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Priority Health Update

Priority Health Managed Care Committee Member

Flora Varga

Flora Varga, Cancer & Hematology Centers of West Michigan

New clinical edit goes into effect Oct. 15, 2022

Ensuring your patients, our members, receive the right care at the right price is central to our partnership with you and all providers in our network. To help us achieve this goal, we’ll implement a new clinical edit – “Diagnosis Coding, Excludes1” – on October 15.

Coding to the highest level of specificity

This edit stems from ICD-10 coding guidelines, which require coding to the highest level of specificity. Their Excludes1 criteria details diagnosis codes that shouldn’t be reported together because the two codes can’t occur at the same time.

Resubmitting denied claims

You’ll be able to resubmit denied claims with corrected diagnosis codes to receive payment.

Get more information

Reference the ICD-10 coding manual’s Excludes Notes section for more detail and examples.

"Unspecified Codes" clinical edit goes into effect on Oct. 11, 2022
Diagnosis codes should be reported to the highest level of specificity. On October 11, we'll turn on a new clinical edit that will deny certain unspecified diagnoses codes designated as either a Complication or Comorbidity (CC) or Major Complication or Comorbidity (MCC) when reported on an inpatient claim.

This edit will impact facility providers and will apply to all product types.

For more details on recent and upcoming clinical edits, visit our Clinical Edits Listing webpage. 

Check out our newly updated Medicaid billing webpage

Billing Medicaid claims can be confusing, even frustrating. We know.

Over the past several months, we’ve shared tips and guidance on how to effectively complete claims for our Medicaid members – touching specifically on Medicaid edits 21007 and 5169.

Now, that advice is available in the Medicaid billing page in our Provider Manual. Bookmark the page in your browser for quick access to Medicaid claim requirements, including:

  • Which data elements are required in Loops 2320 and 2330A
  • What provider types are allowable by claim type
  • And more

Visit the Medicaid billing page

New clinical edit: Principal or first-listed diagnosis codes
In accordance with ICD-10 guidelines, we’ll implement a new clinical edit on Oct. 1, 2022.

Principal or first-listed diagnosis codes ICD-10 coding guidelines require coding to the highest level of specificity. They’ve designated certain diagnosis codes to be principal or first-listed. As the description indicates, these diagnosis codes should be listed first on the claim.

Details are available in the ICD-10-CM Guidelines – April 2022 update.

Example, per ICD-10
A patient is seen solely for the administration of chemotherapy. Assign code Z51.11, Encounter for antineoplastic chemotherapy, as the first-listed or principal diagnosis.

Assign the malignancy for which the therapy is being administered as a secondary diagnosis.

Resubmitting denied claims 
You’ll be able to resubmit denied claims with corrected diagnosis codes to receive payment. 

Legacy THC providers must wrap up claims, appeals by Dec. 31, 2022
As our merger with Total Health Care (THC) is complete, THC will officially cease operations on Dec. 31, 2022. Legacy THC providers must wrap up any outstanding claims and appeals as outlined below.

What does this mean?  READ ARTICLE 

Visit the Priority Health Provider News Page for Additional Updates:  CLICK HERE 


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