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Watch for missing drug injection and infusion NCCI edits

Medicare Weekly Update, February 3, 2009

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At presstime, we are unable to report on Transmittals due to an error on the CMS Transmittals site. All in all, CMS had a fairly inactive week, so I thought I would instead make you aware of an issue caused by the delay in the National Correct Coding Initiative (NCCI) edits for hospitals. As many of you know, CMS maintains two sets of NCCI edits: one for hospitals and one for physicians. The hospital version of the edits is one quarter behind the physician version. This can cause significant compliance issues for hospitals.

CPT and HCPCS codes are generally updated January 1 of each year. However, because the NCCI edits for hospitals are one quarter behind, the edits that apply to hospitals during the first quarter of a year are the edits for the fourth quarter of the prior year. This would mean that any new codes, adopted January 1, would not be included in the edits for the first quarter. This is especially problematic this year because of the new renumbered drug infusion and injection codes, which are subject to many bundling edits.

For example, CPT replaced the code for therapeutic, prophylactic, or diagnostic injections (90772) with new code 96372 for 2009. The former code 90772 is included in column1/column 2 (comprehensive/component) edits for many surgical procedure codes because injections related to a procedure are bundled into the procedure. This same coding policy would apply to the new code 96372; however, 96372 does not appear in the version of the NCCI edits effective for hospitals January 1–March 31, 2009, because the version being applied is from the fourth quarter of 2008, when this code did not exist.

This and other drug injection and infusion codes that were changed in 2009 are particularly problematic for hospitals in some of their departments. These codes are sometimes “hard coded,” meaning they are assigned by the departments through their charge entry process directly from the chargemaster. However, the procedures they may be bundled to are generally “soft coded,” meaning the coding department assigns those codes. This may result in the procedure code and its bundled injection code both being coded on the claim, simply because two different departments are responsible for the coding. 

Generally, this is caught by the hospital’s internal edits, which include the NCCI edits, prior to submission to Medicare. The internal edits will note that there is a bundling edit that applies and allow for correction before the claim is submitted. However, the edits for the first quarter do not have the new codes included, and therefore can not detect bundling errors related to the new injection and infusion codes, as they would have for the old codes. And because Medicare edits also do not contain the 2009 codes, the claim will not hit an edit when submitted to Medicare and both codes will be paid. 

During the first quarter of 2009, hospitals should ensure they have systems in place to review claims with injection and infusion codes prior to submission, to prevent inadvertently submitting and being paid inappropriately for procedures and their related injections and infusions.

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