Current Issues in Legislation

Updated: June 2021
Misinformation About Telepractice in New Jersey
A recent email newsletter distributed by ASHA, Your 60-Second Advocacy Update, had an article about the state of telehealth in the United States. It highlighted efforts by audiologists and speech-language pathologists across the country to extend reimbursement for telehealth at the same rates as face-to-face services. They lauded states, such as Texas and Indiana, who have been successful, and what their outcomes have been. The article concluded by stating:

“Conversely, some states, such as New Jersey and North Carolina, have rescinded executive orders that granted additional flexibility for telehealth services only during the public health emergency”.

Please note: This is incorrect. ASHA made an error in its reporting.

ASHA was actually referencing the following:

Effective March 1, 2021, no new applications for Temporary Emergency Reciprocity Licenses will be accepted from, and no new temporary reciprocity licenses will be issued to, any out-of-state individuals seeking to practice audiology or speech-language pathology. All individuals holding previously granted temporary reciprocity licenses will remain valid through June 30, 2021, provided the Public Health Emergency remains in place. After June 30, 2021, a full license will be required to continue practicing in the state.
https://www.njconsumeraffairs.gov/Pages/Temporary-Emergency-License-for-Out-of-State-Practitioners.aspx

Had this information been true, the effects of this change would have had the potential to have significant implications for audiologists and speech-language pathologists. Its impact would affect many settings including early intervention, healthcare and private practices. The issue was taken up immediately by NJSHA’s President and the Private Practice and Healthcare Committees. Even though it was said we would look into this question when we have a chance, it started immediately. Our lobbyist, Lynn Nowak, was able to obtain official clarification on Sunday that this information is incorrect. Thanks to the immediate action of our lobbyist and NJSHA volunteers, we determined that the information was erroneous by the end of the Memorial Day weekend.

Currently, telepractice in New Jersey continues to be a viable service that is recognized as effective and reimbursable at the same rate as face-to-face interventions. There is, however, currently an expiration date of January 1, 2022 to the New Jersey Governor’s executive orders. NJSHA is continuing to work with our lobbyists and various committees to extend this deadline indefinitely. Our work to achieve this goal is regularly updated on the NJSHA website by the Legislative, Healthcare, Private Practice and Early Intervention committees. Keep visiting the NJSHA website to get the most current and accurate information.

The need to implement telepractice in all settings has been a quick and unforeseen change in how we deliver services to our clients and patients. We, as speech-language pathologists and audiologists have embraced the challenge and been creative, collegial and successful. We have discovered new avenues to provide services to populations in unconventional ways that have, very quickly, become conventional. Let’s work together and keep this new tool in our toolbox available in the future.

If you are interested in helping with this project, please reach out to us by emailing info@njsha.org. Watch our website for exciting information about micro volunteering opportunities.

Updated: April 2021
NJSHA’s Legislative Committee works hand-in-hand with our governmental affairs consultants, Lynn Nowak and Jacy Lance at Porzio Governmental Affairs.

We are currently in the middle of a two-year legislative session which began on January 14, 2020 and will end on January 11, 2022. The COVID-19 pandemic has forced the New Jersey Legislature to operate remotely for over a year. In March the Legislature finished the first quarter of regular business and is now working on the Fiscal Year 2022 Budget, taking most of April and May for Departmental Budget Hearings, where each Department in the Administration goes in front of the Senate and/or Assembly Budget Committees to defend the Budget Proposal that Governor Murphy presented in February. The Budget process will continue through June 30, 2021.

Aside from the Budget, telehealth/telemedicine payment parity remains a top legislative priority and NJSHA continues to participate in the administrative process regarding the promulgation of regulations for the Single Licensure of Audiologists. We monitor NJSHA-related bills as they move through the legislative and regulatory processes and will update this page regularly. Please note that there are over 9,000 bills currently introduced in the Legislature and we are tracking 299 bills for NJSHA.


