Chapter 3- Denials National Correct Initiative NCCI

Question 1

NCCI (CCI)

Answer 1

NCCI, also shortened to CCI, is an automated edit system used to indicate specific CPT® code pairs and whether they can be reported on the same date of service for the same beneficiary by the same provider.

Question 2

CMS implemented the NCCI to promote correct coding methodologies and to control improper assignment of codes resulting in inappropriate reimbursement. NCCI coding policies are based on:

Answer 2

*Analysis of standard medical and surgical practices.

*Coding conventions included in CPT.

*Coding guidelines

*Local and National coverage determination.

*Review of current coding practices.

Question 3

NCCI is used by professional coders and billers to determine codes considered by CMS to be bundled for procedures and services deemed necessary to accomplish a major procedure.

Answer 3

Bundled procedure codes are not reported separately. The components of a bundled procedure are included in the comprehensive procedure code.

Question 4

Local CMS carriers (MACs) began using the NCCI edits on January 1, 1996. Since October 2010, the Patient Protection and Affordable Care Act § 6507 (ACA) required state Medicaid programs to incorporate NCCI methodologies into their claims processing. Many commercial health plans also utilize the NCCI edits in their claims processing.

Answer 4

MACs are entities (third-party payers, insurance companies) that contract with the federal government to adjudicate and process claims in the geographical region for which they have been given jurisdiction.

Question 5

August of 2000, NCCI edits were added to the Outpatient Code Editor (OCE) to assist MACs in processing Part B claims for outpatient hospital services.

Answer 5

The NCCI includes two types of edits:

1.Procedure to Procedure (PTP) edits

2.Medically Unlikely Edits (MUEs)

Question 6

Procedure to Procedure (PTP) edits

Answer 6

PTP edits apply to code pairs that should not be billed together because one service inherently includes the other.

Question 7

Medically Unlikely Edits (MUEs)

Answer 7

MUEs indicate a maximum number of units of service (UOS) allowable under most circumstances for a single CPT® or HCPCS Level II code billed by a provider on a single date of service for a beneficiary.

Question 8

The NCCI is composed of two provider-type choices of code pair edits and three provider-type choices of MUEs.

Answer 8

PTP Code Pair Edits

*NCCI edits — practitioners:

*NCCI edits — hospital:

Question 9

MUEs

Answer 9

*Practitioner MUEs

*Durable medical equipment (DME) supplier MUEs:

*Facility outpatient MUEs:

Question 10

Many NCCI edits are based on the standards of medical/surgical care.

Answer 10

Services integral to another service are considered component parts of the more comprehensive service

examples:
*cleaning, shaving, prepping skin

*draping and positioning pt.

*insertion of urinary catheter

*surgical approach

*Surgical cultures

*surgical closure

Question 11

According to the NCCI Policy Manual, there are general principles that can be applied to the edits:

Answer 11

1. The component (column 2) service is an accepted standard of care when performing the comprehensive (column 1) service.

2.The component service is usually necessary to complete the comprehensive service.

3.The component service is not a separately distinguishable procedure when performed with the comprehensive service.

Question 12

Column 1/Column 2 Edits

Answer 12

the table has a Modifer
0 = not allowed
1= allowed
9=not applicable

This indicator determines whether a CCM causes the code pair to bypass the edit. This indicator will be either “0,” “1,” or “9.” The definitions of each are:

Question 13

examples

Answer 13

Medical: Since a cardiac stress test (codes 93015-93018) includes multiple electrocardiograms, an electrocardiogram (code 93005 or 93010) is not separately reportable.

Surgical: Since a myringotomy (code 69421) requires access to the tympanic membrane (ear drum) through the external auditory canal (EAC), removal of impacted cerumen (code 69210) from the EAC is not separately reportable.

Question 14

Modifiers and NCCI Edits

Answer 14

HCPCS Level II or CPT® modifiers may be used to bypass the NCCI edits in certain circumstances when appropriate.

Question 15

It is important as a biller to understand modifier usage.

Answer 15

This allows for proper appeals to be filed when warranted and to understand when a write-off should be done instead.

Question 16

The reimbursement process will be delayed if an appropriate modifier was warranted but not appended.

Answer 16

Not understanding correct modifier usage will cause an initial denial and require extra work to rebill and receive appropriate payment.

Question 17

The modifiers that may be used to bypass the NCCI edits include:

Answer 17

Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
Global surgery modifiers: 24, 25, 57, 58, 78, 79
Other modifiers: 27, 59, 91, XE, XS, XP, XU

Question 18

Modifiers 76 Repeat procedure or service by same physician or other qualified healthcare professional and 77 Repeat procedure or service by another physician or other qualified healthcare professional are not NCCI edit modifiers and cannot be used to bypass edits.

Answer 18

E1-E4 describe upper and lower, right and left eyelids (different anatomic sites)

FA, F1-F9 describe left and right hands, and specific fingers of each (different anatomic sites)

TA, T1-T9 describe left and right foot with each specific toe of each (different anatomic sites)

Question 19

Modifier 25

Answer 19

Modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service.

Question 20

This modifier 25 is appended to minor procedures with either 000 or 010 global days, or procedures not covered by global surgery rules (XXX global indicator).

Answer 20

A separate E/M should not be billed automatically with a minor procedure or an XXX procedure.

Question 21

Modifier 58

Answer 21

Modifier 58 Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period.

Question 22

Modifier 59

Answer 22

The NCCI Policy Manual reiterates the CPT® code book’s definition: “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.

