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CCI Editing and Claim Guidelines

HealthPlus of Michigan’s Medical Policy reflects industry standards consistent with the coding criteria and protocols detailed in the American Medical Association CPT® Manual and Medicare CCI Editing for our Medicare line of business.

The Medical Policy describes the logic and rationale for payment decisions regarding the coding and billing of visits, procedures and certain ancillary services on the CMS-1500 claim form.   

Most of the claim edits are classified into three major categories:

Incidental — a procedure that is performed at the same time as a more complex primary procedure and is clinically integral to the successful outcome of the primary procedure.

Mutually exclusive — two or more procedures that are (typically) not performed during the same patient encounter, on the same date of service.

Re-bundling — two or more procedure codes used to report a service when a single, more comprehensive procedure code exists, that more accurately represents the service performed by a provider.

To remain consistent with industry standards, the table below displays the HealthPlus lines of business and how claim check is applied:

Line of Business

Application Method

HealthPlus Commercial

Claim Check

HealthPlus Medicare

CCI Edits

HealthPlus Partners

CCI Edits

HealthPlus MIChild

CCI Edits and Claim Check

County HealthPlans

CCI Edits and Claim Check

You may see the following explain codes, consistent with the Medical policy, on your EOP:

Explain Code

Description

V9

Denied- Multi –unit line denied for more than one reason

HE

Denied-Same procedure previously paid

HF

Denied-Itemization, invoice, documentation/electronic remark needed

HG

Denied-Procedure/modifier billed and quantity must correspond

HP

9U

Denied-included in another procedure or service

Payable-Replaced/rebundled

The HealthPlus website includes a code auditing reference tool, Clear Claim Connection (CCC), that allows you to view code auditing rules and associated clinical rationale. Log into the secured site at www.healthplus.org, using your personal login information, to utilize the CCC resource.

For questions related to completing or submitting a claims adjustment contact the Customer Service Department at 1-800-332-9161.

Additional Resources: