Transcript National Correct Coding Initiative (NCCI)

National Correct Coding Initiative
(NCCI) and Mutually Exclusive Edits
(MUE)
Deciphering the NCCI and MUE tables, how
appropriate interpretation impacts reimbursement
May 20, 2016
Today’s Agenda
Welcome and opening comments
2
NCCI edits promote correct coding and avoid inappropriate reimbursement
3
General correct coding guidelines
8
NCCI general principles for medical/surgical procedures
11
How to interpret NCCI edits
15
What are Medically Unlikely Edits (MUE)?
21
Question & answer
30
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NCCI edits promote correct coding and avoid
inappropriate reimbursement
NCCI edits promote correct coding and avoid
inappropriate reimbursement
•
The National Correct Coding Initiative (NCCI or CCI edits) was implemented to promote
national correct coding methodologies and control improper coding which leads to
inappropriate reimbursement.
•
When two or more procedures are billed together, the claim is sent through a scrubber.
The scrubber has automated prepayment edits which prevent improper coding and
billing for covered Part B services.
•
4
-
One table for physicians/practitioners
-
One table for outpatient hospital services
The National Correct Coding Initiative was implemented in 1996 and is updated
quarterly.
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Medically Unlikely Edit (MUE) flag for maximum
number of units allowed
•
A Medically Unlikely Edit (MUE) is a maximum number of units allowed under
ordinary conditions for a single Current Procedural Terminology/Healthcare
Common Procedure Coding System (CPT/HCPCS) code billed by a provider on
a date of service for a single beneficiary.
•
Center for Medicare and Medicaid Services (CMS) implemented the MUEs in
1997.
5
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NCCI policy manual for Medicare services
breakdown
Introduction
Purpose
The Omnibus Budget Reconciliation Act of 1989 amended the Social Security
Act to assure uniform payment policies and procedures were followed by all
carriers (A/B MACs) so the same service would be reimbursed similarly in all
carrier (A/B MACs) jurisdictions for Physician Services. This was the
implementation of the Medicare Physician Fee Schedule.
Coding policies are based on coding conventions based on the American
Medical Association (AMA) CPT manual, National Coverage (NCD) and Local
Coverage Determinations (LCD), coding guidelines developed by national
societies, standard medical and surgical practice and/or current coding
practice.
Background
To encourage consistent, correct coding to reduce inappropriate
reimbursement.
6
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NCCI policy manual for Medicare services
breakdown (cont’d)
Additions, deletions or
modifications to
CPT/HCPS codes
CMS Policy Initiatives
Comments from AMA,
national or local
organizations,
medical/surgical
societies and others
*Note: Correspondence – NCCI is maintained by Correct Coding Solutions, LLC for CMS
1)
2)
3)
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National Correct Coding Initiative Policy Manual for Medicare Services (http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitED.index.html)
MUE Overview (http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.html)
Current quarterly version update changes for NCCI PTP edits and published MUEs (http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Version_Update_Changes.html)
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General correct coding guidelines
General correct coding guidelines
•
Coding based on standards of medical and surgical practice
•
Medical and surgical package (pre, intra, post-operative included)
•
Evaluation and Management Services (E&M)
•
Modifiers and modifier indicators
•
Monitoring services and standard preparation for anesthesia services
•
Anesthesia service Included in the surgical procedure
•
CPT/HCPCS Procedure Code definition
•
CPT Manual and CMS Coding Manual instructions
•
CPT “Separate Procedure” definition
9
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General correct coding guidelines (cont’d)
•
Sequential procedure
•
Laboratory panels
•
Misuse of column 2 code with column 1 code
•
Mutually exclusive procedures
•
Gender specific procedures
•
Add-on codes
•
Excluded service
•
Unlisted procedure codes
•
Modified, deleted and added code pairs/edits
•
Medically unlikely edits (MUEs)
10
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NCCI general principles for medical/surgical
procedures
NCCI general principles for medical/surgical
procedures
XXX: Does not apply to the global surgical package
YYY: Defined by the carrier ( A/B MAC processing claims for
practitioners)
Medicare
Physician Fee
Schedule
ZZZ: Procedure is related to another procedure and the applicable
global period for ZZZ code is determined by the related procedure
MMM: For maternity procedures
000,010,090*: E/M procedures are separately reportable on the same date of
service with the aforementioned global periods under limited circumstances
*For 090 global period, the E/M service separately reportable if the decision for surgery is on the same date of
service as the major surgical procedure with modifier 57
12
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Why is it important to understand Medicare
surgical global packages
•
Procedures with 000 or 010 global days are considered minor surgical procedures.
