Neurology & Pain Management Coding Alert

Question: Is it true that HCFA has recalled all black box edits?

Georgia Subscriber

Answer: The unpublished edits that were responsible for many unsubstantiated denials were discontinued on Sept. 5, 2000, by the Health Care Financing Administration (HCFA), says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.

For the past two years, HCFA had used both published and unpublished edits computer instructions developed to help Medicare payers identify improper claims. The published edits are listed in the Correct Coding Initiative (CCI), which is updated and printed quarterly. The CCI contains a list of procedures that Medicare considers to be components of a more comprehensive procedure. The codes for these component procedures are bundled by the CCI into the codes for the comprehensive procedures. These bundled coding combinations are not separately reimbursable unless the component procedure represents a distinct procedure or service from others billed on the same date of service, according to the Medicare Carriers Manual (MCM). The manual also states that this distinct procedure or service may represent a different session, different surgery, different anatomical site or organ system, separate incision/ excision, different agent, different lesion, or different injury or area of injury.

The commercial edits are proprietary and may not be made available to the public in a mass publication like the CCI. Upset over the use of edits that were not available for public review, the American Medical Association passed a resolution criticizing the commercial edits and renamed them the black box edits.

HCFA chose not to renew its contract with HBO and Co., the software vendor that supplied the edits, according to Callaway-Stradley. HCFAs contract with HBO and Co. expired on Oct. 1.

As a result of the discontinued edits, neurology coders should monitor claims that were filed before the Sept. 5 effective date, says Callaway-Stradley. The removal of the black box edits is not retroactive and only affects claims filed after the effective date, she cautions.

Callaway-Stradley also warns that because a coder believes that a particular coding combination was a black box edit does not mean that it will be reimbursed in the future. Many of the so-called black box edits are really standard edits, she explains. Even if they are not listed in the CCI, there are procedures that are considered standard components of other procedures by the CPT, and these still will not be separately reimbursable.

Coders confused about which codes this decision affects should verify any doubt they have for billing component codes with their local Medicare carrier before submitting claims.