Prepayment Clinical Validation Review Process

by | Aug 4, 2019

Effective with dates of service on or after September 5, 2019, multiple Anthem plans announced they will initiate a prepayment clinical validation review process for claims with a number of modifiers, including 25 (Significant, separately identifiable E/M service on the same day of the procedure or other service), 59 (Distinct procedural service), 57 (Decision for surgery), LT (Left side), RT (Right side) and other anatomical modifiers, states the notice published in the June 2019 edition of the Providers Newsletter for a variety of Anthem plans.

According to the new policy, registered nurses and coders will review claims to “evaluate the proper use of these modifiers in conjunction with the edits they are bypassing”, such as the National Correct Coding Initiative (NCCI)

Obviously Anthem wants to prevent the misuse of modifiers and it is critical to make sure that you have proper documentation to sustain the use of these modifiers. How this is going to affect practices remains to be seen.

For the anesthesia providers, the most common scenario will be the use of the modifier 59 when in addition to the primary anesthetic the anesthesia provider will place a nerve block for postoperative analgesia. A great way of documenting the block is to have a separate record indicating the block was done at the surgeon’s request and placed for postoperative pain management. If you are unable to document on a separate record, this information needs to be documented clearly on the anesthesia record.

Modifiers LT and RT apply to codes that identify procedures which can be performed on paired organs or on injections that can be done bilaterally.

Modifier 25 is to be used only to capture physician work done when separate E/M services are provided at the time of another E/M visit or procedural service. The E/M service must be separate and the problem must be distinct from the other E/M service provided or the procedure being completed.

According to DecisionHealth’s review of the policy announcements, Colorado and Nevada will review claims with dates of service on or after September 1st. Anthem Medicaid plans will review claims with dates of service on or after September 5th. The remainder of plans will review claims with a date of service on or after October 1st.

As reported by DecisionHealth, see the list below for plans grouped by the date of service as to when reviews will begin, as well as a link to the policy announcement.

Sept. 1

Sept. 5
California Medicaid, Medicare Advantage
Kentucky Medicaid
New York Medicaid
Virginia Medicaid (HealthKeepers)
Wisconsin Medicare Advantage

Oct. 1.
New Hampshire
New York (Empire BlueCross BlueShield)