The decision to perform the minor surgical procedure is included in the payment for
the procedure. There are no global days associated with a procedure assigned with
000 and ten days for a procedure assigned with 010.
•
If the E/M service is separate and identifiable from the minor surgical procedure the
E/M service is reportable. The E/M service and the minor surgical procedure do not
require different diagnosis code(s). Applying modifier 25 on the E/M service is
appropriate. For example: patient presents to office for cough and sore throat.
Walking to exam room, the patient trips and falls requiring a suturing of a deep
wound of the forearm.
•
For both minor and major surgical procedures, the post-operative E/M services are
included in the payment for the procedure.
•
During the post-operative service, an E/M service may be separately reportable if
the service is unrelated to the minor/major procedure. Modifier 24 is appropriate.
•
Global Package XXX, are never reported with an E/M service. These procedures
include the pre-operative, intra-operative and post-operative procedures.
13
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How to appropriately use modifier(s)
•
May be applied only if the medical record documentation and clinical circumstances
justify the use of an alphanumeric modifier.
•
Modifiers are generally used for encounters related to separate patient encounters,
separate anatomic sites or separate specimens, not solely to bypass a NCCI
procedure to procedure (PTP) edit.
•
Modifiers include anatomic, global surgery and other.
•
Examples include:
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•
Anatomic: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
•
Global: 24, 25, 57, 58, 78, 79
•
Other: 22, 27, 59, 76, 91, XE, XS, XP, XU
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How to interpret NCCI edits
NCCI general principles for medical/surgical
procedures
16
Component (column 2) service is an accepted standard of care when
performing the comprehensive (column 1) service.
1
Component service is usually necessary to complete the comprehensive
service.
2
Component service is not separately distinguishable procedure when
performed with the comprehensive service.
3
Services which are integral to the procedures are not separately reportable.
Some examples are cleansing, shaving and prepping of skin, insertion of
Intravenous (IV) medications, insertion of urinary catheter, etc.
4
NCCI edits are classified as procedure to procedure edits (PTP) or other.
5
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Example of NCCI table
CPT only copyright 2014 American Medical Association. All rights reserved.
Column1/Column 2 Edits
Column 1 Column 2 * = In existence Effective Date Deletion Date Modifier
prior to 1996
*=no data
0=not allowed
1=allowed
9=not applicable
15945 64510
20090401
*
1
15945 64517
20090401
*
1
15945 64520
20090401
*
1
15945 64530
20090401
*
1
15945 64550
20090401
20090401
9
15945 69990
20000605
*
0
15945 90760
20060101
20081231
1
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PTP Edit Rationale
Standards of medical / surgical practice
Standards of medical / surgical practice
Standards of medical / surgical practice
Standards of medical / surgical practice
Standards of medical / surgical practice
Misuse of column two code with column one code
Standards of medical / surgical practice
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How to interpret NCCI edits
Each code pair is assigned a modifier indicator.
Indicator
Description
Indicator “0”
Determines a modifier cannot be used to bypass an edit. The
two codes cannot be billed together for the same patient on the
same date of service during the same episode. The component
code will be denied and the comprehensive code is eligible for
payment.
Indicator “1”
Determines a modifier may be used to bypass an edit if the
appropriate circumstances are met. For instance, when a
procedure is performed on contralateral organs or structures and
the documentation in the medical record supports the use of the
modifier.
