HP Provider Relations October 2010 National Correct Coding Initiative.

HP Provider RelationsOctober 2010

National Correct Coding

Initiative

2 National Correct Coding Initiative October 2010

Agenda

– National Correct Coding Initiative (NCCI)

– NCCI editing

– Correct use of modifiers

– Avenues of resolution


Objectives

– Understand what NCCI is

– Understand who is affected and when the changes will take place

– Understand the use of modifiers

– Understand how to resolve NCCI questions

ChangeNational Correct Coding Initiative implementation


What is it?

National Correct Coding Initiative

– In the 1990s, the Centers for Medicare & Medicaid Services (CMS) developed the NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payment

– NCCI has been in place for many years and most providers are familiar with the editing methodologies used with Medicare

– Based on input from a variety of sources:• American Medical Association (AMA) Current Procedural Terminology (CPT®)

guidelines

• Coding guidelines developed by national societies

• Analysis of standard medical and surgical practices

• Review of current coding practices

CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.



– The recent healthcare legislation passed into law (H.R. 3962), requires that Medicaid programs incorporate compatible methodologies of the NCCI into their claims processing system

– Section 6507 mandates that NCCI methodologies must be effective for claims filed on or after October 1, 2010

– Initial editing will encompass three basic coding concepts:• NCCI Column I and Column II

• Mutually Exclusive (ME) Edits

• Medically Unlikely Edits (MUE)



– The NCCI Policy Manual is located at http://www.cms.gov/NationalCorrectCodInitEd/

http://www.cms.gov/NationalCorrectCodInitEd/


How does it work?


– NCCI editing is applied to claims reporting:• Same date of service

• Same member

• Same billing provider NPI

– Also included in NCCI editing are:• Claims with Third Party Liability (TPL) amounts

• Claims denied by the primary insurance


Who will be affected?


– Included in NCCI:• Physician claims

• Institutional outpatient claims

• Type of bill 13X and 83X

– Excluded from NCCI:• Medicare crossover

• Dental

• Home health

• Hospice

• Inpatient

• Long-term care

• Waiver

• Pharmacy


When is implementation?


– Professional claims – October 28, 2010• Includes column I/II, ME, MUE

– Healthcare reform legislation mandates NCCI methodologies must be effective for claims filed on or after October 1, 2010

– HP will mass adjust claims received on or after October 1, 2010, through the implementation date


Institutional outpatient


– Outpatient claims targeted for April 1, 2011

– Bill type 13X and 83X• Column I and Column II

• ME

• MUE

– HP will mass adjust claims received on or after October 1, 2010, through the implementation date

DefineColumn I/Column II, MUE, and ME


New Edits for NCCI

– New explanation of benefit (EOB) codes have been developed that specifically identify:• When a claim detail has encountered an NCCI edit

• When a claim could not process through NCCI editing for an unexpected event

– BT201036 defines these edits including:• New EOB numbers

• EOB Descriptions

• Purpose of EOBs


New NCCI Edits ExampleNew EOB

EOB Description Purpose of EOB

4181 Service denied due to a National Correct Coding Initiative (NCCI) edit. Go to http://www.cms.gov/NationalCorrectCodInitEd/ for information regarding NCCI coding policies.

This EOB will identify when a detail on a professional (CMS-1500) claim has denied for Column I/II and/or ME edit.

4183 Units of service on the claim exceed the Medically Unlikely Edit (MUE) allowed per date of service. Go to http://www.cms.gov/NationalCorrectCodInitEd/ for information regarding maximum number of units of service allowed for the service billed.

This EOB will identify when the units of service allowed on a claim detail exceed the MUE unit limit as defined by CMS.






New NCCI Edits ExampleNew EOB

EOB Description Purpose of EOB

4185 The claim did not process through NCCI editing. The claim will be reprocessed or adjusted at a later date. Please monitor future Remittance Advice statements for processing activity related to this claim.

This EOB will identify when a claim could not go through NCCI editing due to an unexpected event. The claim is allowed to continue through normal processing and will be subject to a mass adjustment at a later to date.

9092 The claim was subjected to NCCI editing methodologies.

This EOB will identify when a claim has gone through NCCI editing and did not encounter any Column I/II, ME, or MUE edits.


