Community First is committed to providing ongoing information as we move towards the implementation of new Claims Editing Software (CES). On April 1, 2022, Community First will implement a claims pre-payment auditing process that identifies frequent correct coding errors. Coding edits are based on Current Procedural Terminology (CPT), Medicaid guidelines, industry standard National Correct Code Initiative (NCCI) policy and guidelines, and industry payment rules and guidelines as specified by a defined set of indicators in the Medicare Physician Fee Schedule Data Base (MPFSDB).

Community First will implement Optum Claims Editing Software (CES) on April 1, 2022. The new CES will identify frequent correct coding billing errors such as:

  • Bundling and unbundling coding errors
  • Duplicate claims
  • Services include in global care
  • Incorrect coding of services rendered

All edits within the CES comply with national coding standards and are most likely part of the normal billing practice of providers. All claims must follow the proper coding guidelines. This requires the usage of correct modifiers, correct place of service codes, and correct usage of ICD-10 codes in the primary diagnosis field.

The information in this document is intended to ensure that you are reimbursed based on the code or codes that correctly describe the healthcare services provided. Community First reimbursement uses Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines. Reference to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement.

Ensure your billing systems are up to date with Texas state standards to ensure your claims are processed efficiently and paid quickly.

Additional information on Edit Pairs can be found at: Coding_Edits

Additional information on Place of Service Codes can be found at:

For additional information, please contact the Provider Relations division by phone at (210) 358-6294 or by email at


Modifier 26- Professional Component

The total service/procedure described by a single CPT code is comprised of two distinct portions: a professional component (designated by Modifier 26), and a technical component (designated by modifier TC).

The professional component of a diagnostic service/procedure is provided by the physician and may include supervision, interpretation, and a written report. The technical component of a diagnostic service/procedure accounts for equipment, supplies, and clinic staff, such as technicians. Fees for the technical component generally are reimbursed to the facility of practice that provides or pays for the equipment and supplies.

To identify professional service only for a service that includes both professional and technical components, append modifier 26 to the appropriate CPT code. Please note that this modifier is appropriate when the physician supervises/or interprets a diagnostic test.

Do not append modifier 26 if there is a dedicate code to describe only the professional/physician component of a given service. Example: 93010 Electrocardiogram, routing ECG with at least 12 leads; interpretation and report only

Understanding the correct an appropriate use of this modifier will be key to filing clean claims and avoiding denials for duplicate billing or incorrect use of modifier.


The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines for Coding and Reporting, developed through a collaboration of The Centers for Medicare and Medicaid services (CMS), the National Center for Health Statistics (NCHS), and the Department of Health and Human Services (DHHS), provides clear direction on the coding and sequencing of diagnosis codes.

Examples of Factors Influencing Health Status (category of codes beginning with Z)

  • Codes Z15.03-Z15.09, Z15.81, Z5.89
  • Category Z16- Sequence the infection code first
  • Category Z17- Sequence the malignant neoplasm of breast code first
  • Category Z19- Sequence the malignant neoplasm code first
  • Code Z33.1- this code is a secondary code only for use when the pregnancy is in no way complicating the reason for visit. Otherwise, a code for the obstetric chapter is required
  • Category Z3A- Sequence first complications of pregnancy, childbirth, and the puerperium (O00-O9A), followed by a code from Category Z3A to identify the specific week of the pregnancy
  • Codes Z55-Z65- These codes should only be reported as secondary diagnoses
  • Codes Z68.1-Z68.24, Z68.51-Z68.54- These BMI codes should only be reported as secondary diagnoses
  • Category Z91.1- Sequence the underdosing of medication (T36-T50) first
  • Category Z91.13- Sequence the underdosing of medication (T36-T50) first.
  • Code Z91.83- Sequence the underlying disorder first

ICD-10 codes found on the Factors Influencing Health Status Category List (category of codes beginning with Z) will be denied when billed as the Primary Diagnosis Codes.


Modifier 59 allows PTs to charge for two separate services that have been paired by the National Correct Coding Initiative (NCCI) as one. However, there are many other factors that affect its use and may cause errors.

The NCCI identified certain procedures that therapists often perform together in the same treatment period as edit pairs. Should you charge for any two CPT codes that make up an edit pair, the payer will automatically pay for only one of those services. This is unless those services were provided wholly separate from each other and modifier 59 is applied to one of the codes.

Modifier 59 signifies separate payment for code pairs that are considered to have just one payment. For example, code 97110, which indicates therapeutic procedure one or more ears (each for 15 minutes) links to several other codes to perform edit pairs. To be able to charge for 97110 as well as its partner code in an edit pair separately, the services need to have been performed in different time periods (different 15-minute periods in this case) and have modifier 59 attached to the linking code.

Modifier 59 as intended primarily for surgical procedures but does affect physical, occupational and speech therapy billing and is widely recognized. There are certain conditions necessary for this modifier to be effective. First, is that you use it with an existing edit pair. Some codes represent mutually exclusive procedures and can therefore never be billed with another code.

For a guide on how and where to look up edit pairs, visit


Place of Service Codes are two-digit codes places on health care professional claims to indicate the setting in which a service was provided. The place of service code helps the insurer to ascertain the place where the medical service was rendered. Matching of the current location of service codes to the procedural codes is crucial while reimbursing claims. If the Place of Service Code does not correlate with treatment code(s), the claim will be denied.

All home modification services must be billed with location 12, as the treatment is occurring in the patient’s home. For a complete list of service codes, please visit


This information is intended for those providers who bill on a UB-04 claim form, or it’s electronic equivalent, or it’s successor form. This applies to all products and all network and non-network facility emergency departments (including hospital emergency departments) and free-standing emergency departments.

This section describes how Community First reimburses UB claims billed with Evaluation and Management (E/M) codes Level 4 (99284/G0383) and Level 5 (99285/G0384) for services rendered in an emergency department.

CMS indicates facilities should bill appropriately and differentially for outpatient visits, including emergency department visits. To that end, CMS coding principles applicable to emergency department services provide that facility coding guidelines should:

  • Follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code
  • Be based on hospital facility resources and not based on physician resources
  • And not facilitate upcoding

Community First will utilize the Optum Emergency Claim (EDC) Analyzer to determine the emergency department E/M level to be reimbursed for certain facility claims. The EDC Analyzer applies an algorithm that takes three factors into account to determine a Calculated Visit Level for the emergency department E/M services rendered. The three factors used in the calculation are:

  • Presenting problems- as defined by the ICD-10 reason for visit (RFV) diagnosis.
  • Diagnostic services performed- based on intensity of the diagnostic workup as measured by the diagnostic CPT codes submitted on the claim (i.e., Lab, X-Ray, EKG/RT/Other Diagnostic, CT/MRI/Ultrasound); and
  • Patient complexity and co-morbidity- based on complicating conditions or circumstances as defined by the ICD-10 principal, secondary, and external cause of injury diagnosis codes.

Facilities may experience denials to the levels 4 or 5 E/M codes submitted on the UB04. In the event you receive a denial, the facility may submit a corrected claim, which Community First will adjudicate based on the new charges and/or additional coding that supports the E/M Level.

Community First will continue to provide guidance and resources as we transition to our new Claims Editing Systems.

For questions or comments, contact Provider Relations at 210-358-6294 or email

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