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Provider Manual

National Correct Coding

Last Updated on January 24, 2019

Security Health Plan uses the national correct coding initiative rules. This coding matrix includes both unbundled codes (procedures that describe a component of a more comprehensive procedure) billed with the more comprehensive procedure code, and mutually exclusive coding combinations. Mutually exclusive code pairs represent services or procedures that, based on either the CPT definition or standard medical practice, would not or could not reasonably be performed at the “same session by the same provider on the same patient.”

Some specific situations that Security Health Plan will be monitoring through the use of this coding matrix are:

  • Separate procedures: If provided as part of a more comprehensive procedure, “separate procedure” codes should not be submitted with their related and more comprehensive codes
  • Most extensive procedures: When CPT descriptors designate several procedures of increasing complexity, only the code describing the most extensive procedure actually performed should be submitted
  • “With/without” services: Certain code descriptors designate procedures performed with or without other services – only submit the code for the service actually performed
  • Sex designation: When code descriptors identify procedures requiring a designation for male or female, submit only the appropriate code
  • Laboratory panels: When a code for a grouping or panel of lab tests exists, bill it – don’t submit codes for the individual lab tests

Codes considered to be bundled will be denied with ANSI code CO97. These may not be billed to the member.