Define

Column I and Column II

– Column I/ 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 HCPCS/CPT code describes the services that were furnished.


Column1/Column II Denial

Line # From DOS To DOS Procedure Code

Description NCCI Editing

01 11/01/2010 11/01/2010 58260 Vaginal hysterectomy for uterus 250 grams or less

Detail is allowed

02 11/01/2010 11/01/2010 58720 Salpingo- oophorectomy, complete or partial, unilateral or bilateral

Detail is denied with edit 4181


Column1/Column II Denial

Line # From DOS To DOS Procedure Code

Description NCCI Editing

01 11/05/2010 11/05/2010 70110 Radiologic exam, mandible: complete, minimum of four views

Detail is allowed

02 11/05/2010 11/05/2010 70100 Radiologic exam, mandible; partial, less than four views



Define

Mutually Exclusive Edits

– Procedure codes that cannot 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 patient encounter

– Two or more procedures performed during the same patient encounter on the same date of service and same billing provider that are not normally performed together


Mutually Exclusive (ME) EditsLine # From DOS To DOS Procedure

CodeDescription NCCI Editing

01 11/15/2010

11/15/2010

58280 Vaginal hysterectomy; with total or partial vaginectomy with repair of enterocele

Detail is allowed

02 11/15/2010

11/15/2010

58263 Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s), with repair of enterocele



Mutually Exclusive (ME) EditsLine # From DOS To DOS Procedure

CodeDescription NCCI Editing

01 11/21/2010 11/21/2010 27440 Arthroplasty, knee, tibial plateau

Detail is allowed

02 11/21/2010 11/21/2010 27438 Arthroplasty, patella, with prosthesis



Define

Medically Unlikely Edits (MUE)

– HCPCS/CPTs 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 units of service allowed on the claim, not the units of service billed



Line #

From DOS To DOS Procedure Code

Description Units of Service billed

NCCI Editing

01 12/11/2010 12/11/2010 99232 Subsequent hospital care for the evaluation and management of a patient, patient is not responding to therapy or has a minor complication

6 Detail is denied with edit 4183 – Units of service on the claim exceed the Medically Unlikely Edit (MUE) allowed per date of service.

**If the dates of service were consecutive, the date span should represent the appropriate ‘From and To’ period. The MUE units allowed for this code is one per day.

Exceptions


Exceptions


To align with current IHCP policy, the following are exceptions to the MUE unit limit:

–A4253 – Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips:

• The MUE unit limit is two and IHCP policy allows four units (or 200 test strips) per month

–A4259 – Lancets, per box • The MUE unit limit is one and IHCP policy allows two units per month

These are examples only, not a complete list of unit limitations that may exist


Exceptions

NCCI Code Auditing

– Antepartum Care• 59425 – Antepartum care only; four to six visits

• 59426 – Antepartum care only; seven or more visits

• Billed with modifiers

−U1 – Trimester one – 0 through 14 weeks, 0 days

−U2 – Trimester two – 14 weeks, one day through 28 weeks, 0 days

−U3 – Trimester three – 28 weeks, one day, through delivery

• And when billed on the same date of service as the lab codes listed in BT201036 will not be subject to NCCI Column I/II editing

Chapter 8 of the IHCP Provider Manual “Obstetrical Care” section provides specific billing information and a complete list of lab services allowed for each trimester

BillModifiers and date spans


What is correct?

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

• Special circumstances


Use of modifiers

– Correct use of modifiers is essential to accurate billing and reimbursement for services provided.

