MEDICAL ASSISTANCE BULLETIN
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1 ISSUE DATE September 12, 2014 SUBJECT EFFECTIVE DATE September 15, 2014 MEDICAL ASSISTANCE BULLETIN NUMBER BY Implementation of National Correct Coding Initiative Related Modifiers Vincent D. Gordon, Deputy Secretary Office of Medical Assistance Programs PURPOSE: The purpose of this bulletin is to inform providers the Department of Public Welfare (Department) will begin accepting National Correct Coding Initiative (NCCI) -to- (PTP)-associated modifiers that are not currently recognized by the Medical Assistance (MA) Program. These changes must be implemented to support the Centers for Medicare and Medicaid Services (CMS) NCCI program. These changes are effective for dates of service on and after September 15, SCOPE: This bulletin applies to MA enrolled providers who render services to beneficiaries in the MA fee-for-service (FFS) delivery system and submit professional and outpatient claims as indicated in Attachment A of this bulletin. This bulletin does not apply to providers who render services to MA beneficiaries in the HealthChoices managed care delivery system. Providers rendering services to beneficiaries in the MA managed care delivery system should address any coding or billing questions to the appropriate managed care organization. BACKGROUND: The Patient Protection and Affordable Care Act (ACA) of 2010 mandated the implementation of the NCCI. CMS issued State Medicaid Director Letter # on September 1, 2010, identifying two types of NCCI edits to be applied to services performed by the same provider for the same beneficiary on the same date of service, regardless of whether services are reported on the same claim or on different claims. The two types of edits are: (1) NCCI PTP edits - These edits define pairs of Healthcare Common Coding System (HCPCS) / Current Procedural Terminology (CPT) codes that should not be reported together. COMMENTS AND QUESTIONS REGARDING THIS BULLETIN SHOULD BE DIRECTED TO: The appropriate toll free number for your provider type Visit the Office of Medical Assistance Programs Web site at
2 2 (2) Medically Unlikely Edits (MUE) units-of-service edits - These edits define for each HCPCS / CPT code the number of units beyond which the reported number of units is unlikely to be correct. The Department implemented NCCI program edits in two phases. The first phase was implemented on December 1, 2011, and is addressed in MA Bulletin titled Announcing the Federally Mandated Implementation of the National Correct Coding Initiative (NCCI) in the Pennsylvania Department of Public Welfare s Medical Assistance Program. This phase included NCCI -to- (PTP) code pairs that are subject to Incidental and Mutually Exclusive coding policies and editing as defined by CMS. Edit definitions are identified in the bulletin. The second phase was implemented on November 1, 2012, for claims received on or after November 1, 2012, and is addressed in MA Bulletin titled Federally Mandated Implementation: Updates to National Correct Coding Initiative (NCCI). This phase incorporated Medically Unlikely Edits or units of service limits as defined by CMS. This phase also included edit message updates that are identified in the bulletin. While the types of NCCI program edits have not changed, CMS has added new program requirements and expanded claims adjudication rules including providing specific guidance for the implementation and use of NCCI related modifiers. These requirements are outlined in the most current version of the Medicaid NCCI Edit Design Manual located on the CMS National Correct Coding Initiative (NCCI) in Medicaid website and can be viewed by accessing the following link: Systems/National-Correct-Coding-Initiative.html DISCUSSION: This bulletin addresses the federally mandated requirement that every state must incorporate into its Medicaid Management Information System (MMIS) NCCI PTP-associated modifiers for HCPCS codes and CPT codes. CMS permits the use of NCCI PTP-associated modifiers when: Based on clinical circumstances; and, Used in accordance with HCPCS/CPT Manual instructions and definitions for the procedure code combination reported. A complete listing of all NCCI PTP-associated modifiers is identified in Attachment B of this bulletin. CMS indicates in their quarterly edit files which code pairs are eligible for an edit bypass when an NCCI PTP-associated modifier is reported. As a result, a modifier may be used in conjunction with a procedure code to allow for payment of both services within a code pair; however, MA policy will continue to be utilized in claims processing logic and any decision
3 making processes. This will ensure that services are processed in accordance with the most current regulations to prevent incorrect payment of claims. The NCCI PTP-associated modifiers are as follows: Anatomical modifiers: RT, LT, *E1, *E2, *E3, *E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, *LC, *LD, *LM, *RC, *RI Non-anatomical modifiers: *24, *25, *27, *57, *58, *59, *78, *79, 91 3 *Denotes the NCCI PTP-associated modifiers that are not currently recognized by MA. The following anatomical modifiers should be reported with the procedure codes indicated below. The modifiers will not affect the claim payment amount; however, failure to use these modifiers could result in a claim delay or denial. s Modifiers s Modifiers E2, E E2, E E1, E E1, E LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E E1, E E1, E E1, E E1, E E1, E E1, E3
4 67911 E1, E2, E3, E E1, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E2, E E1, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E E1, E2, E3, E LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI LC, LD, LM, RC, RI 4
5 93567 LC, LD, LM, RC, RI LC, LD, LM, RC, RI 5 The following procedure codes will have modifiers right (RT), left (LT) and bilateral (50) enddated because they are being replaced with the appropriate anatomical modifier as indicated above. s Modifier 24 and modifier 25 may be reported with the following procedure codes for the provider type/specialty () combinations indicated below: /180 31/ / / /180 31/ Modifier 27 may be reported with the following procedure codes for the combinations indicated below: / / / / / / / / / / /017 Modifier 57 may be reported with the following procedure codes for the combinations indicated below:
6 / / Modifier 59 may be reported with the procedure codes indicated below: G0462 V5014 Modifier 78 may be reported with the following procedure codes for the combinations indicated below:
7
8 /318 31/ /318 31/ /318 31/ /318 31/ /318 31/
9 /318 31/319 31/ /318 31/ / / / / / /
10 /311 31/318 31/319 31/336 31/ / / /140 G0458 Modifier 91 may be reported with procedure code G0462. PROCEDURE: Effective for dates of service on and after September 15, 2014, the Department will allow the submission of NCCI PTP-associated modifiers with the procedure codes indicated above. If CMS adds or expands NCCI program requirements related to the use and implementation of modifiers, that information will be included in an updated bulletin. If the Department makes any changes to the use and implementation of modifiers, that information will also be included in an updated bulletin. CMS has not provided specific guidance to indicate modifiers can be reported with procedure codes subject to MUE s. Reminders Providers should use the MA Program Fee Schedule, as well as the appropriate coding manuals and clinical guidelines, to ensure that claims are submitted with the correct procedure codes and modifiers for the service provided to reduce unnecessary claim denials and ensure correct payment of services. Please note: Current MA procedures surrounding the payment and reimbursement amount for services submitted with a valid NCCI related modifier will remain the same. The requirements in the billing guidelines and claims processing time-frames will not be affected by the implementation of NCCI related modifiers. In addition, claims will continue to be subject to the appropriate edits and audits to ensure that services are
11 11 processed in accordance with the most current, appropriate regulations to prevent incorrect payment of claims. Modifier 50 identifies a procedure that is performed bilaterally. This modifier is currently recognized by MA and its usage has not changed as outlined in QuickTip #68 titled Using the 50 Modifier on Medical Assistance (MA) Claims. Attachment A: NCCI Claims Criteria Attachment B: NCCI PTP-associated Modifiers and Descriptions REFERENCES AND RESOURCES: CMS National Correct Coding Initiative (NCCI) in Medicaid website: Systems/National-Correct-Coding-Initiative.html
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