SEMI Eligibility: On February 1, 2021, led by School Affairs Committee (SAC) Chair Nicole Ford, four NJSHA members joined Lynn Nowak on a Zoom call with four representatives from the Department of Human Services, specifically the Division of Medical Assistance and Health Services, to discuss the impact that the COVID crisis and remote/hybrid learning have had on the provision of billable speech-language pathology services under SEMI (the Special Education Medicaid Initiative) program. We spoke with Medicaid’s Medical Director, the Chief of Behavioral Health, the Deputy Director, and the Director of Managed Provider Relations. NJSHA received VERBAL clarification on issues such as providing services to students temporarily living out of state but within the US (allowed), providing services to students temporarily living out of the country (not allowed), providing instruction via packets being sent home (not allowed) and providing instruction via phone call only (not allowed). We are awaiting a more formal, written response. The issue of CFs with temporary licenses being able to bill for SEMI has been referred to the Department’s legal team.

Regionalization: In March 2021, the Senate undertook a rather fast-moving bipartisan effort to pass legislation which provides financial incentives for school districts with declining enrollment to pursue regionalization, and lifts barriers for schools considering consolidation. The text of the bill (S3488, Sweeney, D-Gloucester) was released on March 5, moved quickly through the Senate Education and Budget Committees, and was passed unanimously in the Senate on March 25. Led by SAC members Sue Goldman and Robin Kanis, NJSHA sent a detailed letter of support to the bill’s prime sponsor, Senate President Steve Sweeney, as well as to key Senate staff working on the bill. This bill is currently awaiting action in the Assembly, and NJSHA will continue to monitor the process and deliver testimony in support when it is heard in committee. Read the bill. Read NJSHA’s letter of support.

Extra Year for Students with Disabilities: Another fast-moving bi-partisan effort that occurred in the Senate in March was the passage of legislation to allow students turning 21 during the 2020-2021, 2021-2022 or 2022-2023 school years to continue receiving services for an extra year. Doing so will protect students from being “aged out” of eligibility when they turn 21 and allow them to continue receiving schooling and services in the year when they reach the age of 22. The bill (S3434, Addiego, D-Burlington and Sweeney, D-Gloucester) passed the full Senate on March 25 and is awaiting a hearing in the Assembly.

Telemedicine Payment/Reimbursement Parity: The COVID-19 pandemic and the transition to virtual provision of many healthcare services revealed a flaw in the 2017 law authorizing tele-medicine, which was drafted to require coverage parity, but in practice, it was discovered that this did not translate to payment/reimbursement parity. In June 2020, NJSHA President Robynne Kratchman provided testimony to the Assembly Health Committee to highlight the importance of resolving payment parity issues and the impact the current disparities are having on providers. Read NJSHA’s testimony. A4179, sponsored by Assemblywoman Downey (D-Monmouth) has been second referenced to the Assembly Appropriations Committee.

In October 2020, the Senate Health Committee began their consideration of this issue. First was a strictly informational hearing, concerning the provision of services via telemedicine/telehealth during the COVID-19 pandemic, including how those services are covered under health benefit plans, and the ways in which State law concerning the provision of services using telemedicine and telehealth may be revised or restructured on a permanent basis. Robynne again provided valuable testimony and insights from a provider perspective. Read Robynne Kratchman’s testimony to the Senate Health Committee.

In January 2021 the Senate version of the bill, S2559, sponsored by Senator Gopal (D-Monmouth) was approved in the Senate Health Committee. On March 22 the bill was approved in the Senate Budget Committee and on March 25 it was passed unanimously by the full Senate. The Senate legislation differs from the original bill that was heard in the Assembly Health Committee in June of 2020. When the bill is heard before the Assembly Appropriations Committee it will likely be amended and made identical to the Senate version. Read the version passed by the Senate.

We continue to track and monitor this legislation closely as well as communicate with both the sponsors and aides to the relevant committees to ensure that we have advance access to proposed amendments and are able to advocate for and protect NJSHA members’ interests.

