Ob-Gyn Coding Alert

Effective October 1, 2000, the Health Care Financing Administration (HCFA) announced that they will cease using code edits that are not open to public comment or disclosure. Instead, HCFA will seek out [commercial claims] contracts that do not contain confidentiality restrictions, according to Randolph D. Smoak, Jr., MD, with the American Medical Association (AMA). By way of background, on October 1, 1998, HCFA purchased 241 black box coding edits licensed from HBOC/McKesson for the Medicare program (this is the same company that produces the ClaimCheck code edit software) and implemented these edits despite vigorous and longtime AMA and medical specialty society opposition. These undisclosed computer edits deny submitted procedure codes that are not identified beforehand.

Coders and physicians have been caught in the trap of being accountable to unpublished coding rules, says Melanie Witt, RN, CPC, MA, from the American College of Obstetrics and Gynocologists. Meanwhile, she offers these tips to coders to ferret out and challenge the current black box edit software.

Theyll be hard to spot because the denial messages will look exactly like the ones used with the published Correct Coding Initiative (CCI) edits, she acknowledges. But by comparing explanation of benefits (EOB) denials with the codes on the latest CCI edit list (Version 5.2), those that dont appear are probably the secret edits. If youve found one, dont be afraid to ask your carrier to explain the rationale behind it. HCFA has indicated that the carriers will give the physician an explanation if the claim denial is appealed, she says. HCFA has not indicated, Witt says, whether an explanation on appeals of old claims will continue after the HBOC/McKesson license agreement expires. The black box edits would disappear, but additional edits will probably be added to take their place. However, those edits would be subject to public comment and disclosure.