Claims Editing Enhancements and Correct Coding Reminders

Harvard Pilgrim is enhancing our existing claims editing for commercial plans to improve the overall accuracy of our claims processing, effective for dates of service beginning March 1, 2021. Enhancements will include, but are not limited to, prepayment review of modifiers based on the claim details and the patient’s claim history.

In advance of these claims editing enhancements, Harvard Pilgrim would like to offer the following reminders related to correct coding and appropriate reporting of modifiers:

  • Modifiers should only be appended/reported when the medical record documentation clearly supports the use of the modifier.
  • Modifier 24 should only be appended/reported when the evaluation and management (E/M) service was performed during a postoperative period for a reason that is unrelated to the original procedure.
  • Modifier 25 should only be appended/reported when the patient’s condition required a significant, separately identifiable E/M service that is above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.
  • Modifier 59 should only be appended/reported when the documentation supports a distinct procedural service that is not normally reported together with the primary procedure. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury that is not ordinarily encountered or performed on the same day by the same provider.
  • Modifier 79 should only be appended/reported to indicate that the procedure or service that was performed was unrelated to the original procedure.

For more information, please refer to Harvard Pilgrim’s commercial Coding Overview Payment Policy.

Publication Information

Helen Connaughton,
Director, Network Operations

Annmarie Dadoly,

Joseph O’Riordan,

Kristin Edmonston,
Production Coordinator