Single License Law Update – May 17, 2021
After a long-awaited legislative process, and more than ten years of effort from a small working group of audiologists from the New Jersey Speech-Language-Hearing Association (NJSHA) and the New Jersey Academy of Audiology (NJAA), New Jersey audiologists are at long last able to dispense hearing aids by virtue of their audiology license!  

On May 17, 2021, the official Adopted Amendment: N.J.A.C. 13:44C-7.1 was published in the New Jersey Register VOLUME 53, ISSUE 10. This language expands the New Jersey Scope of Practice of Audiology to include the dispensing and fitting of hearing aids. Effective Date: May 17, 2021.

The audiology single license bill was signed by Governor Murphy in March of 2019, and established a new law permitting certain audiologists to dispense and fit hearing aids by virtue of their audiology license, without requiring a separate hearing aid dispensing license. Since that time, we have been waiting for the remaining steps in the legislative process to implement the law, namely the adoption of the official rule change to the audiologist scope of practice.

Single license for audiologists has been a top legislative priority of NJSHA for many years. Through the perseverance of our Executive Board, Audiology Committee, Legislative Committee and Lobbyist, NJSHA is proud to have been instrumental in changing the outdated legislation which required audiologists to have a separate hearing aid dispensing license.

New Jersey audiologists will now only require a single license to practice their full scope, which includes the fitting and dispensing of hearing aids, and will follow guidelines established by The Audiology and Speech-Language Pathology Advisory Committee for regulating all aspects of the practice of Audiology in New Jersey. The Audiology and Speech-Language Pathology Advisory Committee is scheduled to meet this Thursday, May 20, 2021. We will continue to keep the website updated as more details become available. Thank you to all who have worked over many years to achieve this goal.

Single License Law Update – January 21, 2021
At the January 21, 2021 meeting of the Audiology and Speech-Language Pathology Advisory Committee meeting, it was reported that the regulation implementing the Audiology Single Law is moving along in the administrative review process. It was moved out of the Director’s Office in Consumer Affairs on January 12 and is now in regulatory review. After no update was provided at the March 12th Hearing Aid Dispensers Examining Committee (HADEC) meeting, or the March 18th Aud-SLP Advisory Committee meeting, we have requested a meeting with the Attorney General’s Office and the Division of Consumer Affairs to get more information about the expected timeline. The next Aud-SLP Advisory Committee meeting is scheduled for May 20, 2021 and the next HADEC Meeting is scheduled for May 21, 2021. We continue to engage in discussions and outreach to relevant individuals to highlight the importance of this regulation being finalized.

Single License Law Update – December 11, 2020
The Audiology and Speech-Language Pathology Advisory Committee met on December 10, 2020 to discuss, among other things, the rules formally proposed by the Committee on October 5 which implement the 2019 law which allows audiologists to be able to dispense hearing aids without obtaining a HAD license. The good news is the Committee only received two comments from the public regarding the proposed changes during the 60-day comment period following publication of the proposal in the New Jersey Register. Both comments were in support, so there will not be any changes to the language moving forward. However, we did receive word from the Committee’s regulatory analyst that there continues to be a lengthy process to finalize the proposed regulatory change to the Audiologist scope of practice. Specifically, the language needs to (again) be reviewed by the Division of Consumer Affairs, the Office of Administrative Law, the Attorney General’s office, and Governor’s Counsel. The estimate is that it will be at least another 6 months before we see the final rules adopted and published in the New Jersey Register to officially authorize audiologists to dispense hearing aids without a separate hearing aid dispenser license.

LEGISLATIVE UPDATE

Advisory Council on Deaf and Hard of Hearing: In the 2018-2019 legislative session, NJSHA worked to secure amendments to this bill to add a speech language pathologist who has experience working with deaf and hard of hearing populations to the membership of the Council. An audiologist was already included in the bill as introduced. The bill numbers for the 2020-2021 session are S2441 (Kean, R-Union) and A4151 (Vainieri Huttle, D-Bergen). The amendments requiring the inclusion of an audiologist and speech language pathologist remain in the current bill. It was heard, amended and released by the Senate Health Committee on December 7, 2020 and passed unanimously by the full Senate in January 2021. The bill is referred to the Assembly Human Services Committee and is awaiting a hearing. Read the bill.

The below three bills were heard and released by the Assembly Human Services Committee on December 10, 2020. NJSHA’s support for all three bills was submitted to the Committee. The sponsor of all three bills, Assemblyman Chiaravalloti, is vice chair of the Committee and has expressed his appreciation for our support.

  • Medicaid Coverage for Hearing Devices: A856 Chiaravalloti (D-Hudson) – This bill expands Medicaid coverage for assistive hearing devices including hearing aids, cochlear implants when prescribed or deemed medically necessary by a physician or audiologist. Read A856.
  • Interactions between Law Enforcement and Individuals who are Deaf/HoH: A870, Chiaravalloti (D-Hudson) – Requires Director of Division of the Deaf and Hard of Hearing in DHS to evaluate and report on interactions occurring between law enforcement and individuals who are deaf or hard of hearing. Read A870
  • Law Enforcement Training Programs: AR35, Chiaravalloti (D-Hudson) – urges all law enforcement agencies to implement training programs on how to approach individuals who are hearing impaired. Read AR35.

On March 1, 2021 AR35 was passed unanimously by the Assembly. A870 is waiting for a vote in the full Assembly, and A856 is waiting for a second hearing in the Assembly Appropriations Committee. None of these bills yet have Senate sponsors.

Induction Loops: A5464 (Benson, D-Mercer) is a bill introduced on March 15 that requires the installation of an induction loop listening system in certain buildings open to the public upon new construction or substantial renovation. NJSHA is aware of the bill, and led by Marykate Vaughn, is engaging in internal discussions regarding the proposal and options for registering support. Lynn has reached out to the sponsor, Assemblyman Benson, to determine his plans for moving the bill. Read A5464 here.

In mid-September 2020, NJSHA President Robynne Kratchman sent a letter to Renee Clark, the executive director of the Audiology and Speech-Language Pathology Advisory Committee, regarding a potential scope of practice infraction by a Registered Dental Hygienist (RDH) who is routinely performing services that are explicitly included under the New Jersey SLP scope but not the RDH, specifically treating orofacial myofunctional disorders. The executive director of the New Jersey Board of Dentistry was copied on the letter. To date, we have received no response from either executive director. Additionally, the Audiology and Speech-Language Pathology Advisory Committee did not include receipt of this correspondence as part of their December 10 or March 18 agenda. We continue to follow up on this with our Advisory Committee and the Dental Board and if necessary, will seek action from other governmental entities.

The New Jersey Department of Education: On April 7, 2021, members of the State Board of Education approved a resolution designating May as Better Hearing and Speech Month. The Resolution was presented during a virtual State Board of Education meeting. NJSHA President-Elect Kathy Palatucci accepted the Resolution and made a few remarks. Following NJSHA’s statement, there were comments from the Board. Board Member Sylvia Sylvia relayed a story about her son, Jack who is now 24 years old and a graduate of Johns Hopkins University. He is hearing impaired and benefited greatly from SLP school services beginning at age 3. He was, in her words, “97% unintelligible” and could not say the sound /k/, a part of his name. One day he came home from school so excited and ran to his mother. He showed her that he learned how to say /k/ by putting his hand on his neck to feel the sound. He could finally say his name! The very next year he was in fully-integrated classes and communicating “too much!” She has never forgotten that special day for her son and she thanked our profession. Also, Commissioner Allen-McMillan shared her own struggle with stuttering as a young child. She expressed appreciation for the SLP therapists who helped her improve her communication. But she was even more thankful for the way her therapist provided hope. Read the resolution. Read the remarks from President-Elect Kathleen Palatucci.

