Corporate Compliance

Note from the Instructor: Improved Edit Resources from CMS

Medicare Insider, May 5, 2015

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This week’s note from the instructor is written by Kimberly Anderwood Hoy Baker, JD, regulatory specialist for HCPro.  
In last week’s note, Judith wrote about the Medical Unlikely Edits (MUE), one aspect of the National Correct Coding Initiative (NCCI). This week I thought I would take the opportunity to review the new, improved format for another of the NCCI edits, the Procedure to Procedure (PTP) edits. Additionally, CMS has made available an extended Integrated Outpatient Code Editor (IOCE) data file that contains information on many of the other edits applied through the broader IOCE, giving providers even more information on the edits applied to their claims.
Updates to the PTP Edit File
The latest version of the PTP edits, published for April, contains a new column with the rationale for each edit. The rationale column includes descriptions such as:
·         Standards of medical/surgical practice,
·         HCPCS/CPT procedure code definition,
·         CPT® ‘separate procedure’ definition, or
·         Misuse of column two code with column one code.
I was unable to find a further explanation of the meaning of these rationale, but they do give providers a place to start further researching the basis of a PTP edit.
The new rationale column also identifies “Mutually exclusive procedures.” This is important because this information has not been available since the reformatting of the excel files containing the edits in April 2012. CMS places the codes in column one and column two differently for mutually exclusive edits than for the other bundling edits. For mutually exclusive edits, the first column contains the least expensive code, and if the provider does not apply a modifier, the column two code (or more expensive code) will be rejected for payment.  
It’s important to review mutually exclusive edits carefully. For the other bundling edits, if no modifier applies, the column one code is generally the correct code and the column two code should be removed. However, for mutually exclusive procedures either code could be correct. The coder needs to reassess the pair of codes to determine not only if a modifier applies, but also, if a modifier doesn’t apply, which code to remove. Failure to do this will cause the lower paying code to pay, when the higher paying code may represent the correct code for the procedure provided. 
New IOCE Data File Available
Beginning in January, CMS has made available the IOCE Quarterly Data files, along with PC and Mainframe software. Previously, CMS had only published the IOCE Specifications, which contains a detailed explanation of the edits, and the IOCE Summary of Data Changes, which contains a listing of the codes changed for that quarter. CMS continues to publish these two files along with the new files on the CMS website.
The new Quarterly Data File contains all HCPCS/CPT® codes and information about the codes and their inclusion in various edits applied through the IOCE. The file provides the status indicator for each code and information such as whether it is:
·         Treated as a conditionally bilateral code for coding purposes,
·         A procedure that requires a device to be billed,
·         A device that satisfies the procedure/device edit,
·         A separate procedure under the inpatient only separate procedure exception, or
·         A comprehensive APC procedure.  
This file, along with the detailed explanations in the IOCE Specifications, allows providers to research edits applied through the IOCE and determine how to correct claims.
Unfortunately, I have tried several times to download and install the PC software that is also now available and have been unable to get the software to run on my computer. I have viewed it on another computer and it appears to allow a provider to enter various codes and modifiers and receive the output from the IOCE (i.e., whether an edit applies). I encourage interested providers to download the software, though it appears to run better on Windows 7® and prior versions. 
Overall, the new information available through these two edit systems gives providers access to far more information in researching and resolving the reasons for denials. CMS seems to be providing more information to providers about their edits and this is a very positive trend for provider compliance, as well as revenue integrity.  

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