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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

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NCCI Website http://www.cms.gov/Medicare/Coding/NationalCorrectC odInitEd/index.html http://www.cms.gov/Medicare/Coding/NationalCorrectC odInitEd/index.html

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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,

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http://www.aapc.com/login.aspx?r=http://www.aapc.com/index.aspx

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Lets Practice!!

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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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Dont forget May MAYnia! Invite a friend or co-worker! THANK YOU!!!!