– Chapter 8, Section 4 of the IHCP Provider Manual gives detailed descriptions of modifiers

– The CMS provides carriers with guidance and instructions on the correct coding of claims and using modifiers through manuals, transmittals, and the CMS Web site• Providers can access the CMS Web site at www.cms.hhs.gov

– The National Correct Coding Initiative (NCCI) provides updates each quarter for correct modifier usage for each CPT code http://www.cms.gov/NationalCorrectCodInitEd/

http://www.cms.hhs.gov/



Distinct procedure or service on the same dayModifier 59

– Should only be used when there is no other modifier to correctly clarify the procedure or service

– A distinct procedure may represent the following: • Different session or patient encounter

• Different procedure or surgery

• Different site or organ system

• Separate incision or excision

• Separate lesion

• Separate injury or area of injury in extensive injuries

– If multiple units of the same procedure are performed during the same session, the provider should report all the units on a single detail line, unless otherwise specified in medical policy


Bilateral procedure

Modifier 50

– Bilateral procedures performed during the same operative session on both sides of the body by the same physician

– Units billed would be entered as 1 because one procedure was performed bilaterally

– Modifier 50 is only required when the use of 50 is mandated by verbiage within the CPT coding manual


Multiple procedures

Modifier 51

– Multiple procedures or services are performed on the same day or during the same operative session by the same physician

– The additional or secondary procedure or service must be identified by adding modifier 51 to the procedure or service code


Procedures that can be performed on paired organs

Modifiers LT and RT

– Identifies procedures that can be performed on paired organs such as ears, eyes, nostrils, kidneys, lungs, and ovaries

– Should be used whenever a procedure is performed on only one side to identify which one of the paired organs was operated on

– CMS requires these modifiers whenever appropriate


CMS-1500

Span Dates

– Providers must be sure to complete the “From” and “To” dates on all claims even if the service was for one single date of service

– Services within the same calendar month and in a consecutive day pattern, must be billed with the appropriate units of service and “From” and “To” dates

– Failure to report the correct date span and the number of units performed during the date span could result in a claim denial


Example

Span Dates

– Detail is allowed and does not encounter NCCI edits.

From DOS To DOS Procedure Code Description Units of Service

10/03/2010 10/07/2010 E0202 Phototherapy 5


Processing expectations

Web interChange

– Claims are usually viewable within two hours via the Claim Inquiry function

– On rare occasions, claims will not be available for viewing within the usual two-hour time frame

– If the delay is longer than 24 hours, providers may contact HP Customer Assistance to determine the reason for the delay• 1-800-577-1278, or

• (317) 655-3240 in the Indianapolis local area

InquireAvenues of resolution


Claims Denials/Inquiry

– Follow normal avenues of resolutions

– IHCP Web site at www.indianamedicaid.com

– Customer Assistance• 1-800-577-1278, or

• (317) 655-3240 in the Indianapolis local area

– Written Correspondence• Written Correspondence

P.O. Box 7263Indianapolis, IN 46207-7263

– Provider relations field consultant

http://www.indianamedicaid.com/


New options

Claims Denials/Inquiry

– New options• http://www.cms.gov/NationalCorrectCodInitEd – Column I and II, Mutually Exclusive

(ME), and Medically Unlikely Edit files. These files contain specific code pairs for Column I /II and the Mutually Exclusive edits.

• Administrative review

http://www.cms.gov/NationalCorrectCodInitEd


Requirements

Administrative Review

– Administrative review must be requested within seven days of notification of claims payment or denial• Used when there are unusual circumstances in which a provider believes the claim

was coded correctly and would like reconsideration of the NCCI editing

– Complete an IHCP Programs Inquiry form or write a letter stating:• Reason for disagreement

• Denial or amount of reimbursement

• Clearly note “Administrative Review” on the form or letter

• Attach all pertinent documentation

• Add “Attention To: Health Care Administrative Review Specialist”

– The IHCP Programs Inquiry form can be obtained from the Indiana Medicaid Web site in the forms section at www.indianamedicaid.com

http://www.indianamedicaid.com/


Address

Administrative Review

– Send forms or letters to:• Attn: Healthcare Administrative Review Specialist

Written CorrespondenceP. O. Box 7263Indianapolis, IN 46207-7263

Contact


For NCCI information only

Concerns about Specific NCCI Edits?

– Submit comments in writing to:• National Correct Coding Initiative

Correct Coding Solutions, LLCP.O. Box 907Carmel, IN 46082-0907

– Send to the attention of Niles R. Rosen, M.D., Medical Director and Linda S. Dietz, RHIA, CCS, CCS-P, Coding Specialist

– Send questions regarding NCCI table edits only; do not send claims questions or claim appeals

Questions

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HP Provider Relations October 2010 National Correct Coding Initiative.

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