Eli's Rehab Report

Question: A claim was rejected because of an edit that isnt published in the CCI. Is there a list of these edits somewhere else so I can keep track of what claims are going to be rejected and which claims will go through?

Michigan Subscriber

Answer: You are probably referring to the black box edits, a list of unpublished commercial edits that have never been available directly to medical practices and have caused a lot of confusion to billers and physicians. The good news is that HCFA has instructed local carriers that it discontinued using black box edits effective Sept. 1, 2000.

For the past two years, HCFA used both published and unpublished edits computer instructions developed to help Medicare payers identify improper claims.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.

In October 1998, HCFA to realize an estimated $205 million in savings added an additional 500 procedure-to-procedure edits to ensure that Medicare did not pay separately for services that should be billed together. These edits were developed with commercially available off-the-shelf software and are often referred to as commercial edits.

HCFA declined to publish this list of commercial edits because of what the HCFA administrator referred to as ownership issues and the need to stay ahead of unscrupulous providers. In the Medicare Carriers Manual, local payers were instructed, commercial edits are not part of the CCI. 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 AMA passed a resolution criticizing the commercial edits and renaming them the black box edits.

Physical medicine and rehabilitation (PM&R) coders should monitor claims that were filed before the Oct. 1 effective date because the removal of the black box edits is not retroactive and affects only claims filed after the effective date.

Even if you believe that a particular coding combination is a black box edit, it may still not be reimbursed in the future. Many of the black box edits are standard edits, and even if they are not listed in the CCI, there are procedures that are considered standard components of other procedures by the CPT. These procedures will not be separately reimbursable.

If you are confused about which codes this decision affects, verify billing component codes with your local Medicare carrier before submitting claims.

Answer provided by Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.