Question 23

Modifier 59

Answer 23

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.

Question 24

Medicaid and NCCI

Answer 24

As stated earlier, the ACA requires Medicaid to utilize the NCCI edits. CMS allows states to deactivate edits that conflict with state laws, regulations, administrative rules, payment policies, and/or level of operational readiness.

Question 25

The Medicaid NCCI program consists of six methodologies:

Answer 25

1.A methodology with Procedure-to-Procedure (PTP) edits for practitioner and ambulatory surgical center (ASC) services

2.A methodology with PTP edits outpatient hospital services

3.A methodology with PTP edits for durable medical equipment

4.A methodology with MUEs for practitioner and ASC services

5.A methodology with MUEs for outpatient hospital services for hospitals

6.A methodology with MUEs for durable medical equipment.

Question 26

The Medicaid NCCI edits apply only to Medicaid fee-for-service claims reimbursed for HCPCS/CPT® codes.

Answer 26

Each of the Medicaid NCCI methodologies has four components:

1.A set of edits

2.Definitions of types of claims subject to the edits

3.A set of claim adjudication rules for applying the edits

4.A set of rules for addressing provider appeals of denied payments for services based on the edits

Question 27

Medically Unlikely Edits (MUEs)

Answer 27

To help reduce the paid claims error rate for Medicare Part B claims, CMS developed Medically Unlikely Edits (MUEs).

MUEs define the maximum units of service that a provider would report, under most circumstances, for a single beneficiary, on a single date of service, for a specific HCPCS/CPT® code.

Question 28

Table provided with the following:

Answer 28

HCPCS/CPT® Code—This indicates the HCPCS Level II code or CPT® code.

Practitioner Services MUE Values—This indicates the number of units that may be billed for the HCPCS Level II code or CPT® code.

MUE Adjudication Indicator (MAI)—This indicates the type of MUE and its basis. An MAI of 2 indicates an edit for which the MUE is based on regulation or sub-regulatory instructions (policy), including the instruction that is inherent in the code descriptor or its applicable anatomy. An MAI of 3 indicates an edit for which the MUE is based on clinical information.

MUE Rationale—The adjudication indicator specifies whether it is due to anatomic consideration, nature of service, code descriptor or CPT® instruction, clinical data, or CMS policy.

Question 29

Question: When we report 77078 Computed tomography, bone mineral density study, 1 or more sites, axial skeleton (e.g., hips, pelvis, spine) and 77080 Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine) on the same claim, 77080 is denied. Why is this?

Answer 29

Answer: Because these two codes have a modifier status of “0,” NCCI edits instruct coders to only report the column 1 code (77078).

Question 30

The practice of bundling and unbundling code pairs is a common one in diagnostic radiology.

Answer 30

When the provider performs two or more imaging services together, it’s your responsibility to confirm that there are no bundling edits between the respective codes.

Question 31

If you perform an edit check on a code pair, it’s up to the NCCI algorithm to determine whether the two codes should, in fact, be joined.

Answer 31

sometimes the guidelines call for you to combine two codes into one, more comprehensive code. In these instances, you aren’t deciding whether one code should be submitted alongside another.

Question 32

In the case of bundling, you will perform an NCCI edits check and, depending on the results, either exclusively report the column 1 code or report both codes with an overriding modifier on the column 2 code.

Answer 32

. On the other hand, combining two codes calls for the two respective codes to be merged into a third, more comprehensive code.

Question 33

Question: Notes indicate that the pain management specialist performed a computed tomography (CT) scan on a patient’s left leg. I reported 73701, as the operative notes indicate that the specialist used contrast material during the CT. The payer denied the claim; what did I do wrong?

Answer 33

The payer might not have seen proof of contrast material. If the notes are inaccurate and the specialist actually performed a CT without contrast, you’d choose 73700 Computed tomography, lower extremity; without contrast material for the service.

The payer might require laterality modifiers on CT exams. If you need a laterality modifier, you would report modifier LT Left side appended to 73701… with contrast material(s).

Depending on the patient’s condition, the payer might not have approved her for a CT scan. Check the payer’s approved list of diagnoses for leg CTs; if you cannot locate one, call a payer rep and ask about diagnosis codes relevant to 73701.

You might have chosen the wrong leg CT code. There are two codes for leg CT scans with contrast material: 73701 and 73702 … without contrast material, followed by contrast material(s) and further sections. If the provider began the CT without contrast material, then used contrast to take more sections, you’d report 73702 instead of 73701.

Question 34

Question: An established patient came to our provider with a deep 10 cm cut on his right arm. We billed a level-four E/M service along with an Adacel® injection administered with 96372. Our doctor also closed the wound with Dermabond using G0168, so we appended modifier 51 to 96372 to indicate we had performed multiple procedures. We are now being told that 96372 will not be paid with the G0168 unless a valid modifier is used? Doesn’t the 51 cover that? And if not, what modifier should we use?

Answer 34

Answer: There could be several reasons for the denial. The first could be that you used G0168 Wound closure utilizing tissue adhesive(s) only for the Dermabond closure. As this is a Medicare code, many private payers do not recognize it, preferring the simple closure codes 12001-12018 instead.

Question 35

Question: We reported 99407 with 99213 and the claim was denied, even though we used modifier 25 with 99213. We noticed that there are no NCCI edits barring us from billing these together, so we can’t figure out what the problem is. Can you advise?

Answer 35

The code 99407 describes “Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes.” This code may be reported in addition to other E/M services provided on the same day, but it does require face-to-face counseling by the physician personally to do so.