Cardiology Coding Alert

Question: I follow Correct Coding Initiative edits, but some insurers don't follow these guidelines. Why not?

Virginia Subscriber

Answer: You're right. Some insurers follow CCI edits, but some don't. This is strictly up to each payer and their stated goals for coverage. Those who don't use CCI edits may instead follow McKesson edits. McKesson is a clinical editing system that is not in a public domain, and therefore you are not given specific information about what edits your payer is applying each time you bill. Most of the time, you learn what they are by following the denial patterns.

For instance, Aetna follows McKesson edits and generally does not alter the edits that come with the package. CIGNA does as well, but you may find reimbursement after a review. And you may successfully overturn bundles with Blue Cross Blue Shield (BCBS) depending on the representative you talk to. But other payers, such as UnitedHealthCare, do not follow McKesson edits at all. These insurers have developed internal edits that you may also not know about in advance.