Indicator “9”
Indicator “9” determines the edit has been deleted and a modifier
is not appropriate.
18
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CMS adds further explanation for modifier 59
distinct procedural service
•
The modifier is used inappropriately most often.
•
Used to indicate that two or more procedures are performed at different anatomic sites
or different patient encounters.
•
To be used only if another modifier cannot further explain the relationship of the two
procedures being billed.
•
Modifier 59 is not appropriate for evaluation and management (E/M) services. Modifier
25 is appropriate for separate and distinct services.
•
XE, XS, XP, XU became effective January 1, 2015 to increase the specificity on the
usage of modifier 59. These are to be used in lieu of modifier 59.
•
For Medicare claims, the “X” modifiers are to be used prior to modifier 59 as “X” further
defines the relationship of the procedures performed. Some third-party payers have
not adopted the usage of the “X” modifiers, please review their individual guidance.
19
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CMS adds further explanation for modifier 59
distinct procedural service (cont’d)
Definitions
XE: Separate
Encounter
A service that is distinct because it occurred during a separate encounter.”.
Only to be used to describe separate encounters on the same date of service.
XS: Separate
Structure
A service that is distinct because it was performed on a separate
organ/structure.
XP: Separate
Practitioner
A service that is distinct because it was performed by a different practitioner.
XU: Unusual NonOverlapping
Service
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The use of a service that is distinct because it does not overlap usual
components of the main service.
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What are Medically Unlikely Edits (MUE)?
What are Medically Unlikely Edits (MUE)?
•
An MUE for a HCPCS/CPT code is the maximum number of Units of Service (UOS)
under most circumstances allowable by the same provider for the same beneficiary on
the same date of service.
•
As of April 1, 2013, CMS introduced date of service MUEs.
•
MUEs are adjudicated as either claim line edits or Date of Service (DOS) MUEs.
•
MUEs adjudicated as a claim line edit, UOS on each claim line are compared to MUE
value for the HCPCS/CPT code on the claim line.
•
If the units of service on that claim line exceeded the MUE value, the entire claim line
is denied.
•
DOS MUEs are adjudicated as all the UOS on each claim line for the same date of
service for the same HCPCS/CPT code are summed and the sum is compared to the
MUE value.
•
If the sum exceeds the MUE value, all claim lines are denied.
Source:
Note: Chapter I General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services Revison Date 1/1/2016 Section V
22
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What type of edit is an MUE?
•
An MUE is a coding edit which needs to follow the guidance discussed during this
presentation.
•
MUEs are NOT:
Medical necessity edits
The claims processing contractor may
have more restrictive guidance or
number of units for a HCPCS/CPT
code. The more restrictive MUE needs
to be followed for correct billing for the
number of units.
23
Utilization edits
Many HCPCS/CPT codes are billed
with less than the MUE value, however
some codes are billed with the
commonly units reported. These
claims may be subject to review by the
claims processing contractor, and other
government agencies.
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MUE adjudication considerations
•
The MUE files on the CMS NCCI website display an “MUE Adjudication Indicator” (MAI)
for each HCPCS/CPT code. An MAI of “1” indicates that the edit is a claim line MUE.
An MAI of “2” or “3” indicates that the edit is a DOS MUE.
•
Appropriate use of modifiers may be reported with CPT/HCPCS codes for the claim line
adjudication of MUEs. For example the use of anatomic modifiers for the same CPT
code for the same DOS.
•
MUEs for HCPCS codes with an MAI of “2” are absolute date of service edits. These
are “per day edits based on policy.”. HCPCS codes with an MAI of “2” have been
rigorously reviewed and vetted within CMS and obtain this MAI designation because
UOS on the same date of service in excess of the MUE value would be considered
impossible because it was contrary to statute, regulation or sub regulatory guidance.
