Changelog

What you will see

Automated claim validation (ClaimCleaner) checks the side of service on each line: the RT and LT modifiers, and the side in each diagnosis code. Validation now changes the right or left side only when the line documents that side, with one exception below. The sides that a line documents are the sides of its diagnosis codes and of its RT, LT or 50 modifier.

• No undocumented side. Validation does not add an RT or LT modifier, or a right or left diagnosis code, for a side that the line does not document.
• No reversed side. Validation does not change a documented right side to left, a left side to right, or a sided code to an unspecified code.
• Both sides on one line. When a line documents both sides, validation does not choose one side. It can only make the line bilateral: modifier 50, or the bilateral code of the same condition.
• Same condition only. When validation adds the side to a diagnosis code with an unspecified side, the new code must describe the same condition. For example, a dislocation code does not become a subluxation code.
• Every diagnosis stays on the line. When validation corrects the side of two or more diagnoses on one line, each diagnosis gets its own correction and keeps its place in the list. A secondary diagnosis does not move to the first-listed position.
• No retired codes. Validation does not add a diagnosis code that is not valid for the date of service. For example, it does not add M54.5 (low back pain), which is not billable for dates of service after September 30, 2021.
• One exception. Validation reads the side of a diagnosis code from the code set. A few bilateral codes, for example M17.0 (bilateral primary osteoarthritis of knee), do not carry a side there yet. Validation reads such a code as a code with no side, so it can still add that code to a line that documents one side or no side, or put it in place of a right or left code of the same condition.

For example: an interventional radiology claim bills a thrombectomy of the right leg veins (37187) with I82.411 and I82.421 (right femoral and right iliac vein thrombosis) and no side modifier. Validation adds RT and keeps both right-side codes.

Nerve block lines and the side of the surgery

• Validation no longer changes the side of the diagnoses on the main anesthesia line to match the RT or LT modifier of a nerve block line. The main anesthesia line keeps the side that the surgery documentation states.
• When a nerve block line carries RT or LT and the surgery documentation states the other side, validation reports the difference. The autocoder does not show this report to a coder yet, so no alert appears for it. In a sample of 2,336 recent fully automated anesthesia cases, the difference occurred on 1 case.

Alert changes

• No alert is added or removed.
• ClaimCleaner Added ICD Code, ClaimCleaner Added Anesthesia Modifier and ClaimCleaner Added Surgical Modifier can appear less often, because validation makes fewer side changes. On radiology claims, ClaimCleaner-Added Contralateral Diagnosis Stripped (Undocumented) can also appear less often.

What to look out for

• Expect fewer side changes from validation on anesthesia and radiology claims.
• When the record does not document a side, the line keeps the side as coded. Add the side from the record when your payer requires it.
• On a line that documents one side or no side, check a bilateral diagnosis that validation added, for example M17.0.
• On a claim with a nerve block, compare the side of the block line with the side of the surgery. The autocoder does not ask about a difference yet.
• Nothing changes in your configuration.

What you will see

Modifiers 59, XE, XS, XP, and XU exist for one purpose: to bypass a Medicare NCCI edit between two codes on the same claim. When no edit exists, the codes pay separately on their own and the modifier is unnecessary. Payers flag unnecessary distinct-service modifiers in audits.

Before this change, the autocoder sometimes placed one of these modifiers on a code pair that has no NCCI edit. Example: a diagnostic cervicocerebral angiogram that bills carotid angiography (36224) and vertebral angiography (36226) together. Medicare holds no edit between those codes, so no modifier is needed, but an XS could still appear on the vertebral line.

Now the autocoder checks the licensed NCCI edit table at claim build. If a line carries 59 or an X modifier and no edit pairs its code with any other code on the claim, the modifier is removed. The claim carries an informational note, "Distinct-Service Modifier Removed (No NCCI Edit)", as an audit trail. No action is needed.

The check is careful in three ways. A modifier on a real edit pair is never touched. A modifier on a repeated code (the same code on two lines) is never touched, because it can mark a separate encounter. And when the NCCI data is not available in a deployment, nothing is removed.

A related alert also improved. The "may need distinctness modifier" review alert used to appear on every claim with two or more procedures. It now appears only when a real NCCI edit pairs the codes, so it no longer asks your team to add a modifier the claim does not need.

What to look out for

• Radiology and interventional radiology claims with several procedures will show fewer 59 and X modifiers. The removed ones were unnecessary.
• If a payer outside Medicare requires a distinct-service modifier for a policy of its own, tell your Hank representative.

