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.

This release closes 14 findings from a full review of the anesthesia coding stack. Several of them change what your coders will see.

Every OB case is held for review. A claim whose primary anesthesia code is obstetric (01958-01969) now carries the "OB case review" hold. This rule existed in configuration before but never fired because of a defect. If your organization does not want every OB case held, the rule can be turned off or downgraded per facility.

OB add-on codes require their primary. A claim that bills 01968 or 01969 without the 01967 labor analgesia primary is held. An add-on billed alone is a guaranteed payer rejection.

Supervision cases bill both providers. When medical direction drops to supervision (more than 4 concurrent cases), the claim now bills the physician line with modifier AD and the CRNA line with modifier QX. The CRNA line used to disappear, which underbilled the case.

Deliberate hypothermia and controlled hypotension are billed again. Codes 99116 and 99135 were blocked entirely. They now bill when the record documents the technique, and every such line carries a review flag so a coder confirms the documentation and the payer.

Post-op pain epidurals follow the NCCI rule. An epidural placed for post-op pain bills separately (with modifier 59) only when the case was done under general anesthesia. Under spinal or other anesthesia it is bundled, with the NCCI reason recorded on the claim. Placement in the OR no longer causes a silent drop.

Two new safety holds.

• If the extracted anesthesia provider is the operating surgeon, the claim is held. Medicare does not pay the operating physician for anesthesia.
• If a surgical procedure has no anesthesia crosswalk (an unlisted code, for example) and may outweigh the crosswalked procedures, the claim is flagged so a coder verifies the anesthesia code and its base units.

TEFRA settings are honored. A TEFRA attestation requirement your organization turned off is now truly excluded from evaluation. Sites with disabled requirements may see fewer "TEFRA requirements unmet" holds.

What to look out for: more held OB claims (by design), two-line supervision billing, occasional 99116/99135 lines with review flags, and the two new hold reasons in your review queues.

What you will see

The primary-diagnosis alert now reads like a person wrote it. The old alert said "Primary dx Z12.11 (Encounter for screening for malignant neoplasm of colon (billable=True)) not attested as reason for procedure. Validator: src=unattested: return record to provider." The new alert says where the diagnosis was found in plain words, what to confirm, and what to do: "Primary diagnosis Z12.11 (Encounter for screening for malignant neoplasm of colon) is not documented as the reason for this procedure in the anesthesia record or the procedure note. Where it was found: only the problem list or past history. Confirm the documentation supports this diagnosis, or select the diagnosis the record supports. Do not bill from a problem list or history alone." The alert identifier, severity, and hold behavior do not change.

The alert fires less often on screening and delivery claims. The autocoder now reads the pre-anesthesia evaluation and the other anesthesia record sections when it checks the primary diagnosis, so an indication documented only on the pre-anesthesia evaluation counts. It also treats the documented encounter type as the reason for the procedure: "screening colonoscopy" on the record supports the screening code, and a normal delivery note supports the delivery code. A procedure with no indication documented anywhere still routes to a coder.

Cesarean claims keep the documented indication as the primary diagnosis. The autocoder used to fall back to O82, "cesarean delivery without indication," whenever a cesarean was performed. Per the FY 2026 ICD-10-CM Official Guidelines, the condition that led to the cesarean is the principal diagnosis. A repeat cesarean for a prior uterine scar now bills O34.21- first. O82 appears only when the record documents that there was no indication.

Separate billing of a postoperative pain injection (62322 family) now follows the full NCCI conditions. A separate flat-fee line requires all three: the case ran under general anesthesia, the surgeon's request for postoperative pain management is documented, and the injection was not the operative anesthetic. When these are met, the line carries modifier 59 or XU automatically. When any is missing, the block folds into anesthesia time and the alert tells the coder exactly how to recover the flat fee: obtain the surgeon's request, then bill the code with modifier 59 or XU.

Pre-printed form labels are not services. On paper checkbox forms, an unmarked pre-printed option could be read as a performed service: an unticked "Labor Epid to C-Section" row became a cesarean, an empty arterial line grid row became 36620, an empty "E" box became 99140. The autocoder now requires real documentation: cesarean codes need documented cesarean anesthesia, a line needs a placement note or a time, and 99140 needs a documented emergency condition.

What to check

If your review workflow matches on the exact text of the primary-diagnosis alert, update the match: the identifier primary_icd_not_attested is unchanged, but the description text is new.

O80 is coded only when a delivery happened during this stay. O80 reports an encounter for a full term uncomplicated delivery. A labor only case that carried O80 could be billed as a delivery again when the patient came back. The autocoder now requires a documented delivery in this stay. It also requires an outcome of delivery code (Z37) as a secondary diagnosis. It blocks O80 whenever any pregnancy complication is coded.

External cause codes are suppressed on anesthesia claims. Codes from the V, W, X and Y chapters no longer appear on these claims.

A condition documented as a past event is coded as history. A prior heart attack or a prior stroke gets a history code, not a code for a current condition.

An abdominal case documented above the navel routes to 00790. The autocoder selects the upper abdomen code when the record documents an incision or an exploration above the umbilicus. Anesthesia billing follows the operative field, not only the name of the procedure.

What to look out for: a labor only encounter no longer carries a delivery diagnosis. Confirm that the record states the delivery when you expect O80. An abdominal case documented above the navel carries 00790 and the base units of that code.

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.