Chapter 7: Medical Necessity Flashcards
How is Medical Necessity defined by payers?
all payers define it differently
Which act states that Medicare will not cover services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member”?
Social Security Act
What are MUEs used to indicate?
Medically Unlikely Edits released by CMS to indicate the number of units that can be reported for a service or procedure on the same day by the same physician for the same beneficiary
What does NCCI/CCI stand for?
National Correct Coding Initiative
(CCI is short for NCCI)
What is an automated edit system used to indicate specific CPT code pairs and whether they can be reported on the same DOS for the same beneficiary by the same provider?
NCCI/CCI
Why did CMS implement the NCCI?
To promote correct coding methodologies and to control improper assignment of codes resulting in inappropriate reimbursement.
What are NCCI coding policies based on?
- standard medical and surgical practice
- CPT coding convention
- guidelines by national medical specialties and CPT advisory committee
- LCDs and NCDs
- current coding practices
When does CMS update NCCI Policies?
updates quarterly and the policy manual annually
What began on January 1, 1996?
CMS carriers (MACs) began using the NCCI edits
When did the Patient Protection and ACA require state Medicaid programs to incorporate NCCI methodologies into their claims processing?
October 2010
What is a MAC responsible for?
For making coverage decision policies and protecting the integrity of the Medicare program
Who were NCCI edits originally developed for?
Part B claims
NCCI includes what two types of edits?
- Procedure to Procedure (PTP)
- bundled codes
- Medically Unlikely Edits (MUEs)
- Units of Service allowed (UOS)
What is a Mutually Exclusive Edit?
MMEs are included in PTP edits for pairs that are unlikely to be performed on the same patient on the same DOS
The NCCI is composed of two provider type choices of code pair edits and three provider type choices of MUEs. What are the PTP pair edits?
- Practitioners: physician, non physician practitioners, and ASC (Ambulatory Surgery Centers)
- Hospitals: Types of Bills (TOBs) subj. to OCE (outpt coding editor) for the OPPS.