Inpatient Facility Coding & Compliance Alert

The NCCI Manual was initially tailored for physicians.

It’s the first quarter of the year and the 2016 NCCI (National Correct Coding Initiative) edits are making their way through your coding think tanks. Have you faced conflicting statements when trying to apply the guidelines? If so, you are not alone. Here’s a low down on the implications and how to cope.

NCCI Manual: A Bridge or a Divide?

The application of the coding, and thus billing, directives to the hospitals has created some consternation, because the NCCI guidelines were originally developed for physicians, and later on brought across to the hospital side as well. Moreover, the basic difference between physician coding and hospital based coding lies in the fact that professional coding is performed based on what the physician does, whereas on the facility side the coding is primarily based on resource utilization.

Example 1: As per the manual, in a minor surgery, the requisite E/M (evaluation and management) services are included in the payment for the surgery. Therefore, the E/M level along with the 25 modifier (Significant, separately identifiable evaluation and management  service by the same physician or other qualified health care professional on the day of  the procedure or other service) is not warranted. Now, if you attempt to apply this on the hospital side, which is for APCs, there is an immediate problem. What is a minor surgery for APCs? There is a formal definition for physicians within the MPFS (Medicare Physician Fee Schedule), implying those surgeries with a 0-day or 10-day post-operative period are considered minor. However, the definition of a minor surgical procedure for APCs is quite detailed involving the status indicators.

Example 2: Let’s say a patient presents to a hospital’s emergency department with a laceration on the arm. The laceration will be repaired and appropriately coded. But what about the E/M level? Try evaluating this for both the ER physician and the hospital on the facility side, and note the difference!

Background

The NCCI policy manual consists of coding policies and guidelines, and forms the basis for development of NCCI edits. Initiated in the early 1990s, this manual’s original directives were for physicians. With the implementation of APCs (Ambulatory Payment Classifications) in 2000, the edits and coding directives were also brought across to the hospital side.

Here’s more: On the facility side, EMTALA (Emergency Medical Treatment and Labor Act) requires that a medical screening examination (MSE) be performed by a qualified medical person. Thus, resources are consumed mandating an E/M level along with the 25 modifier. On the other hand, for the ER physician, the inclusion of the 25 modifier will depend on what the physician did and the associated documentation.

Beware: Auditors might tend to read this guidance for not reporting the E/M level with the minor surgery and maintain that there should be no E/M level reported by either the physician or the hospital.

Takeaway: Carefully read and interpret the guidance provided in the NCCI Coding Policy Manual, particularly for hospital coding staff who are performing the coding, and thus billing, for the facility component. In some cases there is specific guidance for hospital coding.

“Read and then re-read the guidance because the language can be confusing,” says Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA. Also note that the directives in this manual may be different from the guidance provided by the AMA (American Medical Association) even through the CPT^® Manual itself.

See: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html for further information and to download the manual.