National Correct Coding Initiative

Transcription

1 National Correct Coding Initiative & Medically Unlikely Edits Clinical i l Practice Management

2 National Correct Coding Initiative Edits (NCCI) What Are NCCIEdits? NCCI edits are pairs of CPT or HCPCS Level II codes that are not separately payable except under certain ti circumstances. The edits are applied to services billed by the same provider for the same beneficiary on the same date of service. All claims are processed against tncci tables. tbl

3 Two Types of Edits Arranged by Two Sets of Tables I. Column 1/Column2 Correct Coding Edits identifies code pairs that should not be billed together because one service is an integral part of the other or should not be reported together for other reasons II. Mutually Exclusive Edits identifies code pairs that, for clinical reasons, are unlikely to be performed on the same patient on the same day. For example, a mutually exclusive edit might identify two different types of testing that yield equivalent results.

4 Edit Codes All edits consist of code pairs that are arranged in two columns (Column 1 and Column 2) Codes that are listed in Column 2 are not payable if performed on the same day on the same patient by the same provider as the code listed in Column 1 unless the edits permit the use of a modifier associated with NCCI. Column 1 generally represents the major procedure or service and Column 2 often represents the component part of the Column 1 code. However, within the mutually exclusive edits table, the Column 2 code generally represents the procedure or service with the higher work Relative Value Unit (RVU) and is the non payable procedure or service when reported with the Column 1 Code.

5 Indicators Each code pair is assigned a correct coding modifier indicator of 0, 1 or 9. The indicators mean: 0 There are no modifiers associated with NCCI that are allowed to be used with this code pair; there are no circumstances in which both procedures of the code pair should be paid. 1 The modifiers associated with NCCI are allowed with this code pair when appropriate. 9 This indicator means that NCCI edits do not apply to this code pair. The edits have been deleted for this code pair.

6 Column1 generally represents themajor procedure or service and Column 2 often represents the component part of the Column 1 code. However, within the mutually exclusive edits table, the Column 2 code generally represents the procedure or service with the higher work Relative Value Unit (RVU) Example of Edit Codes Modifier 0=not * = In existence prior to Effective Deletion Date allowed 1=allowed 9=not Column 1 Column Date *=no data applicable and is the non payable procedure or service when reported with the Column 1 Code * * * * * 1 The column 1/column 2 correct coding edit table contains two types of code pair edits. One type contains a column 2 (component) code which is an integral part of the column 1 (comprehensive) code. The other type contains code pairs that should not be reported together where one code is assigned as the column 1 code and the other code is assigned as the column 2 code. If two codes of a code pair edit are billed by the same provider for the same beneficiary for the same date of service without an appropriate modifier, the column 1 code is paid. If clinical circumstances justify appending a CCI associated modifier to the column 2 code of a code pair edit, payment of both codes may be allowed.

7 What Goes With What Providers should not report more than one physical medicine and rehabilitation therapy service for the same fifteen minute time period. (The only exception involves a supervised modality defined by CPT codes which may be reported for the same fifteen minute time period as other therapy services.) Some CPT codes for physical medicine and rehabilitation services include an amount of time in their code descriptors. Some NCCI edits pair a timed CPT code with another timed CPT code or a non timed CPT code. These edits may be bypassed with modifier 59 if the two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter. NCCI does not include all edits pairing two physical medicine and rehabilitation services (excepting supervised modality services) even though they should never be reported for the same fifteen minute time period.

8 Re Evaluations NCCI contains edits with column one codes of the physical medicine and rehabilitation therapy services and column two codes of the physical therapy and occupational therapy re evaluation CPT codes of and respectively. The re evaluation services should not be routinely reported during a planned course of physical or occupational therapy. However, if the patient s status should change and a reevaluation is medically reasonable and necessary, it may be reported with ihmodifier 59 appended ddto CPT code or as appropriate.

9 Reporting in Same 15 Minute Time Frame The NCCI edit with column one CPT code (Manual therapy techniques, one or more regions, each 15 minutes) and column two CPT code (Therapeutic activities, direct patient contact, each 15 minutes) is often bypassed by utilizing modifier 59. Use of modifier 59 with the column two CPT code of this NCCI edit is appropriate only if the two procedures are performed in distinctlydifferent different 15 minute intervals. The two codes cannot be reported together if performed during the same 15 minute time interval.

10 Speech Language Pathology Codes Speech language pathologists may perform services coded as CPT codes 92507, 92508, or They do not perform services coded as CPT codes 97110, 97112, 97150, 97530, or which are generally performed by physical or occupational therapists. Speech language pathologists should not report CPT codes 97110, 97112, 97150, 97530, or as unbundled services included in the services coded as 92507, 92508, or

11 Modifiers When applicable, the following modifiers should be applied to the Column 2 code to allow payment when the code pair has a 1 indicator: Anatomical Modifiers: Eye: E1 Upper left eyelid E3 Upper right eyelid E2 Lower left eyelid E4 Lower right eyelid

12 Modifiers Hand: FA Left hand, thumb F1Left hand, second digit F2 Left hand, third digit F3Left hand, fourth digit F4Left hand, fifth digit F5 Right hand, thumb F6Right hand, second digit F7 Right hand, third digit F8Right hand, fourth digit F9Right hand, fifth digit

