Claims Processing Edits

These edits are being added in order to comply with the final Health Insurance Portability and Accountability Act (HIPAA) rule, which named the ICD-9-CM Volume 3 Procedure Codes (including The Official ICD-9-CM Guidelines for Coding and Reporting) as the HIPAA standard medical code set for inpatient hospital services, and the HCPCS/CPT codes as the HIPAA standard medical code set for physician services and other health care services (including outpatient hospital procedures). With the implementation of these edits, Humana will:

1. No longer accept outpatient hospital claims with ICD-9-CM Vol 3 procedure codes in either or both the Procedure Information segment (BQ) or Other Procedure Information (BR). Humana will follow the HIPAA standard medical code set of HCPCS/CPT codes for outpatient services. Humana's rejection message will state, "ICD-9 valid only for hospital inpatient bill types."
   
   
2. No longer accept an inpatient hospital claim with a HCPCS/CPT code in either or both the Procedure Information segment (BP) or Other Procedure Information (BO). Humana's rejection message will state, "ICD-9 must be used for hospital inpatient reporting."

Download and Print

November 29, 2008, Claim Code Edits
View a list of updates to Humana's claim code-editing software that affects several areas of the American Medical Association (AMA) Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases, 9th Edition/Revision (ICD-9) code sets.
(44 KB) Download DOC
English

Significant Edits
View a list of edits that affect at least 500 claims per year and differ from AMA CPT or CCI coding guidelines.
(65.4 KB) Download PDF
English

Customized Edits
View a list of edits added to standard claims editing logic by Humana.
(96 KB) Download PDF
English

Modifier 59 Edits
View a list of code combinations that Humana has determined are not appropriately reported together with a modifier 59 and which differ from AMA CPT coding guidelines.
(17.9 KB) Download PDF
English