Proper Use of NCCI Edits and Modifiers Across Departments: Ensuring Compliant Billing Processes

Transcription

1 Proper Use of NCCI Edits and Modifiers Across Departments: Ensuring Compliant Billing Processes Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS

2 Speaker Info Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS Sarah Goodman is president/ceo and principal consultant for SLG, Inc., of Raleigh, NC, and a participating partner with ChargemasterCare of Portland, OR. She is a nationally known speaker and author on the charge description master, outpatient facility coding, and billing compliance, and has more than 28 years of experience in the healthcare industry. Sarah has been actively involved and held leadership roles in a number of professional organizations on the local, state, and national levels. **Certificates of attendance and CEUs, when available, must be requested through the online evaluation.** Evaluation for Live Event: We d like to hear what you thought about the audio conference. Please take a moment to fill in the survey located here: Requests for continuing education credits and certificates of attendance must be submitted within 10 days of the live event. Evaluation for CD Recording: Please use the following link to submit your evaluation of the recorded event: Please note: All links are case sensitive

3 Proper Use of NCCI Edits and Modifiers Across Departments: Ensuring Compliant Billing Processes C4CM Webinar presented by Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS February 10, 2014 About the Speaker Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS is president/ceo and principal consultant for SLG, Inc., of Raleigh, NC, and a participating partner with ChargemasterCare of Portland, OR. She is a nationally known speaker and author on the charge description master, outpatient facility coding, and billing compliance, and has more than 28 years of experience in the healthcare industry. Sarah has been actively involved and held leadership roles in a number of professional organizations on the local, state, and national levels. 2 1

4 Disclaimer Every reasonable effort has been taken to ensure that the educational information provided in today s presentation is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility situation. 3 Agenda Overview of NCCI edits, including add-on codes and medically unlikely edits Suggestions for determining when to use modifiers to override NCCI edits Highlights of compliance risks associated with NCCI edits and associated modifiers Discussion of some of the NCCI changes for 2014 Identification of applicable NCCI edits across multiple departments Q&A session 4 2

5 Overview of NCCI Edits So, what exactly is the National Correct Coding Initiative (NCCI)? The NCCI was developed by CMS to prevent inappropriate payment of services when incorrect code combinations are reported, i.e., codes that should not be billed by the same provider for the same patient on the same date of service. NCCI edits are used by Medicare carriers and other payers in adjudicating claims. Information about the edits can be found on the CMS Web site at the following link. 5 NCCI Toolkit Overview of NCCI Edits CMS has published a very helpful guide to assist in navigating and understanding the Medicare NCCI tools. MLN/MLNProducts/Downloads/How-To-Use-NCCI-Tools.pdf 6 3

6 Types of Edits Overview of NCCI Edits NCCI includes three types of edits: NCCI Procedure-to-Procedure (PTP) edits, Medically Unlikely Edits (MUE), and Add-on Code Edits. Procedure-to-Procedure (PTP) Edits These prevent inappropriate payment of services that should not be reported together. Each edit has a column one and column two HCPCS code. If a provider reports the two codes of an edit pair for the same beneficiary on the same date of service, the column one code is eligible for payment but the column two code is denied unless a clinically appropriate NCCI-associated modifier is also reported. 7 Overview of NCCI Edits Types of Edits (continued) Add-on Code Edits These are codes that are eligible for payment if and only if one of their primary codes is also eligible for payment. Listings of such HCPCS add-on codes with their respective primary codes may be found in CMS Transmittal 2636, CR Medically Unlikely Edits (MUEs) These prevent payment for an inappropriate number/quantity of the same service on a single day. An MUE for a given HCPCS code is the maximum number of units of service which may be reported by the same provider for the same beneficiary on the same date of service

