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Billing > Chapter 7: Medical Necessity > Flashcards

Chapter 7: Medical Necessity Flashcards

1
Q

How is Medical Necessity defined by payers?

A

all payers define it differently

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2
Q

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”?

A

Social Security Act

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3
Q

What are MUEs used to indicate?

A

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

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4
Q

What does NCCI/CCI stand for?

A

National Correct Coding Initiative
(CCI is short for NCCI)

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5
Q

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?

A

NCCI/CCI

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6
Q

Why did CMS implement the NCCI?

A

To promote correct coding methodologies and to control improper assignment of codes resulting in inappropriate reimbursement.

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7
Q

What are NCCI coding policies based on?

A
  • standard medical and surgical practice
  • CPT coding convention
  • guidelines by national medical specialties and CPT advisory committee
  • LCDs and NCDs
  • current coding practices
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8
Q

When does CMS update NCCI Policies?

A

updates quarterly and the policy manual annually

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9
Q

What began on January 1, 1996?

A

CMS carriers (MACs) began using the NCCI edits

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10
Q

When did the Patient Protection and ACA require state Medicaid programs to incorporate NCCI methodologies into their claims processing?

A

October 2010

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11
Q

What is a MAC responsible for?

A

For making coverage decision policies and protecting the integrity of the Medicare program

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12
Q

Who were NCCI edits originally developed for?

A

Part B claims

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13
Q

NCCI includes what two types of edits?

A
  1. Procedure to Procedure (PTP)
    • bundled codes
  2. Medically Unlikely Edits (MUEs)
    - Units of Service allowed (UOS)
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14
Q

What is a Mutually Exclusive Edit?

A

MMEs are included in PTP edits for pairs that are unlikely to be performed on the same patient on the same DOS

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15
Q

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?

A
  1. Practitioners: physician, non physician practitioners, and ASC (Ambulatory Surgery Centers)
  2. Hospitals: Types of Bills (TOBs) subj. to OCE (outpt coding editor) for the OPPS.
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16
Q

The NCCI is composed of two provider type choices of code pair edits and three provider type choices of MUEs. What are the MUEs?

A
  1. Practioner MUEs
  2. DME Suppliers
  3. Facility Outpt MUEs: TOB (Type of Bill) 13X, 14X and 85X (Critical Access Hospitals)
17
Q

Which HCPCS codes are subject to the NCCIs MUEs DME Supplier edits?

A

HCPCS Codes A, B, E-V, AND codes under the DME MAC Jurisdiction

18
Q

What does it mean if a service is integral to another service?

A

component parts of the more comprehensive service.
*Component parts are included in the comprehensive service. NOT billed separately

19
Q

What are some services that may be integral to many procedures?

A
  • cleaning, shaving, peeping of skin
  • draping & positioning patient
  • Insertion of Urinary catheter
  • surgical approach, cultures, closure
20
Q

According the the NCCI Policy Manual, what are the general principles that can be applied to the NCCI edits?

A
  1. Component (Col 2) is acceptable standard of care when performing the comprehensive service (Col 1).
  2. Component service is necessary to complete the comprehensive service.
  3. Component is not separate distinguishable wen performed with the comprehensive
21
Q

What is considered a standard of medical/surgical practice?

A
  1. insertion of peripheral venous access device
  2. cardiopulmonary monitoring
  3. exposure and exploration of the surgical field
22
Q

Which modifiers can be used to bypass the NCCI Edits?

A
  1. Anatomical Modifiers
  2. Global Surgery Modifiers: 24,25, 57, 78, 79
  3. Other: 27, 59, 91, XE, XS, XP, XU
23
Q

Which 2 modifiers are not NCCI edit modifiers and cannot be used to bypass edits?

A

Mod 76 and 77

24
Q

Which 3 modifiers does the NCCI specifically discuss?

A

Mod 25, 58, 59

25
Q

What does the NCCI manual specifically address regarding the use of Modifier 58 with?

A

Laparoscopic procedures.
Any planned endoscopic procedure that fails and is converted to an open procedure is NOT separately reportable.
Diagnostic endoscopies are NOT separately reportable with another endoscopy of the same organ or body cavity.

26
Q

What are the X[ESPU] modifiers?

A

est in 2015 by CMS, more specific than mod 59
XE - Separate Encounter
XS - Separate Structure
XP - Separate Practitioner
XU - Unusual non overlapping service

27
Q

ACA requires Medicaid to use the NCCI edits. The Medicaid NCCI Program consists of what 6 methodologies?

A
  1. PTP edits for practitioner and ASC
  2. PTP edits outpatient hospital
  3. PTP edits for DME
  4. MUEs for Practitioner and ASC
  5. MUEs for outpatient hospital
  6. MUEs for DME
28
Q

ACA requires Medicaid to use the NCCI edits. The Medicaid NCCI Program consists of 6 methodologies and each has 4 components. What are the 4 components?

A
  1. a set of edits
  2. types of claims subj. to edits
  3. claim adjudication rules
  4. rules for appeals
29
Q

Which policy should be followed if there is an LCD and NCD for the service you are billing?

A

Medicare contractors are required to follow the NCD unless and NCD does not specifically exclude or limit an indication or circumstance

30
Q

What is an Outpatient Code Editor (OCE)?

A

Software that edits outpatient hospital claims to detect incorrect billing data and determine if the Ambulatory Surgery Center (ASC) limit should apply to each claim and reviews each HCPCS and ICD10 code for validity and coverage

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