Ophthalmology and Optometry Coding Alert

Remember to exercise caution when using a modifier to break an NCCI edit.

Chances are your coding software seamlessly implements the quarterly National Correct Coding Initiative (NCCI) edits, but you may face a denial without knowing why — unless you know how NCCI Procedure-to-Procedure (PTP) edits work.

Have you ever been stumped when trying to interpret the most recent NCCI update or wondered why the Centers for Medicare & Medicaid Services (CMS) produces this comprehensive listing? If so, this one’s for you. We put together this handy guide chock full of expert advice in an attempt to answer those questions and help you use this valuable tool to improve your CPT^® coding accuracy.

“PTP edits were developed to promote national correct coding methods, to control improper coding leading to inappropriate payments for Medicare claims, and to prevent unbundling of services,” said Arlene Dunphy, provider outreach and education consultant at the Medicare Administrative Contractor (MAC) National Government Services (NGS) in the webinar, “The National Correct Coding Initiative and Medically Unlikely Edits.”

Or, as CMS explains it, the purpose “is to prevent improper payment when incorrect code combinations are reported” by assembling “code pairs that should not be reported together for a number of reasons” (www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/).

NCCI’s coding policies are based on the CPT^® manual, the HCPCS Level II manual, national and local Medicare policies, and coding guidelines that national societies developed. PTP edit pairs, which are updated quarterly, are just one type of NCCI edit. There are also medically unlikely edits (MUEs) and add-on codes.

Understand What Edit Pairs Are

CMS creates an edit pair when it regards a specific service as being a component part of a larger, more comprehensive service. In PTP edits, when your provider submits two bundled codes, the Column 1 code is eligible for payment, but Medicare will deny the Column 2 code unless both codes are clinically appropriate, according to Dunphy. Also, your provider must include supporting documentation in the medical record.

NCCI does not include all possible code combinations, so providers are obligated to code correctly, even if edits do not exist, Dunphy said. Services that are denied based on PTP code pair edits may not be billed to Medicare beneficiaries, and you cannot utilize an advance beneficiary notice (ABN) to seek payment.

Make Sure To Know Why MUEs Matter

In addition to PTP edit pairs, “CMS has created Medically Unlikely Edits, or MUEs, to reduce coding errors and fraud,” explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. “MUEs represent the maximum number of times one service can be performed on one patient and are usually determined by such biological factors as how many organs or limbs typically exist in the human anatomy, or whether the service is gender specific. They are CMS’ way of deciding how many units you can bill on one service line,” Falbo further elaborates.

Identify Different Modifier Indicators

CMS assigns Column 1 status to the comprehensive service and Column 2 status to a code they regard as being a component part of the Column 1 service.

Each PTP edit pair is then assigned one of three modifier indicators. An indicator of 0 means that the pair cannot be unbundled with an NCCI-associated modifier and that only Column 1 procedures will be paid in claims featuring both services by the same provider for the same beneficiary on the same date of service (DOS). An indicator of 1 means that both services may be reported together if an NCCI-associated modifier is appended to the Column 2 code and both services are eligible for payment. An indicator of 9 means the pair has been deleted, and that you can ignore the indicator.