ED Coding and Reimbursement Alert

Scope out these new CCI edits for fluoroscopy use and heparin lock procedures

Professional services provided in the ED escaped attention in the latest round of new NCCI edits, effective July 1; however, there are a few facility issues you should know about.

Overview: CMS is implementing edits in the National Correct Coding Initiative (NCCI) that mostly impact neurosurgery coding. These edits are applicable to claims for services rendered to Medicare and Medicaid patients. The edits (1,368 edits in total for Medicare and Medicaid and 24,069 for Medicaid only) represent three different groups explained below.

Group I -- (42 new edits) In NCCI version 18.2 scheduled for July 1, 2012, CMS will implement Group I edits consisting of three types of edits, based on practice expense inputs:

Note that these types of edits are updated annually based on changes in the CMS Practice Expense file.

Group II -- (1,326 new edits) This group contains mostly neurosurgical codes that will not typically be provided in the ED setting.

CMS will implement edits bundling CPT® codes 95938 (Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs) and 95939 (Central motor evoked potential study [transcranial motor stimulation]; in upper and lower limbs) into the same codes into which CPT® code 95920 (Intraoperative neurophysiology testing, per hour [List separately in addition to code for primary procedure]) is bundled. The NCCI bundles add-on CPT® code 95920 and all its primary codes into certain cranial and spinal operative procedures since neurophysiological monitoring by the physician performing the surgical procedure is not separately reportable. The new edits, like the existing edits, will not allow use of NCCI-associated modifiers.

Group III -- Pertains to wheelchair related items not applicable to the ED. These edits will not be implemented until October 2012.

If the chart documentation demonstrates justification, all these edits can be circumvented with modifiers

According to NCCI, a modifier indicator of a "0" means no modifiers associated with the NCCI may be used to bypass the edit(s) and a "1" means modifiers associated with NCCI may be used to bypass the edit(s) under specific circumstances.