How to Use The National Correct Coding Initiative (NCCI) Tools

Presented by Lori Dafoe, CPCHow to Use The National Correct Coding Initiative (NCCI) Tools1AgendaHow it Impacts YouNCCI History and DefinitionUsing the NCCI Tools/AAPC CoderReal Life ExamplesResources

2Why 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.3Background and HistoryNCCI was originally developed for Medicare in 1996

Founded on Coding Policies4NCCI Websitehttp://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html

5What 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 IIColumn 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.6NCCI Table Example

7Modifier Indicator Table

8Mutually Exclusive EditsProcedure 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.9Medically 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.10Use of ModifiersModifiers 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 billingReimbursementNCCI editingClarification of procedures11Modifiers 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

12NCCI Edits and How they WorkType INCCI Code Pair Edits(Procedure to -Procedure)Type IIMedically Unlikely Edits (MUEs)13Mutually Exclusive ProceduresExample : Column I / Column II Code 11719 / 11720CPT 11719 (Column I)Trimming of non-dystrophic nails, any number1 = modifierallowedCPT 11720(Column II)Debridement of nail(s) by any method(s); one to fivePolicy: Modifier -59 is allowed if appropriate documentation is present. 14CPT Coding Manual Instruction/GuidelineExample: Column I / Column II Code 17000 / 11000CPT 17000Column IDestruction, pre-malignant lesion; first1 = modifierallowedCPT 11100Column IIBiopsy of skin, single lesionPolicy: Modifier -59 is allowed if appropriate documentation is present.

15More Extensive ProcedureExample: Column I Code/Column II code 45385/45380

CPT 45385Column IColonoscopy, flexible, proximal to splenic flexure; w/removal of tumor(s), polyp(s), or other lesion(s) by snare technique1 = modifier allowedCPT 45380Column II Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiplePolicy: Modifier -59 is allowed if appropriate documentation is present. 16How to Locate NCCI Tables and ManualCode pair edits, MUE tables, and NCCI manual are accessed on the CMS website athttp://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.htmlHow to Use the NCCI ToolsNCCI Policy Manual for Medicare ServicesModifier -59 Article: Proper Usage

17NCCI ExampleColumn1/Column 2 EditsColumn 1Column 2* = In existence prior to 1996Effective DateDeletion Date*=no dataModifier0=not allowed1=allowed9=not applicable325557694220130101*1Okay, so here we have our example. We see that there is a bundling edit, but it can be over-ridden by the use of a modifier. What do you do next?18Dont Get Bungled Up by Bundled Codes

So now, we know what NCCI edits are, and how to find them, and what modifiers can be used to unbundle services. Now lets look at when its appropriate to use it. 19Clinical Example: CPT 32555 & CPT 76942

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21To Bundle, or Not to Bundle?

22Modifier -59, CPT Manual DefinitionDifferent session Different patient encounterDifferent procedure or surgery, Different site or organ system, Separate incision/excision, Separate lesion, orSeparate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. 23Example 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, 24

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25Lets Practice!!

26Coding Scenario 1:Yes! -59Append 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.27Coding Scenario 2:Yes! -59Append to CPT 26115 & 26111 (Column II Codes). Rationale: Excision of tumors were performed on separate digits, requiring separate incisions and repairs.28Coding Scenario 3:No!N/AN/ARationale: 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.29Coding Scenario 4:No! N/AN/ARationale: The comprehensive metabolic panel includes a total calcium.30Coding Scenario 5:Yes! -59Append 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.31Dont forget May MAYnia! Invite a friend or co-worker!THANK YOU!!!!32