General Billing and Coding Guidelines

Quartz follows CPT coding guidelines, CMS guidance including NCCI bundling and MUE edits, and industry standards. Quartz Medicare Advantage will follow CMS guidelines unless specifically contracted to do otherwise, and Medicaid claims are required to follow instructions found on the ForwardHealth Portal, Medicaid online handbook, and the ForwardHealth Provider Updates.

All nationally recognized code sets (CPT, HCPCS, ICD-10-CM) and modifiers are accepted on claims, and payment is subject to benefits under specific contracts.

Quartz uses a claim editing system to review each claim line for coding issues and ensure compliance with relevant CPT and CMS coding guidelines. This includes unbundling, duplicate claims, new patient-visit auditing, patient diagnosis correlated with procedure appropriateness, validation of procedure modifiers, detection of multiple procedure reductions, age appropriateness of procedures and diagnoses, and sex-specific procedures and diagnoses versus patient sex. In cases of claims where there is a conflict between legal sex in the member record and specific diagnosis code, the addition of a KX modifier to the claim line or use of condition code 45 will indicate that the coding is appropriate.

Enforcement of coding policies will be conducted through periodic claim checks. These periodic reviews will ensure that Quartz is accurately and properly processing claims according to the coding policies set forth and that providers are submitting accurate claims. On occasion, this policy may require providers to submit supporting documentation of the services reported to substantiate care and billing. Questions about coding policies are addressed in our Provider Manual, which can be found on the Quartz website. This should be the first stop for the most up-to-date information. Appeals can be submitted through the Provider portal; please allow up to 30 days for review.

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