7 Procedure-to-Procedure (PTP) Edits The PTP edits used to consist of two tables: Column One/Column Two Correct Coding Edit Table and Mutually Exclusive Edit Table. However, effective April 1, 2012 with version 18.1, these tables were combined into one file: the Column One/Column Two Correct Coding edit file. The file contains edits which are pairs of HCPCS codes that in general should not be reported together. Each edit has a Column one and Column two HCPCS code. When a provider reports both codes of an edit pair, the Column two code is denied, and the Column one code is eligible for payment. 9 Procedure-to-Procedure (PTP) Edits There are four PTP edit zipped files (current version 20.0) which can be downloaded from the link below: Two for Hospital Outpatient and two for Physician (practitioner) services Each is sorted by the HCPCS in Column One. Keep in mind that the zipped files contain both a spreadsheet and text copy of each file and are rather large (> 10 MB). They may require some assistance from your IT department to bypass firewalls and download

8 Procedure-to-Procedure (PTP) Edits Each PTP edit has one of the following assigned Modifier Indicators: 0 which means that under no circumstances may a modifier be used 1 which means an appropriate NCCI-associated modifier may apply 9 which denotes that the code once had an edit, but the edit pair has been deleted, and is therefore, no longer relevant. 11 Add-on Code Edits An Add-on code is a HCPCS code that describes a service that, with one exception (i.e., if two or more physicians of the same specialty in a group practice provide critical care services to the same patient on the same date of service), is always performed in conjunction with another primary service. Beyond this exception, an add-on code is eligible for payment only if it is reported with an appropriate primary procedure performed by the same practitioner and is never eligible for payment if it is the only procedure reported by a practitioner. A complete list for 2014 can be downloaded from CMS at the link below Code-Edits-Report.zip 6

9 Add-on Code Edits Add-on codes may be identified in three ways: The code is listed in CMS Change Request (CR) 7501 (or subsequent ones) as a Type I, Type II, or Type III add-on code. The add-on code generally has a global surgery period of ZZZ on the Medicare Physician Fee Schedule (MPFS) Database. The add-on code is designated by the symbol + in the CPT Manual. The code descriptor of an add-on code generally includes phrases such as each additional or (List separately in addition to primary procedure) Add-on Code Edits The add-on codes have been divided into three groups to distinguish the CMS payment policy for each group. Type I - A Type I add-on code has a limited number of identifiable primary procedure codes. With the exception of critical care, Type I add-on codes are never paid unless a listed primary procedure code is also paid. 14 7

10 Add-on Code Edits The add-on code groups (continued) Type II - A Type II add-on code does not have a specific list of primary procedure codes. Claims processing contractors are encouraged to develop their own lists of primary procedure codes for this type of add-on codes. Type II add-on codes are never paid unless a listed primary procedure code designated by the contractor is also paid. 15 Add-on Code Edits The add-on code groups (continued) Type III - A Type III add-on code has some, but not all, specific primary procedure codes identified in the CPT Manual. CR 7501 lists the Type III add-on codes with the primary procedure codes that are specifically identifiable. However, claims processing contractors are encouraged to develop their own lists of additional primary procedure codes. 16 8

11 Medically Unlikely Edits (MUEs) An MUE is designed to reduce errors due to clerical entries and incorrect coding based on: anatomic considerations HCPCS/CPT code descriptors and coding instructions established CMS policies nature of a service/procedure, analyte or equipment unlikely clinical treatment An updated list for 2014 can be downloaded from CMS at the link below Medically Unlikely Edits (MUEs) CMS publishes most MUE values on its Web site, but other values are confidential and remain unpublished. MUE values are maintained by CMS Contractors. To suggest alternative MUE value(s) and rationale, write to: National Correct Coding Initiative Correct Coding Solutions, LLC PO Box 907 Carmel, IN Direct questions about the MUE program to: valeria.allen@cms.hhs.gov 18 9

12 Medically Unlikely Edits (MUEs) MUE values are not utilization guidelines. Providers may be subject to a review of their claims even if they report units of service less than or equal to the MUE value for a HCPCS code. A value of 0 (zero) units assigned to an MUE identifies those codes that have been discontinued for 2014 (or prior) or that Medicare does not cover or has terminated coverage. Note that not all HCPCS codes have an MUE. 19 Medically Unlikely Edits (MUEs) MUEs affect hospital outpatient departments, physicians and non-physician practitioners, as well as DME suppliers. Examples of MUE allowable units of service include: HCPCS/CPT Code Outpatient Hospital Services MUE Values G G G G G G G G G G G

