Improvement
Medicare Advantage colonoscopy rules, and fewer discontinuous time alerts on obstetric claims
Work processed after carries this change.
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Every release and every piece of in-flight work for Medical Auto Coding. Filter by status, kind, or tag, then read the full notes below.
| Status | Kind | What changed | Version | Ticket | Date |
|---|---|---|---|---|---|
| Released | Improvement | Medicare Advantage colonoscopy rules, and fewer discontinuous time alerts on obstetric claims | No version | No ticket |
Work processed after carries this change.
Medicare Advantage and managed Medicaid plans follow the Medicare colonoscopy rules. The autocoder used to pick the payer rules from the plan name alone. A plan whose name carries no Medicare or Medicaid marker, for example Humana Gold Plus, Keystone 65, Devoted Health, or AmeriHealth Caritas, could get the commercial rules of the company that administers the plan. The autocoder now also reads the insurance type recorded on the case. These plans get the Medicare or Medicaid row. A recent audit found such plans on about 2 percent of cases.
A surveillance colonoscopy is billed as a screening for every payer except three. Cigna, UHC, and BCBS Nebraska treat surveillance as diagnostic. That list is complete. Every other payer treats a personal history of colon polyps as a high-risk screening. This includes Medicare, Medicaid, VA, and Tricare. In testing, the autocoder could apply a Medicare surveillance exception that does not exist and produce 00811. The same record now produces 00812.
The discontinuous time alert no longer fires on a labor epidural with a cesarean delivery. The autocoder now groups the anesthesia time segments by anesthesia code before it counts them. A labor epidural line and a cesarean delivery line are two services, not a break in one anesthetic. A provider handover also does not count as a break when the two segments touch, for example one segment that ends at 07:00 and the next that starts at 07:01. A true gap inside one anesthesia code still raises the alert.