• Understanding and complying with the National Correct Coding Initiative (NCCI) has just gotten a lot easier!

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  • Understanding and complying with the National Correct Coding Initiative (NCCI) has just gotten a lot easier!

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What can you do about claim denial due to unbundling?

Unbundling continues to be a top claim denial reason for providers. It may be due to the National Correct Coding Initiative (NCCI) which was implemented in 1996.  CMS’ claims payment processing system uses “edits” to identify and reject incorrect combinations of HCPCS procedure codes.

Over 1.6 Million Edits

Know what medical procedures can and cannot be billed together by the same physician in the same session in seconds. Medicare and private payers use NCCI to audit your CPT and HCPCS coding – why not use the same tables they use and lower your audit exposure!

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The National Correct Coding Initiative (NCCI)

Are your claims getting denied for unbundling or incorrect code combinations? It may be due to the National Correct Coding Initiative (NCCI). The NCCI was implemented in 1996 by CMS (formerly HCFA) to identify and eliminate incorrect billing of medical services by looking at all combinations of codes “edits” on a single patient encounter often resulting in a claim denial.

The purpose of the NCCI Procedure-to-Procedure (PTP) edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains one table of edits for physicians/practitioners and one table of edits for outpatient hospital services. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table have been combined into one table and include PTP code pairs that should not be reported together for a number of reasons. The purpose of the NCCI MUE program is to prevent improper payments when services are reported with incorrect units of service.

The National Correct Coding Initiative promotes national correct coding methodologies and reduces improper coding which may result in inappropriate payments of Medicare Part B, Medicaid and private insurance claims.

New for 2017 MUE edits

CMS developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.

What are Correct Coding Initiative (CCI) edits?

Correct Coding Initiative (CCI) edits are pairs of Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Level II codes that are not separately payable except under certain 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 the CCI tables. There are over 1.6 million Edits. An Edit is a pair of two codes.

What are the Column 1/Column 2 Edits?

Although the Column 2 code is often a component of a more comprehensive Column 1 code, this relationship is not true for many edits. In the latter type of edit, the code pair edit simply represents two codes that should not be reported together, unless an appropriate modifier is used. For example, a provider should not report a vaginal hysterectomy code and a total abdominal hysterectomy code together.

Many procedure codes should not be reported together because they are mutually exclusive of each other. Mutually exclusive procedure cannot reasonably be performed at the same anatomic site or beneficiary encounter. An example of a mutually exclusive situation is the repair of an organ that can be performed by two different methods. Only one method can be chosen to repair the organ. A second example is a service that can be reported as an initial service or a subsequent service. With the exception of drug administration services, the initial service and subsequent service cannot be reported at the same beneficiary encounter.

In addition, the descriptor of some HCPCS/CPT codes includes a gender-specific restriction on the use of the code. HCPCS/CPT codes specific to one gender should not be reported with HCPCS/CPT codes for the opposite gender.

What modifiers are allowed with the CCI edits?

Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass an NCCI edit if the clinical circumstances do not justify its use. In the modifier indicator column, the indicator 0, 1, or 9 shows whether an NCCI associated modifier allows the code pair to bypass the edit. The 0 means no modifiers are allowed, the 1 means modifiers may be used when appropriate, the 9 means the edit was deleted retroactively. The following anatomical modifiers are allowed: E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, RC, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9 The following global surgery modifiers are allowed: 25, 58, 78, 79 Other modifiers that are allowed: XE, XP, XS, XU, 59, and 91.

How should modifier “25″ be reported under the CCI?

Modifier “25″ should be appended to an evaluation and management (E/M) code when reported with another procedure on the same day of service. Appending modifier -25 to the E/M code indicates to the carriers or fiscal intermediaries that as a result of the patient’s condition, the physician performed a significant, separately identifiable E/M service above and beyond the other service provided.

How should modifier “59″ be reported under the CCI?

Modifier 59 is used to indicate a distinct procedural service. To appropriately report this modifier, append modifier -59 to the column 2 code to indicate that the procedure or service was independent from other services performed on the same day. The addition of this modifier indicates to the carriers or fiscal intermediaries that the procedure or service represents a distinct procedure or service from others billed on the same date of service. In other words, this may represent a different session, different anatomical site or organ system, separate incision/excision, different lesion, or different injury or area of injury (in extensive injuries).

When used with a CCI edit, modifier -59 indicates that the procedures are different surgeries when performed at different operative areas or at different patient encounters.

How should Modifier “91″ be reported under the CCI?

Modifier 91 should be appended to laboratory procedure(s) or service(s) to indicate a repeat test or procedure on the same day. This modifier indicates to the carriers or fiscal intermediaries that the physician had to perform a repeat clinical diagnostic laboratory test that was distinct or separate from a lab panel or other lab services performed on the same day, and was performed to obtain medically necessary subsequent reportable test values. This modifier should not be used to report repeat laboratory testing due to laboratory errors, quality control, or confirmation of results.

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CorrectCoder for Edits
is being used by providers, administrators, private payers, managed care, HMO/PPO/PHO/TPAs, billing services and health care consultants. With over 1.25 million ”edit pairs” (two codes that cannot be billed by the same day by the same physician), and rules for exceptions (modifier -59)

CorrectCoder for Edits is imperative for full reimbursement.

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