July 30, 2024
Coding Validation Implementation
In an effort to detect potential coding errors and incorrect billing practices and ensure your claims are paid quickly and efficiently, we are adding new edits based on correct coding rules that address complex coding situations for the Medicaid line of business.
Effective October 1, 2024, Molina Healthcare of Wisconsin, Inc. (Molina) is adding new review functionality to improve the accuracy of our claims processing by addressing modifier coding that is too complex to auto-adjudicate and has a human review component. The new edits are based on correct coding rules, published by national industry sources and administrative bodies, to detect potential coding errors and incorrect billing practices. Modifiers have been defined by the American Medical Association (AMA), and adopted by Centers for Medicare and Medicaid (CMS), to provide additional information about the services that were rendered.
Modifiers 25, 59, XE, XS, XP and XU are among the most commonly used modifiers; therefore, the new edits will be evaluating the correct use of these and other overriding modifiers.
When preparing claims for submission, it is important to make sure that all appropriate diagnosis codes are assigned to the claim and that modifiers are used only when clinically appropriate based on published guidelines.
Additional information about when to use modifiers can be found in the CPT manual, in the Provider and NCCI manuals found on CMS’s website.
If you do not agree with a denial due to the incorrect use of modifiers, you have the right to file an appeal by submitting the medical record that supports reimbursement
Questions?
Please reach out to your provider relations representative or email us at MHWIprovidernetworkmanagement@molinahealthcare.com.