Claim Codes

Claim Code Edits Clarified

Humana has further clarified the following claim code edit that became effective for all fully insured commercial members on April 10, 2011:

As described by the American College of Radiology (ACR), image–guided radiation therapy (IGRT) is a procedure that utilizes imaging technology to guide an action that modifies the treatment in reference to the intended target. It is appropriate for use with intensity–modulated radiation therapy (IMRT) and stereotactic radiation therapies. Due to its uses and constraints, it is not required for use with two–dimensional (2D) and three–dimensional (3D) conformal radiation or brachytherapy radiation therapies. Therefore, IGRT will not be separately reimbursed when submitted with 2D and 3D conformal radiation or brachytherapy radiation treatment delivery.

The full list of the April 10, 2011, claim code edits can be found here.

Humana has also revised the language in our health care provider notification to clarify the intent of a particular set of edits. The language that was originally used is as follows:

Services that are coded inappropriately based on the CPT or HCPCS procedure code definition submitted on the claim, and/or other information known to Humana, will be reimbursed using the appropriate code when possible. Otherwise, the service will not be reimbursed.

We have revised that language to provide additional clarity. The revised language is as follows:

In order to adjudicate claims accurately and timely, Humana will identify inappropriately coded claims and, when possible, reimburse using the correct code. Humana will only do so based on facts known to Humana, such as the age and gender of the member. For example, if Humana's records indicate the age of the member does not match the description of the CPT code, the claim will be considered based on the CPT code which properly reflects the member's age. If a claim is submitted for CPT 42825 (tonsillectomy, primary or secondary; younger than age 12), and the member is 15 years old, that code will be denied and CPT 42826 (tonsillectomy, primary or secondary; age 12 or over) will be added to the claim. When the correct code cannot clearly be identified, the claim will be returned to the provider. This language will appear on all future code–edit notifications.