13 Modifiers Foot: TA Left foot, great toe T1 Left foot, second digit T2 Left foot, third digit T3 Left foot, fourth digit T4 Left foot, fifth digit T5 Right foot, great toe T6 Right foot, second digit T7 Right foot, third digit T8 Right foot, fourth digit T9 Right foot, fifth digit

14 Modifiers Miscellaneous: LC RC LD LT RT Left circumflex, coronary artery Right coronary artery Left anterior descending coronary artery Left side Right side

15 Modifiers Modifier 59: Proper Use of the 59 Modifier: Distinct Procedural Service: The physician may need to indicate that a procedure or service was distinct or separate from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together but are appropriate under the circumstances. This may represent: A different session or patient encounter. Different procedure Different site Separate injury (or area of injury in extensive injuries). This modifier should only be used when any of the other modifiers listed above are not appropriate. it If the code pair has a 0 indicator, payment will not be made for the Column 2 code even if one of the above modifiers is used. The medical record must reflect that the modifier is being used appropriately to describe separate services. The documentation should be maintained in the patient s medical record and made available to Medicare upon request.

16 CCI Facts & Info Billing the Patient for Services Denied Due to NCCI Services that deny based on NCCI edits may not be billed to Medicare beneficiaries. These denials are based on improper coding rather than medical necessity or a Medicare benefit exclusion. The Advance Beneficiary Notice of Non coverage (ABN) form cannot be used to seek payment from the beneficiary. How Often Are the NCCI Edits Changed? The NCCI edits are under constant refinement. Revisions to the NCCI edits are published quarterly.

17 CCI Facts & Info National Correct Coding Initiative Policy Manual The National Correct Coding Initiative Policy Manual includes policy narratives thatdescribe the principles used to develop edits and also provides examples. The manual includes the coding policies, as well as 13 narrative chapters. Each chapter corresponds to a separate section of the CPT book; one chapter addresses HCPCS. Level II codes and another, the Category III codes. Each chapter is subdivided by subject to allow easier access to a particular code or group of codes.

18 How to Obtain a National Correct Coding Initiative i i Policy Manual The NCCI edits and National Correct Coding InitiativePolicy Manual may be downloaded free from the CMS Web site at: p#topofpage Th N i lt h i li f i S i (NTIS) l b The National Technical Information Service (NTIS) may also be contacted at (800) or (703)

19 What Is an MUE? An MUE is defined as an edit that tests claim lines for the same beneficiary, HCPCS code, date of service and billing provider against a criteria number of units of service. These MUEs will auto deny claim li line items containing tii units of service billed in excess of the MUE criteria.

20 MEDICALLY UNLIKELY EDITS (MUEs) To lower the Medicare fee for service paid claims error rate, CMS established units of service edits referred to as Medically Unlikely Edits (MUEs). The National Correct Coding Initiative (NCCI) contractor develops and maintains MUEs. This set of edits is based on anatomical considerations and addresses approximately 2,800 codes. Although CMS publishes most MUE values, other MUE values are aeconfidential and dae are not published for public viewing.

21 Reporting Medically Reasonable and Necessary Units in Excess of an MUE Value Since each line of a claim is adjudicated di d separately tl against tthe MUE value for the code on that line, the appropriate use of CPT modifiers to report the same code on separate lines of a claim will enable a provider to report medically reasonable and necessary units of service in excess of an MUE value. See the following modifiers to report these types of services: 76 modifier: Repeat procedure by the same physician. 77 modifier: Repeat procedure by another physician. 91 modifier: Repeat clinical diagnostic laboratory test. Anatomical modifier (e.g., RT, LT, F1, F2). 59 modifier: The 59 modifier should be utilized only if no other modifier describes the service.

22 DME MUE Table Updates Billing Patients How to Obtain Practitioner/DME Supplier Table The table listing codes and values (number of units that may be billed) can be found at asp#topofpage. How Often Are the MUE Tables Updated? The MUE values are updated dtdquarterly. Billing the Patient for Services Denied Due to the MUEs Charges gesthat ataede are denied ed to units in excess ecessof the MUEs Usmay not be billed to the beneficiary. The Advance Beneficiary Notice of Non coverage (ABN) form cannot be used to seek payment from the beneficiary.

23 NCCI and Medically Unlikely Edits NCCI Page on the CMS Web Site

24 NCCI and Medically Unlikely Edits

25 NCCI and Medically Unlikely Edits Example of Column 1/ Column 2 Edits The procedure code listed in Column 2 will deny if billed on the same day for the same beneficiary by the same provider as in Column 1. Refer to the modifier column to determine if the procedure may be allowed separately with a modifier.

26 CMS Web Pages of Tables NCCI Page on the CMS Web Site MUE Page on the CMS Web Site

27 Provider Concerns Physicians who want to submit a request for reconsideration of an MUE value should address their concerns to the address listed dbl below. National Correct Coding Initiative Correct Coding Solutions, LLC P.O. Box 907 Carmel, IN Fax: (317) If you have Concerns about the MUE program, other than MUE values for specific codes, contact Valeria Allen valeria.allen@cms.hhs.gov

28 REVISION HISTORY Date Description September 2007 Removed the information about Medically Unlikely Edits (MUEs) December 2008 July 2009 updates. Per Joint Signature Memorandum (JSM)08510, updated the MUE information. Added information regarding MUE values and reporting medically reasonable and necessary units in excess of an MUE value.

29 National Correct Coding Initiative & Medically Unlikely Edits The End