13 Medically Unlikely Edits (MUEs) CMS FAQ 2281: How are claim lines adjudicated against a Medically Unlikely Edit (MUE) for a repetitive service reported on a single claim line? Some contractors allow providers to report repetitive services performed over a range of dates on a single line of a claim with multiple units of service. If a provider reports services in this fashion, the provider should report the from date and to date on the claim line. Contractors are instructed to divide the units of service reported on the claim line by the number of days in the date span and round to the nearest whole number. This number is compared to the MUE value for the code on the claim line. 21 MUEs vs. PTP Edits Essentially, MUEs are concerned with quantities of HCPCS codes while PTP edits are primarily focused on the combination of codes. However, as with PTP edits, modifiers may be used for reporting units in excess of an MUE. Note that it is possible to trigger both MUE and PTP edits for a given claim depending upon the units of service and combinations of codes reported

14 NCCI Edits and Modifier Usage The National Correct Coding Policy Manual was updated by CMS in January 2014 and Chapter 1 includes instructions on reporting modifiers to bypass bundling edits. According to CMS, there are 40 modifiers that can be used, when appropriate, to bypass bundling guidelines. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used NCCI Edits and Modifier Usage The NCCI bypass modifiers include: Anatomic modifiers: -E1 to -E4, -FA, -F1 to -F9, -TA, -T1 to - T9, -LT, -RT, -LC, -LD, -RC, -LM, -RI Global surgery modifiers: -24, -25, -57, -58, -78, -79 Other modifiers: -27, -59, -91 Note that according to the NCCI Policy Manual 2014, modifiers -76 (repeat procedure or service by same physician) and -77 (repeat procedure by another physician) are not NCCIassociated modifiers and thus they do not bypass NCCI edits

15 NCCI Edits and Modifier Usage Modifier -59 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 or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician NCCI Edits and Modifier Usage Modifier -59 (continued) Modifier -59 may be appended: To imaging, surgical and other services as appropriate. Modifier -59 should not be used: If there is HCPCS Level II modifier that better describes the circumstances (e.g., -TA, -LT or -RT). For example, a surgical procedure performed on different toe digits should more likely be reported using -TA, -T1, -T2, etc. Just to mitigate Outpatient Code Editor (OCE)/NCCI edits. Remember: Always use caution with Modifier -59! 26 13

16 NCCI Edits and Modifier Usage Modifier -59 (continued) Due to the fact it is often misused, the OIG has published guidance on use of this modifier NCCI Edits and Modifier Usage Modifier -59 (continued) Although not recommended, modifier -59 is sometimes hard-coded in the chargemaster (CDM). Generally, this is seen in Rehab, Lab and Wound Care. If this is the case, then be certain there is a set of codes with modifier -59 and a set without. Otherwise, compliance issues will ensue. Description HCPCS UB-04 RC DEBRIDE SQ TISS <20SQCM DEBRIDE SQ TISS <20SQCM PT THER PROC/EXER EA 15M PT THER PROC/EXER EA 15M

17 NCCI Edits and Modifier Usage Modifier -25 Modifier -25 may be used to indicate a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. Note that the same physician/practitioner does not have to conduct the procedure and the E/M service in order for modifier -25 to apply in the facility setting. What is important is that the same facility provided the procedure and the E/M service. 29 NCCI Edits and Modifier Usage Modifier -25 (continued) Modifier -25 should be used in conjunction with: E/M service codes within the range of , , and with HCPCS codes G0101 and G0175 as well as G0463, which replaced codes (new patient visit) and (established patient visit) and is assigned to APC 0634 as of January 1, Procedure codes having a payment status indicator of S or T under the Outpatient Prospective Payment System (OPPS) to avoid triggering an Outpatient Code Editor (OCE) edit. Remember: Modifier -25 is appended to the E/M code, not the procedure