The New Jersey State Senate and General Assembly also presented NJSHA with a joint resolution to recognize May 2021 as Better Hearing and Speech Month and pay tribute to NJSHA’s record of service, leadership and commitment. Read the resolution.

The Audiology and Speech-Language Pathology Advisory Committee regulates the profession of audiology and speech-language pathology in New Jersey. The committee licenses audiologists and speech-language pathologists. NJSHA actively monitors this committee to stay aware of new information and provides comment/input on issues affecting the profession.

  • Telemedicine/Telehealth: On November 3, 2019, the Committee proposed new rules to implement the law (P.L.2017, c.117) that provides the framework for the use of tele-medicine and telehealth. As described above under “Triumphs,” NJSHA was actively involved in the crafting of this legislation. The public comment period on the regulations closed on January 3, 2020, and NJSHA submitted comments expressing support of the rule proposal. However, the final rule adoption has not yet published in the New Jersey Register.

Criminal History Checks for Licensure Applicants: S942 Singleton (D-Burlington) / A1393 Lopez (D-Middlesex) – Requires certain standards for professional and occupational boards considering applicants with criminal history records. This bill was heard in the Senate Commerce Committee on January 27, 2020 and then referred to the Senate Budget and Appropriations Committee. The bill was heard in that committee and passed by the full Senate in June 2020. After an eight-month delay, the bill began moving in the Assembly in February 2021 with a hearing in the Assembly Appropriations Committee. The bill was amended in the Assembly, which required concurrence by the Senate once the bill received final approval in the Assembly, which happened on March 1. The Senate provided concurrence on March 25 and the bill is currently on the Governor’s desk. Read the final version of S942.

Chosen Name on Licenses: A2308 Vainieri Huttle (D-Bergen) / S3145 (Greenstein, D-Mercer) also recently passed both houses of the Legislature after some delay. The bill allows professionals to practice under their chosen name, instead of being forced to practice under their legal name, which oftentimes changes after marriage. Currently, licensed professionals are only allowed to practice under their legal name and must therefore update their license or certificate and other business materials if they choose to legally change their name. Now, applications for professional and occupational licenses and certificates will include lines for both the practitioner’s legal name and professional name, if different from one another. The applicant would then be allowed to choose which name would appear on their license or certificate. This legislation started moving in October 2020 in the Assembly, being heard in both the Regulated Professions Committee and Appropriations Committees. In January 2021 the bill was heard in Senate Commerce Committee, and amendments were made. As such, the Assembly had to amend the bill during a voting session on March 1. Then, both houses of the Legislature were able to vote on the bill on March 25. It was passed unanimously and is on the Governor’s desk. Read the final version of A2308.

Horizon Update – April 12, 2021

NJSHA has established a relationship with executives at Horizon. As a consequence, and benefit, NJSHA and Horizon has been meeting regularly with executives at Horizon to address a variety of issues brought to our attention by members. Several of these issues have been resolved. This ongoing open dialogue between NJSHA and Horizon will allow us to continue to work together on concerns as they arise in the future.

As was reported previously, in April 2020 Horizon had put into place a new computer program that screened incoming claims by ICD-10 code. Since the list of codes in the program did not include F and R codes, this change resulted in numerous speech therapy claims being denied or delayed with multiple requests to providers for additional documentation. It took some time and quite a bit of effort to identify the exact system and processes that were involved so that it could be addressed at the root. The issues spanned several areas within the Horizon system.

After months of detective work, collaboration, and communication, Horizon has made needed changes and made these retroactive to 4/1/20. All claims that were denied due to this erroneous culling process were “bulk pulled” and then processed. This has taken longer than we’d like, however, we have been told that all such claims are now being reprocessed and should all be paid by the April 23, 2021.
Horizon does caution that due to specific variances and limits in some self-funded individual plan benefits, which vary significantly in terms of what is and is not covered, that we cannot make a global statement that all specific codes will be covered.

