Updated Payment Policies - December 2023; February 2024

Date: 02/15/24

MHS Health Wisconsin continually reviews and updates our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members.

Updated policies and their effective dates are listed below. 

Thank you for being a valued partner in caring for the health and well-being of our members. If you have any questions about the policies listed above or any our Clinical & Payment Policies, please contact your Provider Relations representative or call the Provider Inquiry Line at 1-800-222-9831. If you are unsure who your representative is, please email us at WI_Provider_Relations@mhswi.com.

Policy Number	Policy Name	Description	Business Line(s)	Effective Date
Prepay Edit	Optum CPI Amisys Phase 1	These analytics review: - HS116: High Dollar IV Hydration - identifies charges associated with IV hydration (CPT 96360 & 96361) when they exceed $1,000 per calendar day as it may suggest the pic line is being left open and no the source of uninterrupted continuous IV hydration therapy as those codes require. - S0061: Custom Prosthetics or Orthotics - identifies high dollar (greater than $500) custom fitted or custom fabricated orthotic DME codes for coding and documentation verification. The medical record will be performed to verify physician orders are present and documentation supports the DME codes billed by the provider.	Medicaid; Medicare	December 1, 2023
Prepay Edit	Optum CPI AMISYS - Phase 3	This analytic reviews: - UCM Universal Commercial Model: Pre-payment medical record review for claims flagged by a predictive scoring model looking for likelihood of waste and error by determining the risk of a billing error on the claim.	Medicaid; Medicare	December 1, 2023
Prepay Edit	Optum CPI AMISYS - Phase 4 (CC.PP.074) Prepay Edit	- FC001 Professional Claims for Select Surgical Procedures Exceeding Targeted Dollar Threshold: Pre-payment medical record review for inappropriate billing of services not documented in the physician clinical notes. There is no medical necessity decision making involved. - C0031 Facility NCCI Modifier Override: The algorithm identifies instances in which providers submit claims that utilize the NCCI bypass modifiers with CPT codes that are not allowed to be billed together for the same recipient, on same date of service, based on Medicare NCCI OCE edits.	Medicaid; Medicare	December 1, 2023
Prepay Edit	Optum CPI Amisys Phase 5	These analytics review: - P0336 Critical Care Coding Review: This analytic reviews medical records for claims that contain critical care CPT codes, but only one diagnosis code. A single diagnosis code on a claim would suggest the claim may be coded incorrectly using the critical care CPT codes. Billing guidelines support the use of critical care CPT codes being appropriately billed with more than one diagnosis code. Claims with 'failure' in the diagnosis description would be excluded. - X0055 Inaccurate Coding of Tongue-Tie and Frenulum Procedures: This analytic reviews claims with a diagnosis of Q38.1 (Tongue-Tie), as they are likely coded incorrectly as an excision procedure and should be coded as an incision. Codes 41115 (excision of the frenulum), 41112 (excision of a tongue lesion), 41116 (excision of floor of mouth lesion), or 41520 (frenuloplasty) when billed with diagnosis Q38.1 will potentially be flagged as the more appropriate code would be 41010 (incision of lingual frenum - frenotomy). - X0483 Adjacent Tissue Transfer Greater than 10 sq cm: When billing for adjacent tissue transfer services, providers must take great care to follow the coding guidelines, since this area presents very complex billing rules that need to be followed. Medical record review will be performed to determine if an adjacent tissue transfer was performed and if the reported defect size is supported by documentation.	Medicaid; Medicare	February 1, 2024
Prepay Edit	Optum CPI AMISYS C0037, C0038	These analytics review: - C0037 Professional NCCI Modifier Override – Procedure Overlap: This analytic looks at non-E&M codes that, when billed together, will trigger the NCCI procedure-to-procedure edits, such that an unbundling modifier would be appropriate. Providers should not use modifiers to bypass an NCCI edit unless the proper criteria for use of the modifiers is met. Medical documentation must support the use of the modifier. -C0038 Professional NCCI Modifier Override – Misuse of Column Two Code with Column One Code: This analytic looks at codes that show the NCCI edit misuse of column two code with column one code, which is when an inclusive column two code (bundled) is billed with a primary code. All non-E&M codes that are not allowed to be billed together for the same member, same DOS, same provider but that can be bypassed with a modifier. The NCCI has identified HCPS/CPT codes that are incorrectly reported with other HCPS/CPT codes because of the misuse of column two code with column one code. If these edits allow the use of NCCI-associated modifiers (modifier indicator of '1'), there are limited circumstances when the column two code may be reported on the same date of service as the column one code.	Medicaid; Medicare	February 1, 2024
Prepay Edit	Optum CPI AM X0150, MP027	These analytics review: "X0150 Color Flow Doppler Echocardiography Code Review: This analytic will tag claims suspected of upcoding when CPT 93306 (Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral doppler echocardiography, and with color flow doppler echocardiography) when billed with a primary diagnosis that would normally indicate a lower level of service. To report 93306, the medical documentation needs to mention certain structures of the heart and their findings to include the left and right atria, left and right ventricles, the aortic, mitral, and tricuspid valves, the pericardium, and the adjacent portions of the aorta. The documents must also include that the cardiologist performed real-time image documentation (2D), M-mode recording, spectral doppler echocardiography, and importantly, color flow doppler echocardiography. Excludes members under the age of 21, claims with diagnosis codes indicating pregnancy, childbirth, or puerperium. MP027 Cross-Coder Outpatient Facility CTA Claims: This analytic will target scenarios where there is a reason to believe the outpatient facility claim is upcoded due to not meeting all documentation requirements for a Computed Tomographic Angiography (CTA) since the professional claim shows a Computed Tomography (CT) of the same body area. Procedure code mismatches for CT/CTA exams on the same member with the same date of service will be flagged. This analytic is checking to see if the codes billed by the medical facility match what the physician did for certain types of CT/CTA scans. If there is a mismatch, medical records will be requested to determine what was documented.	Medicaid; Medicare	February 1, 2024