Medicare Compliance & Reimbursement

NCCI edits could scare up cash-flow woes if providers aren't aware.

Long-term care facilities that don't plan carefully in the coming weeks could be facing the specter of unpaid therapy claims come Halloween.

Starting on Oct. 1, the feds will begin addressing the nursing home industry's questions about Medicare's National Correct Coding Initiative. A few short months later--commencing Jan. 1, 2006--the initiative and its payment restrictions will apply to all Part B therapy services provided in skilled nursing facilities.

Other newcomers to the NCCI initiative will be comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech-language pathology providers and home health agencies, according to the Centers for Medicare and Medicaid Services. NCCI, which until now has applied only to hospital prospective payment claims, is big news for institutional therapy providers, including SNFs. For the unsuspecting nursing facility, the NCCI edits could bring drastic reductions in reimbursement, experts say.

Gear Up For Clean Claims

By extending the edits to the new settings, CMS hopes to make uniform the manner in which all outpatient rehabilitation services are paid, said CMS officials speaking at the last SNF/Long-Term Care Open Door Forum, which was held on Aug. 28.

Take action: SNFs and others new to the program should "begin immediately" to prepare their systems with any necessary software and to educate their staff and management about the NCCI application to 2006 claims.
 
CMS explains the edits are designed to cut costs. These changes "will have a positive budgetary effect as [the program] incorporates safeguards against improper coding and over-payment of therapy services," says the agency in its Medlearn Matters article Special Edition 0545, "Correct Coding Initiative Edits to Apply to All Therapy Providers."

Tip: To stay on top of the transition, and protect Medicare revenue streams, providers should watch for NCCI news from CMS and local contractors (carrier or fiscal intermediary), after Oct. 1, 2005, the agency advises.

In the meantime, here are some tips toward becoming fluent in NCCI basics:

• The National Correct Coding Initiative is based on coding conventions defined in the American Medical Association's Current Procedural Terminology manual, current coding standards, input from specialty societies, and analysis of coding practices.

• For SNFs, the bill types affected by NCCI edits are 22X (inpatient, Part A) and 23X (SNF outpatient), notes Delores Galias of Galias Healthcare Consulting.

• The NCCI edits apply to services billed by the same provider for the same beneficiary on the same date of service.

• Providers can keep revenue on track by knowing how to use modifiers. One modifier that SNFs will probably use frequently is the--59 modifier.

Key: The--59 modifier (Distinct procedural service) lets a provider bill for a distinct procedural service for the same patient on the same day by the same provider.

Modifier--59 is often used when billing for both individual (one-on-one) therapy and group services to the same patient in the same day, as long as the group therapy session is clearly distinct. Failure to use the modifier could result in payment for only the group therapy code.