Cosmetic Surgery Edits
A cosmetic procedure is usually performed for cosmetic reasons , without a medically indicated purpose . A number of surgical procedures may be performed , in full or in part , for reasons that are primarily “ cosmetic ” and where medical necessity does not exist . Usually , the procedure is requested by the patient to improve his or her physical appearance .
Cosmetic surgery edits were developed on a procedure-by-procedure basis by clinical consultants . Each CPT code was reviewed to determine whether it was partially or entirely cosmetic .
Hometown Health ’ s claim review system recognizes that cosmetic services are frequently performed and , at time , could be medically necessary . These procedures are flagged as potentially cosmetic procedures and are subject to additional medical review .
Duplicate Charge Edit
The purpose of this edit is to identify claims that have already been processed for the same provider , member number , service date , service code , and modifier .
The edit comment may indicate “ DUPLICATE CHARGE PREVIOUSLY PROCESSED ”
Evaluation and Management ( E & M ) Services Edit Established Patient , New Visit Procedure Code Not Allowed
The purpose of this edit is to identify claims for a new patient visit procedure when the provider has performed a previous visit within a specific period that qualifies that patient as an established patient .
Our claims review system ’ s handling of separate reporting for E & M services varies according to the type of procedure performed on the same date of service . Specifically , the differentiation between :
• Initial or new patient
• Follow-up or established patient services
In addition , the claims review system adheres to the “ Surgical Package Concept ” and does not allow separate reporting of E & M services when a substantial diagnostic or therapeutic procedure is performed . CPT guidelines for E & M services support this medical visit auditing .
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