Changelog

What you will see

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.

What to look out for

• The claim itself does not change. The total minutes and the combined time range stay the same. Only the alert changes.
• Obstetric claims show fewer FINANCIAL alerts at severity 4. Before this change, this alert was often the only reason a coder had to open a labor epidural claim.
• The gap that counts as a break is 5 minutes by default. Your facility can change this value. Tell your Hank representative if you want a different value.
• On a GI case, read the rationale first. It names the payer bucket and the intent that the autocoder used, so you can check the result fast.
• If a Medicare Advantage or a managed Medicaid case still gets commercial colonoscopy rules, check the insurance type recorded on the case, then tell your Hank representative.

The anesthesia code is now selected from all of the notes. The autocoder was dropping the procedure summary whenever the pre-anesthesia evaluation was also cited. That happens on nearly every GI case, so the anesthesia code was often selected from the pre-anesthesia plan alone. The plan states what was intended, not what was done.

Anesthesia codes on GI cases can change, and that is the correction. A colonoscopy planned as screening and completed with a polypectomy is the clearest example. The plan supports 00812. The procedure report documents the polypectomy, and 00811 is correct. The autocoder now reads that report.

Code lookups now use the date of service. Code descriptions and code validity resolve from the real date of service, not from the current calendar year. A back dated claim now gets the codes of the correct year.

The notes cited on the final anesthesia code are the notes the autocoder used. The citation was previously taken from the first matching note in the record.

What to look out for: review GI anesthesia codes after this change, because the selected code can differ from what you saw before. Back dated claims should stop showing current year code descriptions.