18 NCCI Edits and Modifier Usage Modifier -25 (continued) Reference: Per the Medicare Claims Processing Manual (Chapter 12, 40.1 C), Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status. 31 NCCI Edits and Modifier Usage Modifier -25 (continued) Note as the MCPM states, it is important to determine the intent of the visit before making the decision to assign an E/M code with modifier -25. Example: A 35-year-old female patient presents to the ED for evaluation after a minor MVA and facility E/M guidelines arrive at Level 4 ED service. During the visit, it is determined that the patient requires simple repair of a 2.0 cm laceration of the scalp. Report codes: (Emergency department visit, Level 4) and (Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities; 2.5 cm or less). 42 REV.CD. 43 DESCRIPTION 44 HCPCS / RATE / HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES EMERGENCY DEPARTMENT VISIT REPAIR SUPERFICIAL WOUND(S)

19 NCCI Edits and Modifier Usage Modifier -25 (continued) Due to the fact it is often misused, the OIG has published extensive guidance on use of this modifier NCCI Edits and Modifier Usage Modifier -25 (continued) Modifier -25 is sometimes hard-coded in the chargemaster (CDM). Generally, this is seen in the ED and clinics. If this is the case, then be certain there is a set of codes with modifier -25 and a set without. Otherwise, compliance issues will ensue. Description HCPCS UB-04 RC ED VISIT LEVEL ED VISIT LEVEL ED VISIT LEVEL ED VISIT LEVEL ED VISIT LEVEL ED VISIT LEVEL 1 WITH PROC ED VISIT LEVEL 2 WITH PROC ED VISIT LEVEL 3 WITH PROC ED VISIT LEVEL 4 WITH PROC ED VISIT LEVEL 5 WITH PROC

20 NCCI Edits and Modifier Usage Modifier -91 Modifier -91 is for repeat clinical diagnostic laboratory procedures. Note that each service repeated must be medically necessary, i.e., by physician order to obtain subsequent reportable test values. Modifier -91 should not be used: for poor specimen collection to validate original results for stat results when the original has not yet been received if another code can be used to capture all the services (e.g., GTT) 35 NCCI Edits and Modifier Usage Modifier -91 (continued) The documentation should indicate that the lab procedure was distinct or separate from other lab services performed on the same day. For panel testing, NCCI contains edits pairing each panel code (column one code) with the corresponding individual laboratory tests that are included in the panel (column two code). Refer to the Internet-Only Manuals (IOM), Medicare Claims Processing Manual, Publication , Chapter 16, Section , for more information

21 NCCI Edits and Modifier Usage Modifier -91 vs. -59 CPT Assistant, June 2002, attempts to clarify when modifier -59 vs. -91 should be used. Basically, modifier -59 should be reported when different types of specimens are obtained and can be used if the tests are run simultaneously, concurrently, or in separate sessions on the same date in order to obtain multiple results. Modifier -91 would be used when the physician specifically wants to repeat the same lab test, same specimen type at a later time on the same date to see if the result is different. Remember: Modifier -59 or -91 should be appended to the subsequent services. 37 NCCI Edits and Modifier Usage When determining when or whether to use a modifier, ask: Are there bundling edits based on HCPCS or NCCI guidelines? If not, is there a coding guideline preventing both from being reported together? Was the procedure distinct from other procedures (different site, session, diagnosis, etc.)? Does the NCCI edit have a modifier indicator of 0? Is there a better or more specific modifier than modifier -59? 38 19

22 NCCI Edits and Modifier Usage Stay in compliance with NCCI by: Ensuring HCPCS codes are billed using NCCI-associated modifiers only when they are unbundled to indicate that the physician performed them on different sites/organ systems, through a separate incision/excision, in a separate compartment, or during a separate encounter. Note that unbundled procedures are a focus issue for the Recovery Audit Program. Reviewing commercial and contract payer policies as many have also developed specific modifier guidelines to minimize fraud and abuse. Remember: Ensure documentation supports billed charges NCCI Edit Changes Changes in the NCCI Policy Manual 2014 are noted in red italicized font. The zipped file contains a Table of Contents, an Introduction, a general coding policies chapter and twelve additional chapters based upon HCPCS ranges. The next few slides highlight some of the changes for 2014 and how to handle them