This change affects only organizations that chose the X modifier set in place of modifier 59.

Modifier 59 stays on the lines CMS excludes. Per CMS guidance (MLN1783722), modifier 59 and its X modifier subsets identify services other than evaluation and management. E/M services use modifier 25 instead. The autocoder no longer converts a 59 into XE or XS on an E/M line, an anesthesia line, or a qualifying circumstance line. A modifier 59 that arrives on one of those lines stays 59.

The catch-all XU rule already worked this way. The XE rule (return to the operating room) and the XS rule (separate structure) now follow the same exclusion.

What to look out for: if your organization uses the X modifier preference, expect 59 to remain on E/M, anesthesia, and qualifying circumstance lines. Other lines still receive the X modifiers as before. Organizations that bill with modifier 59 see no change at all.

Modifier G8 is now limited to the six codes CMS names for it. Those codes are 00100, 00160, 00300, 00400, 00532 and 00920. On any other code the autocoder removes G8 and applies QS in its place.

An anesthesia line now carries exactly one of QS, G8 or G9. These modifiers can no longer stack on the same line. QS is the default for monitored anesthesia care. G8 wins when the code qualifies for it, then G9, then QS.

Three new review flags. A line that keeps G8 or G9 carries an informational note to verify the documentation. A line with G9 is flagged when no severe heart or lung diagnosis is coded on the claim. A physical status of P3, P4 or P5 is flagged when no supporting condition is coded on the claim.

What to look out for: expect G8 to disappear from cases outside the six approved codes, and expect QS in its place. Expect new review flags on G9 lines and on claims with a high physical status. When the record supports the modifier or the physical status, confirm that the supporting diagnosis is coded on the claim.

Radiology claims apply the component modifiers your configuration asks for. The rules that decide the professional component (modifier 26) and the technical component (modifier TC) read the billing component set for your organization. That setting stopped reaching the coding step, so the rules had nothing to act on, so no radiology claim received a component modifier from them. The setting is live again, and radiology coding follows it.

While the setting was not reaching the coding step, radiology claims were coded as if no component preference existed. Claims coded in that window may therefore be missing the modifier your configuration calls for. Check them before you submit them.

What to look out for: a radiology claim may now carry a 26 or a TC modifier where recent claims carried none. Check that the billing component configured for your organization matches how you bill: professional, technical, global, or split. Ask your Hank representative if the setting needs to change.

QZ is no longer forced onto every CRNA placed labor epidural. Code 01967 got QZ regardless of your organization's medical direction configuration. The autocoder now applies the same rules that it uses for every other line.

What each configuration gets now. An organization with medical direction turned off gets the provider on the line and no modifier, because that organization assigns anesthesia payment modifiers downstream. An organization that chose to hold CRNA alone cases now gets a hold, instead of a QZ that was billed silently. Every other organization still gets QZ, plus a new informational note for the audit trail.

What to look out for: code 01967 still requires one of AA, QK, QX, QY, QZ or AD on the submitted claim. Payers deny the line without one of them. If your organization assigns modifiers downstream, confirm that the downstream process supplies the modifier on labor epidurals. If your organization holds CRNA alone cases, expect new review queue items where QZ was billed automatically before.

Aetna no longer turns surveillance into diagnostic. Aetna treats surveillance as screening, per the commercial payer guidance dated 2025-12-02. Aetna is removed from the surveillance to diagnostic list, and from the 00811 with PT group.

One payer label is corrected. The row that read BCBS DE, NY, PA and WV now reads Highmark in any state, plus BCBS DE and BCBS WV. The old label mixed Highmark plans with BCBS Pennsylvania plans that are not Highmark. BCBS Independence (Pennsylvania) now has its own rows: 00811 with PT for a lower endoscopy, and 00813 with Z12.11 first for a combined upper and lower endoscopy.

Five payers move to a different group. BCBS Michigan and Priority Health (Michigan) move to the 00811 with PT group. BCBS Arkansas, Anthem Connecticut and BCBS Illinois move to the 00812 with PT group.

The surveillance rule for Cigna, UHC and BCBS Nebraska now applies. An ordering defect meant that this rule never took effect. A surveillance case for these three payers now becomes diagnostic and produces 00811 without PT.

What to look out for: the code and the modifier can differ for the payers named above. Accuracy improves for each of those payers on a screening colonoscopy that converts to diagnostic.