In the future, if there is a reason for Horizon to request additional documentation, when the provider supplies the requested documentation, the claim will be reviewed and paid, or if additional information is needed the provider will receive a letter if denied with the medical director’s name or another letter that states what more is needed to finish clinical determination. These should be reasonable and not simply to delay payment.

Coding Issues
Denials: Another issue that has caused a great deal of frustration has to do with denials due to “Coding Edits” or “Use of Non-Specific Codes” or “Non-Medical Necessity Denials”. Our contacts at Horizon explained that if we receive denials with EOB messages related to coding it may have to do with “common coding edits”. These edits are in the insurance company computer system as “logic” that compares ICD-10 diagnosis codes with valid diagnosis combinations. This is not specific to Horizon but is based on the ICD-10 manual. For example, M26.59 and Q38.1 should not be coded together on the same claim. This will cause a denial for incorrect coding.

This “Diagnosis Code Guideline Policy” is based on the ICD-10-CM Official Guidelines for Coding and Reporting which states: “An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.”

Our members are advised to check the ICD -10 coding book and avoid combining codes that are listed with an “Excludes 1” note as these will result in a denial.

Note, that there are other codes that have “Excludes 2” note. That means that the two codes are considered to be separate and may be used together if appropriate.

(Reference ICD-10-CM Manual, Section 1.A.12a)

The following is provided as an example. In one case we investigated the provider had billed code 92526 with diagnosis codes R13.11(Dysphagia, oral phase), M26.59(Other dentofacial functional abnormalities), Q38.1(Ankyloglossia), F84.0(Autistic disorder) for several date of service. Since the CPT code 92526 was reported with both diagnosis codes Q38.1 and M26.59 together, the system denied the claim.

Per ICD-10 CM Manual 2020, under section Q38-Q45 (Other congenital malformations of the digestive system), there is an Excludes1 notes for dentofacial anomalies (M26.-). Therefore, when a code from the category M26.- (Current claim is billed with M26.59) on the same claim line, then the claim lines associated with the code will be denied. Since the diagnosis codes Q38.1, M26.59 are considered mutually exclusive, these codes should not be reported on the same claim line.

Please refer to the ICD-10 manual for more detailed information on coding edits.

It is suggested that providers code only the primary diagnosis, except when that diagnosis requires a supporting medical diagnosis such as F80.4 (speech and language developmental delay due to hearing loss) requires the H code that describes the type of hearing loss. It is not necessary to code every single condition.

Outstanding claims that were denied due to these errors, should be resubmitted as corrected claims that have been updated with correct diagnoses (no Excludes 1). As long as they meet criteria for the plan’s medical policy, claims should pay. Providers who continue to experience problems after April 23 contact info@njsha.org to follow up.

NJSHA will continue to work with Horizon to resolve these and other issues as they come to our attention.

Should you have specific concerns, please provide us with examples. As we find other issues that are common to many of our members, we can bring these to Horizon for resolution.

Appealing Denials
Out of network providers who choose to appeal denials on behalf of the patient/client can do so. However, the member must provide you with a signed consent form which you must send with the records.

Electronic Funds Transfer
NJSHA members have reported that payments that had been made by check are now being paid via credit card. This was a planned change that Horizon announced through notifications on EOPs since September of last year, the provider newsletter and on the portal.

Credit card payments are termed “SUA” or “single use account”. To opt out of SUA payments, providers must enroll in electronic funds transfer (EFT). To do so, providers can go to horizonblue.com/EFT. Providers must first be registered with Navinet.

Below is the information for EFT that is currently posted at Horizonblue.com/EFT.

Electronic Funds Transfer (EFT)
Electronic Funds Transfer (EFT) is a fast and easy way to receive reimbursement in an electronic format from Horizon BCBSNJ.

