, as well as the opinions of prominent physicians within the specialty To seek additional information from the physicians’ office because there is inconsistent information in the claim.

The types of services that will be evaluated by Code Review are as Follows:

• Policies based on the CPT Manual
• Policies based on health care coding standards
• Bundling/Unbundling of procedures
• Global Periods
• Multiple procedures performed the same day
• Appropriateness of assistance of surgery
• The proper use of modifiers

CodeReview assists the claims processor in evaluating the accuracy of the coding of the procedure(s), not the medical necessity of the procedure(s). When a change is made to your submitted code(s) DMC Care TPA will provide a medical explanation of the reason for the change.

In a few instances where a change is made, it is usually because the CPT-4 Manual or the HCPCS Level II Manual indicates that one of the submitted codes should not be used separately when submitted with another code on the claim. This does not mean that the procedure/service was unnecessary; it means that according to generally accepted coding practice, the procedure/service is not coded separately under this circumstance.

Any appeals regarding CodeReview should be forwarded within sixty (60) days of receipt of denial to:

DMC CARE
Code Review Appeals
P.O. Box 44290
Detroit, MI 48244

E. Billing Codes, Modifiers and Policies

1. General Instructions

Third-Party Administrator claims processing systems use Common Procedure Terminology-fourth revision (CPT-4) codes to identify physician services. Five major sections are included: Medicine, Anesthesia, Surgery, Radiology/Nuclear Medicine and Pathology. Each section contains specific instructions regarding billing policies. The five major sections are subdivided into subsections relating to specialty groupings.

Occasionally, there may be multiple CPT-4 codes which could be used to bill for a service. In these cases, please read each definition carefully and bill the appropriate CPT-4 code.

2. Definitions

Unlisted Procedure or Service – New or unusual procedures may be reported by using the “Unlisted Procedure” code included in each applicable section of the CPT-4 Manual.

3. Modifiers

A CPT modifier is a two-digit code reported in addition to the CPT service or procedure code (Item 24d on the CMS- 1500 form) which indicates that the service or procedure was modified in some way. Understanding how and when to use CPT modifiers is vital for proper reporting of medical services and procedures.

The lack of modifiers or the improper use of modifiers can result in claims delays or claims denials. The following is a list of modifiers that can be used. For a detailed explanation, please refer to your CPT manual.

The most common modifiers used (but not limited to) are:

22 Unusual Procedural Services
When the service(s) provided is greater than that usually required for the listed
procedure. NOTE: An Operative Report must be attached to the claim.

25 Significant. Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above or beyond the usual preoperative and postoperative care associated with the procedure that was performed. Medical documentation is required for claim to be considered for payment.

26 Professional Component
Certain procedures are a combination of a physician component and a technical
component. When the physician component is reported separately, the service
may be identified by adding the modifier ‘26’ to the usual procedure number.

57 Decision for Surgery
An evaluation and management service that resulted in the initial decision to
perform the surgery may be identified adding the modifier ‘57.’

62 Two Surgeons
When two surgeons work together as primary surgeons performing distinct part(s)
of a single reportable procedure, each surgeon should report his/her distinct
operative work by adding the modifier ‘62’ to the single definitive procedure
code. An Operative Report should be attached to the claim.

80 Assistant Surgeon
Surgical assistant services may be identified by adding the modifier ‘80.

F. Claims Appeal Process

The Provider Appeal Process offers prompt review of claims that are initially denied or claims where the Provider disputes the payment amount (For claims related to CodeReview please see Section 4, Subsection D). A Provider has sixty (60) days from the date of the denial or receipt of payment from DMC Care to initiate the appeal process.

If the Provider decides to appeal, all pertinent information and the reason(s) you believe your claim should be reconsidered must be included in the request. Your appeal information should be mailed to the Customer Service Appeals Coordinator at:

DMC CARE
Customer Service Department/Claim Appeals
P.O. Box 44290
Detroit, MI 48244