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Claims edit software updates

Medically Unlikely Edits (MUEs) for Durable Medical Equipment (DME)

At Quartz, we strive to keep you informed about changes that may affect your practice. On June 1, 2023, the following update occurred in our claims edit software system.

Quartz will re-activate this edit to ensure proper coding and billing of units associated with DME. The edit will apply when units billed exceed the CMS-defined allowed amounts. 

Quartz will enforce this edit for our commercial line of business. Services previously reimbursed may no longer receive payment when billing above the MUE allowed amount.

Medically Unlikely Edits (MUEs) for practitioners and facilities

As of July 1, 2023, the following update occurred in our claims edit software system.

Quartz will re-activate this edit to ensure proper coding and billing of units associated with services provided in an ambulatory surgical center, physician practice clinical location, and an inpatient or outpatient facility. The edit will apply when the units billed exceed the CMS-defined allowed amounts.

We will enforce this edit for the Quartz Commercial line of business. Services previously reimbursed may no longer be paid when billing exceeds the MUE allowed amount.

On September 1, 2023, the following updates will occur in our claims edit software system.

History post-operative care modifier rule

Quartz will re-activate this edit to ensure proper coding and billing of shared global operative packages. The edit will apply when Quartz receives a claim for post-operative care (modifier 55) without a corresponding claim for pre-operative and operative care (modifier 54). If you provide split/shared care, you must append modifiers 54 and 55 to the appropriate provider’s claims.

Quartz will enforce this edit for Medicare Advantage and Commercial lines of business. Services previously reimbursed may no longer receive payment if modifiers are missing from split/shared surgical care. Please see the Provider Manual, “Claims & Coding Policies” starting on page 53.

Medicare Hospital Acquired Condition (HACOf) rule

Quartz will activate this edit to ensure proper coding and billing for inpatient claims containing diagnosis codes designated as a Hospital Acquired Condition (HAC), with a non-exempt present on admission (POA) indicator (N or U), and the facility is not exempt from HAC provisions.

Quartz will enforce this edit for Medicare Advantage and Commercial lines of business. Services previously reimbursed may no longer receive payment if you do not bill these codes per the guidelines. Please see the Provider Manual, “Claims & Coding Policies” starting on page 53.

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