Orthopedic Coding Alert

Question: I follow Correct Coding Initiative (CCI) edits, but some insurers don't follow these guidelines. Why not?

Virginia Subscriber

Answer: You-re right. Some insurers follow CCI edits, but some don-t. This is strictly up to each payer and their stated goals for coverage. Those who don't use CCI edits may instead follow CodeCheck by McKesson. McKesson is a clinical editing system that is not in a public domain, and therefore you are not given specific information about what edits your payer is applying each time you bill. Most of the time, you learn what they are by following the denial patterns.

For instance, Aetna follows McKesson edits and generally does not alter the edits that come with the package. CIGNA does as well, but you may find reimbursement after a review. And you may successfully overturn bundles with Blue Cross Blue Shield (BCBS) depending on the representative you talk to. But other payers do not follow McKesson edits at all. UnitedHealthCare (UHC) follows Correct Coding Initiative (CCI) edits with their own twist. In other words, these insurers have developed internal edits that you also may not know about in advance.

Action item: You should negotiate code edit issues and have them spelled out in your payer contracts. Fail to do that, and you will have completely relinquished control to the payer.