Corporate Compliance

Note from the instructor: NCCI Manual Updated for January 1, 2015

Medicare Insider, December 2, 2014

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This week’s note from the instructor is written by Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro.  
 
It was a light week last week for CMS publications as we all prepared for the Thanksgiving holiday. I hope yours was very blessed. CMS did post on its website an update to the National Correct Coding Initiative Policy Manual for Medicare Services which will be effective with dates of service January 1, 2015.
 
The National Correct Coding Initiative (NCCI) edits were created many years ago “to promote national correct coding methodologies and to control improper coding that leads to inappropriate payment in Part B claims.” There are two sets of edits – one for physicians and a separate file for hospitals. NCCI edits apply only to Medicare Part B claims and they do not apply to hospital inpatient services or any other services covered under Medicare Part A.
 
According to the NCCI Manual, the NCCI is developed by CMS for the Medicare program and the most important consideration in developing the edits is CMS Policy. CMS also considers American Medical Association's Current Procedural Terminology (CPT) Manual, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice, and current coding practice.
 
NCCI includes three types of edits:
  • Procedure-to-Procedure (PTP) edits are pairs of CPT or HCPCS Level II codes that are not both separately payable when billed by the same provider for the same beneficiary for the same date of service, unless an appropriate modifier is reported;
  • Medically Unlikely Edits (MUEs) represent the maximum number of units reportable for a HCPCS code by the same provider for the same beneficiary for the same date of service, in most circumstances; and,
  • Add-on Code edits describe a service that is always performed in conjunction with another primary service and is eligible for payment only when provided with an appropriate primary service.  
 
In reviewing the new manual for 2015, it appears Chapter 1 General Correct Coding Policies contains the most changes. Specifically, there were extensive revisions to the MUEs section. The changes included an explanation of the Modifier Adjudication Indicator (MAI), appealing a MAC’s denial, and the prohibition of issuing an Advance Beneficiary Notice or billing the patient when an MUE edit is triggered.
 
Chapter 1 of the updated NCCI manual did incorporate additional guidance in regards to Modifier 59 fromMLN Matters article SE1418. This article was released earlierthis year. It describes the three other limited situations in which two services may be reported as separate and distinct because they are separated in time and describe non-overlapping services even though they may occur during the same encounter.
 
In relation to Modifier 59 and the new subset modifiers X{ESPU}, an updated version of Modifier 59 article is also posted on the NCCI Edit website. Unfortunately, it does not provide any much needed guidance or examples for the use of the new modifiers. We continue to wait for further instruction from CMS and MACs on their required use although CMS is encouraging hospitals and physicians to begin using them on January 1.
 
Coding and billing staff, compliance and auditing staff, as well as department managers should at a minimum review Chapter 1 and any other applicable sections to their line of business. All changes are designated by italicized red font.



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