•
MUEs for HCPCS codes with an MAI of “3” are “per day edits based on clinical
benchmarks.”. MUEs assigned with an MAI of “3” are based on criteria (e.g., nature of
service, prescribing information) combined with data such that it would be possible, but
medically unlikely, that higher values would represent correctly reported medically
necessary services.
Note: Chapter I General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services Revision Date 1/1/2016 Section V
24
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MUE adjudication considerations
Both MAI and MUE values for each HCPCS/CPT code are based on one or more of
the following criteria:
1) Anatomic considerations may limit units of service based on anatomic structures.
2) CPT code descriptors/CPT coding instructions in the CPT manual may limit units of
service.
3) Edits based on established CMS policies may limit units of service.
4) The nature of an analyte may limit units of service and is in general determined by
one of three considerations.
5) The nature of a procedure/service may limit units of service and is in general
determined by the amount of time required to perform a procedure/service.
6) The nature of equipment may limit units of service and is in general determined by the
number of items of equipment that would be utilized.
7) Clinical judgement considerations and determinations are based on input from
numerous physicians and certified coders.
8) Prescribing information is based on FDA labeling as well as off-label information
published in CMS-approved drug compendia.
9) Submitted claims data (100%) from a six month period is utilized to ascertain the
distribution pattern of UOS typically billed for a given HCPCS/CPT code.
25
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MUE drug adjudication considerations
•
HCPCS J code and drug related C and Q code MUEs are based on prescribing
information and 100% claims data for a six month period.
•
Guiding principles utilized in developing these edits:
Guiding Principle
Description
1
If the prescribing information defined a maximum daily dose, this value was used
to determine the MUE value.
2
If the maximum daily dose calculation is based on actual body weight, a dose
based on a weight range of 110-150kg was evaluated against claim data.
3
For “as needed” (PRN) drugs and drugs where maximum daily dose is based on
patient response, prescribing information and claims data were utilized to
establish MUE values.
4
Published off-label usage of a drug was considered for the maximum daily dose
calculation.
5
The MUE values for some drug codes are set to 0.
Note: Chapter I General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services Revison Date 1/1/2016 Section V
26
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Example of outpatient hospital MUE table
Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2015
American Medical Association. All rights reserved.
CPT® is a registered trademark of the American Medical Association.
Applicable FARS\DFARS Restrictions Apply to Government Use.
Outpatient
HCPCS/CPT Hospital Services
Code
MUE Values
G0452
1
G0453
10
G0454
1
G0455
1
G0458
1
G0459
0
G0460
1
G0463
6
G0464
1
G0472
1
G3001
1
G6001
1
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MUE Adjudication Indicator
3 Date of Service Edit: Clinical
3 Date of Service Edit: Clinical
2 Date of Service Edit: Policy
2 Date of Service Edit: Policy
1 Line Edit
3 Date of Service Edit: Clinical
3 Date of Service Edit: Clinical
3 Date of Service Edit: Clinical
2 Date of Service Edit: Policy
2 Date of Service Edit: Policy
2 Date of Service Edit: Policy
2 Date of Service Edit: Policy
MUE Rationale
Nature of Service/Procedure
Clinical: CMS Workgroup
Nature of Service/Procedure
Nature of Service/Procedure
Nature of Service/Procedure
CMS Policy
Nature of Service/Procedure
Nature of Service/Procedure
Nature of Analyte
Nature of Analyte
Prescribing Information
Clinical: Data
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Example of practitioner services MUE table
Current Procedural Terminology (CPT) codes, descriptions and other data only are copyright 2015
American Medical Association. All rights reserved.
CPT® is a registered trademark of the American Medical Association.
Applicable FARS\DFARS Restrictions Apply to Government Use.
