Medicare AdvantageAdministrativeHigh impact
21-623 Claims Editing Updates
Health Net·CA · Physical Therapy, Cardiology, Radiology +3 more·Reimbursement
Effective date
Nov 15, 2021
We identified it
Jun 20, 2026
Summary
New claims editing rules require modifiers for procedures performed on different body sides/areas (especially impacting physical therapy), enhance bundling edits for same-group providers, and add Medicare Advantage coverage determination edits. Claims without required modifiers will be denied with code 255.
Action Required
Immediately: Billing team must update claims editing system to require appropriate modifiers for bilateral procedures and separate anatomical areas, especially for physical therapy services. Update billing software to flag claims missing modifiers before submission to prevent denial code 255. Review and enhance bundling edit rules for providers within same group/specialty/TIN to match expanded NCCI criteria. For Medicare Advantage only, implement NCD editing for cardiac pacemakers, bone density studies, breast biopsies, prostate screening, STI screening, immune globulin treatments, and cancer-related ESA treatments.