23 2014 NCCI Edit Changes Imaging PTP Example Source: NCCI Policy Manual 2014, Chapter IX NCCI Edit Changes Imaging PTP Example (continued) So, what does this mean? Well, for instance, if a breast localization is performed under mammographic guidance, a mammogram to verify placement of the clip cannot also be reported. If a mammogram is performed during a different session on the same date, e.g., in the morning and as a result, a breast procedure is scheduled later in the day, then reporting with a modifier may be appropriate. Column 1 Column 2 Modifier Indicator Active Effective Date Policy Statement Column1 Column2 Category Category /01/2014 HCPCS/CPT procedure code definition Surgery Radiology /01/2014 HCPCS/CPT procedure code definition Surgery Radiology /01/2014 HCPCS/CPT procedure code definition Surgery Radiology 42 21

24 2014 NCCI Edit Changes Laboratory MUE Example Source: NCCI Policy Manual 2014, Chapter X NCCI Edit Changes Laboratory MUE Example (continued) So, how would this be reported on a claim? Well, first, bear in mind that G0452 is a professional fee only. It should be reported on a CMS-1500, not a UB-04. However, the facility should report the related molecular pathology services (e.g., Tier 1 or Tier 2), as appropriate. Secondly, look to the specific NCCI Policy Manual chapter, as sometimes, the guidance clearly indicates how to report. In this instance, modifier -59 is suggested to bypass the NCCI MUE edit. Refer to such guidance on the next slide

25 2014 NCCI Edit Changes Laboratory MUE Example (continued) Source: NCCI Policy Manual 2014, Chapter X NCCI Edit Changes Cardiovascular Medicine Add-on Example Source: NCCI Policy Manual 2014, Chapter XI

26 2014 NCCI Edit Changes Cardiovascular Medicine Add-on Example (continued) Referring back to the Type I add-on edit file, code is listed along with its related primary codes. TYPE I - CPT MANUAL DEFINES ALL ACCEPTABLE PRIMARY CODES (BASED ON 2014 CPT MANUAL, INTERNET-ONLY MANUAL, MEDICARE CLAIMS PROCESSING MANUAL) ADD-ON CODE PRIMARY CODE(S) , 93612, 93619, 93620, 93653, 93654, Code-Edits-Report.zip NCCI Edit Changes Surgery Hospital Outpatient Dept vs. ASC MUE Example Source: NCCI Policy Manual 2014, Chapter VI

27 2014 NCCI Edit Changes Surgery Hospital Outpatient Dept vs. ASC MUE Example (continued) Sometimes the place of service can impact how a procedure is reported and/or what modifier(s) may apply. When it comes to surgical services, CMS advises use of modifier -50 for surgical procedures reported by hospitals and physicians, but the -RT/-LT modifiers in a freestanding Ambulatory Surgery Center (ASC) setting NCCI Edit Changes Contrast Material MUE Example Source: NCCI Policy Manual 2014, Chapter XII

28 2014 NCCI Edit Changes Contrast Material MUE Example (continued) As mentioned earlier in the presentation, some items and services have an MUE value of 0 (zero). Often this means the code has been discontinued or is not covered under Medicare. In this instance, however, code Q9951 (Low osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml) was assigned a 0 value due to its frequent misuse. 51 NCCI Issues Across Departments Chargemaster (CDM) driven coding and units of service: The CDM drives the quantities of certain services, particularly for pharmaceuticals. It is not uncommon for chargemasters to contain a quantity or multiplier field for base doses of HCPCS-coded drugs. Note that this is an OIG and RAC target area and must be used with caution. Triggering an MUE edit may be the first signal that something may be incorrect in the CDM

29 NCCI Issues Across Departments Staff-reported coding and units of service: While the CDM may be setup correctly, errors can still be generated due to staff input of inappropriate units of service or as a result of some codes being hardcoded in the CDM and subsequently soft-coded by HIM. For example, CPR has an MUE value of 4 units. If everyone responding to a code inputs a charge for rather than 1 unit for the entire episode, then an MUE edit may be triggered even though it is correct in the CDM. 53 Summary When it comes to NCCI, here are some tips to keep in mind: Monitor quarterly published NCCI PTP edits and MUEs Review the How to Use the Medicare National Correct Coding Initiative (NCCI) Tools guide Log claim edits triggered by unpublished MUEs Know what modifiers may be used and when Work with department staff to ensure compliant charge capture 54 27

30 Q&A Session Thank you for joining in today s presentation! 55 28