Pulmonology Coding Alert

Question: When specialty society guidelines differ from National Correct Coding Initiative edits, a commercial payer said, we have to defer to the CMS bundles. Our contract does not stipulate that we must follow NCCI edits. The representative claims that because we are following society guidelines, we are "unbundling." We follow NCCI for Medicare, Tricare and Medicaid. When billing commercial payers, do we have to follow NCCI edits or CMS guidelines?


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Answer: Many coding experts recommend that you code uniformly, meaning that you follow CMS guidelines and NCCI edits for all payers. Universal coding keeps you HIPAA-compliant and protects you from accusations of coding for payment. Because payers do not use the same claim edits, some coders prefer to code per insurer These practices either employ large billing staff who can focus on various regulations or are small and handle a low volume allowing this specificity. If the edits contradict specialty-society guidelines, you should work with the society, such as the American Thoracic Society or the American College of Chest Physicians, and the payer to alert them to the inappropriate edit. Before reporting two bundled codes, make sure documentation justifies billing them separately.