How to Use The National Correct Coding Initiative
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Transcript How to Use The National Correct Coding Initiative
How to Use The National Correct
Coding Initiative (NCCI) Tools
Presented by Lori Dafoe, CPC
Agenda
How it Impacts You
NCCI History and Definition
Using the NCCI Tools/AAPC Coder
Real Life Examples
Resources
Why Use It?
Accurate coding and reporting is a critical aspect of proper
billing.
Helps providers avoid coding and billing errors and
subsequent payment denials.
Service denied on NCCI code pair edits or MUEs may not be
billed to Medicare beneficiaries.
Provider cannot utilize an ABN to seek payment from a
Medicare beneficiary.
Background and History
NCCI was originally developed for Medicare in 1996
Founded on Coding Policies
NCCI Website
http://www.cms.gov/Medicare/Coding/NationalCorrectC
odInitEd/index.html
What are “code pair edits”?
NCCI code pair edits are automated prepayment edits that
prevent improper payment when certain codes are submitted
together for Part B-covered services.
Column I and Column II
Column I and Column II Procedures should be reported with
the most comprehensive CPT code that describes the
services performed.
Physicians must not unbundle or report multiple Healthcare
Common Procedure Coding System (HCPCS)/CPT codes
when a single comprehensive code describes the services that
were furnished.
NCCI Table Example
Modifier Indicator Table
Mutually Exclusive Edits
Procedure codes that cannot be reported together because
they are mutually exclusive of each other.
Mutually exclusive procedures cannot reasonable be
performed at the same anatomic site or same patient
encounter.
Two or more procedures performed during the same patient
encounter on the same date of service and the same billing
provider that are not normally performed together.
Medically Unlikely Edits (MUEs)
HCPCS/CPT’s have a defined unit of service for reporting
purposes.
Providers that bill units of service for a HCPCS/CPT code
using a criteria that differs from the code’s defined unit of
service will experience a denial.
MUE editing is based on the edits of service allowed on the
claim, not the units of service billed.
Use of Modifiers
Modifiers may be appended to HCPCS/CPT codes only
when clinical circumstances justify the use of the modifier.
A modifier should not be appended to a HCPCS/CPT code
solely to bypass NCCI editing.
The use of modifiers affects the accuracy of:
Claims billing
Reimbursement
NCCI editing
Clarification of procedures
Modifiers Allowed with CCI
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 allowed:
59, 91
NCCI Edits and How they Work
Type I
NCCI Code Pair Edits
(Procedure – to -Procedure)
Type II
Medically Unlikely Edits
(MUEs)
Mutually Exclusive Procedures
Example : Column I / Column II Code 11719 / 11720
CPT 11719
(Column I)
Trimming of non-dystrophic nails, any number
CPT 11720
(Column II)
Debridement of nail(s) by any method(s); one to
five
1 = modifier
allowed
Policy: Modifier -59 is allowed if appropriate documentation is present.
CPT Coding Manual
Instruction/Guideline
Example: Column I / Column II Code 17000 / 11000
CPT 17000
Column I
CPT 11100
Column II
Destruction, premalignant lesion; first
Biopsy of skin, single
lesion
1 = modifier
allowed
Policy: Modifier -59 is allowed if appropriate documentation is
present.
More Extensive Procedure
Example: Column I Code/Column II code 45385/45380
CPT 45385
Column I
Colonoscopy, flexible, proximal to
splenic flexure; w/removal of
tumor(s), polyp(s), or other lesion(s)
by snare technique
1 = modifier
allowed
CPT 45380
Column II
Colonoscopy, flexible, proximal to
splenic flexure; with biopsy, single or
multiple
Policy: Modifier -59 is allowed if appropriate documentation is present.
How to Locate NCCI Tables and Manual
Code pair edits, MUE tables, and NCCI manual
are accessed on the CMS website at
http://www.cms.gov/Medicare/Coding/National
CorrectCodInitEd/index.html
How to Use the NCCI Tools
NCCI Policy Manual for Medicare Services
Modifier -59 Article: Proper Usage
NCCI Example
Column1/Column 2 Edits
Column 1 Column 2
32555
76942
* = In existence prior
Effective Date
to 1996
20130101
Deletion
Date
*=no data
Modifier
0=not allowed
1=allowed
9=not
applicable
*
1
Don’t Get Bungled Up by Bundled Codes
Clinical Example:
CPT 32555 & CPT 76942
To Bundle, or Not to Bundle?
Modifier -59, CPT Manual Definition
Different session
Different 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.
Example Appeal, Modifier 59
To Whom It May Concern.:
The following information is being provided to clarify our use of the CPT modifier 59 reported with [procedure name] CPT [code]
to indicate that the services are not typically performed together and warrant separate reimbursement.
The CPT modifier 59 was developed by the American Medical Association explicitly for the purpose of identifying services not
typically performed together. According to CPT codes, guidelines and conventions, CPT modifier 59 is appended to indicate that
under certain circumstances the physician may need to indicate that a procedure or service was distinct or independent from
other services performed on the same day. According to the CPT Book, “Modifier 59 is used to identify procedures/services that
are not normally reported together, but are appropriate under these circumstances.” [reason procedure or service was performed.]
The appropriateness of appending modifier 59 on CPT [procedure code] is clearly documented within the patient’s chart and should
be recognized by [health plan].
Based on the circumstances of this case, we are requesting that CPT code [code] be considered for separate reimbursement and
not bundled under payment for the procedure. Please forward this information to your medical review staff for an independent
determination to prevent a computer generated denial based on coding edit software that commonly occurs with CPT modifier
59 claims.
Thank you for your consideration. Please contact [contact name] at [telephone number] in our office should you have any questions
regarding this claim.
Sincerely,
http://www.aapc.com/login.aspx?r=http://www.aapc.com/index.aspx
Let’s Practice!!
Coding Scenario 1:
Yes!
-59
Append to CPT 11100 (Column II Code).
Rationale: Excision of malignant lesion of face was a separate
site from the two biopsies that were performed (left
ear/helix, and right side of neck.
Coding Scenario 2:
Yes!
-59
Append to CPT 26115 & 26111 (Column II Codes).
Rationale: Excision of tumors were performed on separate
digits, requiring separate incisions and repairs.
Coding Scenario 3:
No!
N/A
N/A
Rationale: Even though this was a separate encounter on the
same date, NCCI edits do not allow for these codes to be
billed together under any circumstances.
Coding Scenario 4:
No!
N/A
N/A
Rationale: The comprehensive metabolic panel includes a
total calcium.
Coding Scenario 5:
Yes!
-59
Append to CPT 11301 (Column II Code).
Rationale: Separate lesions. Shave excision performed foor
lesion on patient’s back, while AK’s were destroyed from the
patient’s face.
THANK YOU!!!!
Don’t forget May MAYnia!
Invite a friend or co-worker!