Presented by Lori Dafoe, CPC How to Use The National Correct
Coding Initiative (NCCI) Tools
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Agenda How it Impacts You NCCI History and Definition Using the
NCCI Tools/AAPC Coder Real Life Examples Resources
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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.
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Background and History NCCI was originally developed for
Medicare in 1996 Founded on Coding Policies
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.
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NCCI Table Example
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Modifier Indicator Table
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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.
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Medically Unlikely Edits (MUEs) 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
codes 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.
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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
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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
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NCCI Edits and How they Work Type I NCCI Code Pair Edits
(Procedure to -Procedure) Type II Medically Unlikely Edits
(MUEs)
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Mutually Exclusive Procedures Example : Column I / Column II
Code 11719 / 11720 CPT 11719 (Column I) Trimming of non-dystrophic
nails, any number 1 = modifier allowed CPT 11720 (Column II)
Debridement of nail(s) by any method(s); one to five Policy:
Modifier -59 is allowed if appropriate documentation is
present.
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CPT Coding Manual Instruction/Guideline Example: Column I /
Column II Code 17000 / 11000 CPT 17000 Column I Destruction, pre-
malignant lesion; first 1 = modifier allowed CPT 11100 Column II
Biopsy of skin, single lesion Policy: Modifier -59 is allowed if
appropriate documentation is present.
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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 technique1 = 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.
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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
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NCCI Example Column1/Column 2 Edits Column 1Column 2 * = In
existence prior to 1996 Effective Date Deletion Date *=no data
Modifier 0=not allowed 1=allowed 9=not applicable 3255576942
20130101*1
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Dont Get Bungled Up by Bundled Codes
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Clinical Example: CPT 32555 & CPT 76942
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To Bundle, or Not to Bundle?
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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.
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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 patients 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,
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.
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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.
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Coding Scenario 3: No! 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.
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Coding Scenario 4: No! N/A Rationale: The comprehensive
metabolic panel includes a total calcium.
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Coding Scenario 5: Yes! -59 Append to CPT 11301 (Column II
Code). Rationale: Separate lesions. Shave excision performed foor
lesion on patients back, while AKs were destroyed from the patients
face.
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YOU!!!!