EFT helps our providers:

  • Improve cash flow.
  • Get faster access to funds.
  • Reduce administrative effort and expense.
  • Eliminate the risk of checks being lost or stolen.

EFT Registration for Professionals
EFT registration for participating and nonparticipating physicians, other health care and ancillary professionals is performed through NaviNet®. To register for EFT, sign in to NaviNet.netNaviNet.net opens a dialog window, access the Horizon BCBSNJ Plan Central page and go to > Claim Management > EFT Registration > Enroll.

Once you enroll, we will perform two test deposits (under a dollar) into the bank account you indicated. You must confirm receipt of the test deposits within 30 days to complete your EFT registration. Once you confirm that the tests were successful, it takes only 2 to 4 business days before EFTs begin.

If you’re not yet registered with NaviNet, please visit NaviNet.netNaviNet.net opens a dialog window and click ‘sign up.’

If you have any technical issues pertaining to EFT, please call the eService Desk toll-free at 1-888-777-5075, option 3 or send an email to Provider_Portal@HorizonBlue.com. Representatives are available weekdays from 7 a.m. to 6 p.m.

EFT Registration for Ancillary Facilities
To initiate the EFT registration process for participating and nonparticipating ancillary facilities, please complete the Horizon Blue Cross Blue Shield of New Jersey EFT Ancillary Form and email it to Ancillary_ProviderNetwork@horizonblue.com, or mail it to:
Horizon BCBSNJ
Ancillary Reimbursment/EFT Enrollment
3 Penn Plaza East, PP14K
Newark, NJ 07105-2200

The Horizon Blue Cross Blue Shield of New Jersey EFT Ancillary Enrollment Form ONLY applies to Ancillary Facilities. All other providers must register for EFT through NaviNet. Please refer to Registration for Professionals Section for instructions.

United Healthcare Update 12/14/20

It has recently come to our attention that UHC was denying on site speech therapy but paying teletherapy. The following information from UHC should be helpful to correctly submit claims:
https://www.uhcprovider.com/content/dam/provider/docs/public/commplan/payment-policy/MultiState-Updated-Procedure-to-Modifier-Policy-Professional.pdf

Horizon Update
“Non-Medical Necessity Denials”. Our contacts at Horizon explained that if we receive denials with EOB messages related to coding it may have to do with “common coding edits”. These edits are in the insurance company computer system as “logic” that compares ICD-10 Diagnosis codes with valid diagnosis combinations. This is not specific to Horizon but is based on the ICD-10 manual. For example, M26.59 and Q38.1 should not be coded together on the same claim. This will cause a denial for correct coding.

This is a Diagnosis Code Guideline Policy, which is based on the ICD-10-CM Official Guidelines for Coding and Reporting: “An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note.

Per the ICD-10 CM Manual, A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

(Reference ICD-10-CM Manual, Section 1.A.12a)

One example we had shared, the provider billed code 92526 with diagnosis codes R13.11(Dysphagia, oral phase), M26.59(Other dentofacial functional abnormalities), Q38.1(Ankyloglossia), F84.0(Autistic disorder) for three date of services. Since the code 92526 was reported with both diagnosis codes Q38.1, M26.59 together, Cotiviti made a denial recommendation.

Per ICD-10 CM Manual 2020, under section Q38-Q45 (Other congenital malformations of the digestive system), there is an Excludes1 notes for dentofacial anomalies (M26.-). Therefore, when a code from the category M26.-(Current claim is billed with M26.59) on the same claim line, then the claim lines associated with the code will be denied.

Since the diagnosis codes Q38.1, M26.59 are considered mutually exclusive, these codes should not be reported on the same claim line.

Please refer to the ICD-10 manual for more detailed information on coding edits.
NJSHA will continue to work with Horizon to resolve these and other issues as they come to our attention.

Should you have specific concerns, please provide us with examples. As we find other issues that are common to many of our members, we can bring these to Horizon for resolution.