The presence of additional diagnoses may warrant a comprehensive or detailed visit .
Modifier to Procedure Code Edit
The purpose of this edit is to identify claims billed with a procedure code and a modifier that are not appropriate .
The edit comment may indicate “ INVALID MODIFIER / PROCEDURE COMBINATION ”
Mutually Exclusive Edit
The purpose of this edit is to identify claims billed with two or more procedures that are usually not performed during the same patient encounter , on the same date of service .
Mutually exclusive rules may also govern different procedure code descriptions , for the same type of procedure , for which the provider should be submitting only one procedure .
Generally , an open procedure and a closed procedure performed in the same anatomic site will not be both reimbursed . If both procedures accomplish the same result , the clinically more intense procedure is recommended for reimbursement and the comparable procedure is found mutually exclusive . For example , if a claim is submitted with CPT code 62331 ( Implantation , revision or repositioning of tunneled intrathecal or epidural catheter ) with CPT code 64483 ( injection , anesthetic agent and / or steroid , transforaminal epidural ; lumbar or sacral , single level ) for the same date of service .
The edit comment may indicate “ CPT 62331 IS MUTALLY EXCLUSIVE TO CPT 64483 .”
New Visit Frequency Edit
The purpose of this edit is to prevent inappropriate reporting of a new patient E & M service and is based on the following CPT guidelines :
• A new patient is one who has not received any professional services from the physician or another physician of the same specialty , who belongs to the same group practice , within the past three years
If the provider attempts to report a new patient E & M service more than once in a three year period , our claims review system may recommend the CPT code with the corresponding established E & M service , if one is available .
The edit comment may indicate “ NEW VISIT FOR ESTABLISHED PATIENT ”
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