Special Alert April 2026 - Alert for 6.1 Coding and Reimbursement Policy Changes

REQUIREMENTS: By May 15, 2026: Billing team must implement four separate billing edits in the claims processing system: 1. INPATIENT SEPSIS DENIALS - Update system to automatically deny claims billed with MS-DRG 871 or 872 when BOTH length of stay is less than 3 days AND discharge disposition is to home. Educate coders that these DRGs require extended inpatient stays and may need rebilling under more appropriate DRGs. 2. EMERGENCY DEPARTMENT CRITICAL CARE EDITS - Configure system to deny line-level claims for CPT 99291 and 99292 when ALL of the following apply: services rendered in ED, AND patient discharged to home (status code 01). Exception: Do NOT deny critical care codes for ED visits that result in inpatient admission. Providers should use appropriate ED E/M codes instead for home discharges. 3. SURGICAL ANATOMICAL MODIFIER REQUIREMENTS - Update billing software to flag and deny surgical procedure codes (CPT 10000-69999) that require anatomical modifiers (RT, LT, E1-E4, F1-F9, T1-T9, LC, RC) when modifiers are missing, incorrect, or non-specific (e.g., modifier 59 or XS used instead of anatomical modifier). Educate billing and coding staff that anatomical modifiers must accurately reflect procedure location/laterality. 4. ANESTHESIA PHYSICAL STATUS MODIFIERS - Effective June 1, 2026, configure reimbursement system to NOT pay additional units for physical status modifiers P3, P4, P5 on commercial plans only. Modifiers may continue to be reported for documentation purposes but will receive zero additional payment. Educate anesthesia providers and billing staff that these modifiers no longer generate additional reimbursable units for commercial business. ACTION OWNERS: - Billing team/IT: Update billing software rules and claims processing edits - Medical coding staff: Educate on DRG selection, anatomical modifiers, and clinical documentation requirements - Providers: Communicate anesthesia reimbursement change and ED discharge disposition clinical decision-making - Compliance: Monitor for claims that trigger denials and communicate with providers CONSEQUENCES: Failure to implement these edits will result in automatic claim denials for non-compliant submissions, payment delays, and potential audit findings. Claims submitted without proper anatomical modifiers or with inappropriate critical care/sepsis coding will be denied at line level.