Critical care coding, upcoding of Percutaneous Nephrostolithotomy (PCNL) Procedures, and Transcranial Dopplers with Valid Diagnosis updates

Date: 10/14/24

Thank you for your continued partnership with Meridian and its family of plans. We are committed to continuously evaluating and improving overall payment integrity solutions as required by state and federal governing entities.

As a reminder, Optum supports us by performing prepayment claim auditing. The purpose of the review is to verify the extent and nature of the services rendered for a patient’s condition and to ensure that the claim is coded correctly for the services billed.

For claims received on or after January 1, 2025, providers may experience a slight increase in written requests for medical record submission prior to payment based on the areas outlined below.

Requests will come from Optum and will contain instructions for providing documentation. If the requested documents are not returned, the claim(s) will be denied. Providers will have the ability to dispute findings directly through Optum in the event of a disagreement.

Thank you for your continued participation and cooperation as we work together to render quality healthcare to our members.

Editing Area	Description	Lines of Business
Critical Care Coding Requirements Unlikely to be Met	This review seeks to ensure appropriate critical care billing for illnesses or injuries.	Medicaid Medicare
Upcoding of Percutaneous Nephrostolithotomy (PCNL) Procedures	This review of professional and outpatient claims seeks to ensure that documentation supports billing a complex Percutaneous Nephrostolithotomy (PCNL) Procedure.
Transcranial Dopplers with Valid Diagnosis	This review seeks to ensure that documentation supports billing for Transcranial Dopplers (TCDs).

 

Associated Code for EOP	Description
CPIMR	Medical records and/or other service documentation required