Did you know most private insurance use
the NCCI edits for automatic system denials?
What
is the Medicare National Correct Coding Initiative (NCCI)?
The
Medicare National Correct Coding Initiative (NCCI) (also known as CCI) was
implemented to promote national correct coding methodologies and to control
improper coding leading to inappropriate payment. NCCI Procedure-to-Procedure
(PTP) code pair edits are automated prepayment edits that prevent improper
payment when certain codes are submitted together.
In
addition to PTP code pair edits, the NCCI includes a set of edits known as
Medically Unlikely Edits (MUEs). An MUE is a maximum number of Units of Service
(UOS) allowable under most circumstances for a single Healthcare Common
Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) code billed
by a provider on a date of service for a single beneficiary.
NCCI
tables and manual can be found under the following links.
Why
Would a Health Care Professional, Supplier, or Provider use the NCCI edits tool?
Accurate
coding and reporting of services are critical aspects of proper billing. The
NCCI tools help providers avoid coding and billing errors and subsequent
payment denials. It is important to understand, however, that the NCCI does not
include all possible combinations of correct coding edits or types of
unbundling that exist. Providers are obligated to code correctly even if edits
do not exist to prevent use of an inappropriate code combination.
How
the NCCI coding decision are made?
Coding
decisions for edits are based on conventions defined in the American Medical
Association’s (AMA’s) “CPT Manual,” national and local policies and edits,
coding guidelines developed by national societies, analysis of standard medical
and surgical practices, and a review of current coding practices. Prior to the
implementation of MUEs, the proposed edits are released for review and comment
to the AMA, national medical/surgical societies, and other national health care
organizations, including non-physician professional societies, hospital
organizations, laboratory organizations, and durable medical equipment
organizations. Similarly, proposed PTP code pair edits are released to various
national health care organizations for review and comment prior to
implementation.
MODIFIERS
The
PTP code pair edit simply represents two codes that should not be reported
together, unless an appropriate modifier is used. Many procedure codes should
not be reported together because they are mutually exclusive of each other.
Mutually exclusive procedures cannot reasonably be performed at the same
anatomic site or same beneficiary encounter.
Modifiers
24 – 25 – 57 – 59 are used for separate reimbursement of a service. These
modifiers generally bypass claims systems edits. The use of this modifiers must
be substantiated in the medical records. 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 a PTP code pair edit if
the clinical circumstances do not justify its use.
The
CPT Manual defines these modifiers as follows:
Modifier 24 = “Unrelated
evaluation and management service by the same physician or other qualified
health care professional during a postoperative period”
The
E/M service was performed during the postoperative period of a major surgery
but for a reason unrelated to the original procedure. If the diagnosis codes is
not a clear indication that the visit was unrelated to the surgery, supporting
documentation specifying the 'reason' the visit was unrelated must be submitted
with the claim.
Modifier 25 = “significant,
separately identifiable evaluation and management service by the same physician
or other qualified health care professional on the same day of the procedure or
other service”
Modifier
25 may be appended to an evaluation and management (E&M) CPT code to
indicate that the E&M service is significant and separately identifiable
from other services reported on the same date of service. The E&M service
may be related to the same or different diagnosis as the other procedure(s).
Modifier
25 may be appended to E&M services reported with minor surgical procedures
(global period of 000 or 010 days) or procedures not covered by global surgery
rules. Since minor surgical procedures includes pre-procedure, intra-procedure,
and post-procedure work inherent in the procedure, the provider should not
report an E&M service for this work.
Modifier 57 = “Decision
for surgery”
Evaluation/Management
(E/M) services on the day before major surgery or on the day of major surgery
that result in the initial decision to perform the surgery are not included in
the global surgery payment for the major surgery. Therefore, these services may
be billed and paid separately. In addition to the CPT E/M code, modifier “-57” (Decision
for surgery) is used to identify a visit that results in the initial decision
to perform surgery. The modifier “-57” is not used with minor surgeries because
the global period for minor surgeries does not include the day prior to the
surgery. When the decision to perform the minor procedure is typically done immediately
before the service, it is considered a routine pre-operative service and a
visit or consultation is not billed in addition to the procedure. Insurance
companies may not pay for an E/M service billed with the CPT modifier “-57” if
it was provided on the day of, or the day, before a procedure with a 0 or 10 day
global surgical period.
Modifier 59 = “Distinct
Procedural Service”
Modifier
59 is an important NCCI-associated modifier that is often used incorrectly.
Under
certain circumstances, it may be necessary to indicate that a procedure or
service was distinct or independent from other non-E/M services performed on
the same day. Modifier 59 is used to identify procedures/services, other than
E/M services, that are not normally reported together, but are appropriate
under the circumstances. Documentation must support a different session,
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
individual.
Note: Modifier 59
should not be appended to an E/M service.
Common
appropriate uses;
·
Different
anatomic sites during the same encounter only when procedures which are not
ordinarily performed or encountered on the same day are performed on different
organs, or different anatomic regions, or in limited situations on different,
non-contiguous lesions in different anatomic regions of the same organ. The
treatment of contiguous structures in the same organ or anatomic region does
not constitute treatment of different anatomic sites. (Example; Arthroscopic
treatment of structures in adjoining areas of the same shoulder constitutes
treatment of a single anatomic site)
·
Modifier
59 is used appropriately when the procedures are performed in different
encounters on the same day. For surgical procedures, non-surgical therapeutic procedures,
or diagnostic procedures that are performed during different patient encounters
on the same day and that cannot be described by one of the more specific
modifier.
RECOMMENDATIONS
I recommend that you carefully review the
chapters of the NCCI manual that pertain to the code ranges you most often
bill. These chapters include detailed information about correct coding and use
of NCCI-associated modifiers for separately reportable services, and much more.
This is the first step to end insurances denials
and the correct road for COMPLIANCE.
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