HCPCS/CPT
Code
G0452
G0453
G0454
G0455
G0458
G0459
G0460
G0463
G0464
G0472
G3001
G6001
28
Practitioner
Services MUE
Values
6
40
1
1
1
1
1
0
1
1
1
1
MUE Adjudication Indicator
3 Date of Service Edit: Clinical
3 Date of Service Edit: Clinical
2 Date of Service Edit: Policy
2 Date of Service Edit: Policy
1 Line Edit
2 Date of Service Edit: Policy
3 Date of Service Edit: Clinical
3 Date of Service Edit: Clinical
2 Date of Service Edit: Policy
2 Date of Service Edit: Policy
2 Date of Service Edit: Policy
2 Date of Service Edit: Policy
MUE Rationale
Clinical: Data
Clinical: CMS Workgroup
Nature of Service/Procedure
Nature of Service/Procedure
Nature of Service/Procedure
Nature of Service/Procedure
Nature of Service/Procedure
CMS Policy
Nature of Analyte
Nature of Analyte
Prescribing Information
Clinical: Data
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Today’s speaker
Denise “Dee” DiMauro
Advisory Specialist Senior – Deloitte Advisory
Deloitte & Touche LLP
Tel: (860) 725-3503
Email: [email protected]
Experience
Denise is a Specialist Senior with Deloitte Advisory, and focuses on the Healthcare Provider sector. With over 15 years of supervisory
and management experience, she has conducted training and presented lectures on ICD-9, ICD-10, Coding Compliance, and Billing
Related Issues as AHIMA-approved ICD-10-CM/PCS trainer. Denise’s experience in electronic health records and billing includes
systems such as Epic, Meditech, Cerner (with Powerchart), HPF, and SDK.
Denise has been an active participant on the OIG compliance review team and her specialty areas also include cardiac catheterization
and cardiovascular services, professional fee coding, charge description master (CDM), general hospital outpatient coding/billing,
billing/reporting of chemotherapy drug units, mergers and acquisitions and inpatient/outpatient rehabilitative therapy. Prior to joining
Deloitte, Denise served as Client Manager for Facility and Professional Outpatient Services with a consulting firm and Revenue
Compliance Auditor/Educator with a large academic healthcare system where she assisted with annual audit plan and design, reviewed
physician documentation for E/M coding, performed education to the physician(s) and conducted follow-up monitoring of management
action plans.
Denise performs record selection using RATstats and audit criteria and conducts audits of clinical records, report writing, and
educational session presentations. She regularly collaborates closely with internal audit teams and teaches advanced training in
healthcare compliance (e.g., HIPAA, Compliance Hotline, Privacy, Nondisclosure, and Security). Denise has attained the following
credentials CPMA, CPC, CPC-H.
29
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Today’s speaker
Elizabeth “Liz” Cook
Advisory Specialist Senior – Deloitte Advisory
Deloitte & Touche LLP
Tel: (616) 826-5679
Email: [email protected]
Experience
Liz is a Specialist Senior with Deloitte Advisory, and focuses on the Healthcare Provider sector. With over 25 years of
professional experience in healthcare, she specializes in outpatient and inpatient coding and billing, clinical documentation,
revenue cycle, medical coding educator and ICD10 trainer. As a Certified Electronic Health Records Specialist, she is
experienced with Epic, Cerner, Meditech and RecordsOne systems.
Since joining Deloitte, Liz Cook has participated in compliance, revenue cycle, and internal audit assessments for a wide
variety of health care organizations. She is a specialist used by the firm involving the main focus areas of inpatient, SNF,
hospital outpatient and professional chart auditing, E/M, ICD-9 and ICD-10 coding gap analysis, clinical documentation
excellence and multiple facets of the revenue cycle.
Her experience includes auditing of records through the application of specialist compliance related knowledge and expertise,
while further consulting with internal and external parties to contribute to the ongoing development and improvement of
compliance and risk management, while contributing to the delivery of efficient and effective policies to support a range of
compliance, audit and risk management matters in accordance with government policies and procedures, legislative
requirement and professional standards.
Liz has attained the following credentials: CCS, CPC, CASCC, CHA, CHI, CPhT, CEHRS, and AHIMA ICD10 Trainer.
Currently she serves as President for her local AAPC chapter and is a member of both AAPC and AHIMA.
30
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Question & answer?
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