Wiki NCCI EDITS AND RECONSIDERATIONS

[lindam@caricures.com]

I am looking for a somewhat standard way of asking for reconsideration. Usually when billing a 45385 and a 45380. Also 45388 and 45385. I state per NCCI Edits that both codes are payable when in different areas of the colon. I am just looking for the proper wording that others use when asking for reconsideration. Thank you

 

[daniel]

Unfortunately, these two codes are often denied/pended even with the appropriate modifier. For the claim to be paid, it will have to be appealed. The payer is looking for documentation to include a separate lesion treated with a separate technique which includes the instrument used to treat the lesion(s). If that information is not contained within the endoscopy report, the payer will most likely only pay for one technique. Use of the XS modifier in place of modifier 59 also is recommended since that modifier is more specific and is also accepted by the majority of commercial payers, not just Medicare. It is also important to link the diagnosis as well as enter locations into the comment field (Box 19) for each technique to support "separate lesion" designation. For supporting documentation, please refer to NCCI policy, chapter 6, section H, #25 which states:

The NCCI PTP edit with column one CPT code 45385 (Flexible colonoscopy with removal of tumor(s), polyp(s), or lesion(s) by snare technique) and column two CPT code 45380 (Flexible colonoscopy with single or multiple biopsies) is often bypassed by using modifier 59 or -X{EPSU}. Use of modifier 59 or XS is only appropriate if the two procedures are performed on separate lesions. Use of modifier 59 or XE is only appropriate if the two procedures are performed at separate patient encounters.

 

[jessirussell2003]

I fight these denials quite often. Do you have CODIFY? If not you can use print out off MCR site NCCI Edit section. I use Codify as it prints a really nice NCCI Edits Validation sheet out, showing the insurance companies that yes this IS allowed to be billed together with a qualifying modifier. But, I generally will start off by explaining to them that according to MCR guidelines (I use for MCR and Commerical) and MCD (used for Medicaids).
The CPT 45380 line denied for bundling, in which you will see the Medicare NCCI Edits Validation report to show this can indeed be unbundled with a qualifying modifier on it according to The National Correct Coding Initiative Program. The 45385 was paid on, so I am looking to get the 45380 line item paid on, as it is a justified valid procedure charge and it had the qualifying modifier on it.
So with this information listed, I ask you to please carefully review our documentation and find that our claim is indeed valid and payable, since I am sending in the NCCI Edits Validation Results Report. If you need to review the NCCI policy manual you may find it at : https://www.cms.gov/medicare/coding...iative-ncci-edits/medicare-ncci-policy-manual. When I send in my reconsiderations I will always send the OP note and Path report as well. Most of the times I get them paid. Humana MCR Adv is about the only one that refuses no matter what to pay. Most others I will send a reconsideration packette once or twice sometimes three times and generally they will pay.

I used to add the blurb that both procedures were done in separate areas however, I do not add that any longer as I felt it may have confused them or made them fight back harder stating it was not in separate areas and such. But the blurbs above have worked pretty well for me. Except for good ole Humana.
I hope this helps you. Jessica

 

[lindam@caricures.com]

I fight these denials quite often. Do you have CODIFY? If not you can use print out off MCR site NCCI Edit section. I use Codify as it prints a really nice NCCI Edits Validation sheet out, showing the insurance companies that yes this IS allowed to be billed together with a qualifying modifier. But, I generally will start off by explaining to them that according to MCR guidelines (I use for MCR and Commerical) and MCD (used for Medicaids).
The CPT 45380 line denied for bundling, in which you will see the Medicare NCCI Edits Validation report to show this can indeed be unbundled with a qualifying modifier on it according to The National Correct Coding Initiative Program. The 45385 was paid on, so I am looking to get the 45380 line item paid on, as it is a justified valid procedure charge and it had the qualifying modifier on it.
So with this information listed, I ask you to please carefully review our documentation and find that our claim is indeed valid and payable, since I am sending in the NCCI Edits Validation Results Report. If you need to review the NCCI policy manual you may find it at : https://www.cms.gov/medicare/coding...iative-ncci-edits/medicare-ncci-policy-manual. When I send in my reconsiderations I will always send the OP note and Path report as well. Most of the times I get them paid. Humana MCR Adv is about the only one that refuses no matter what to pay. Most others I will send a reconsideration packette once or twice sometimes three times and generally they will pay.

I used to add the blurb that both procedures were done in separate areas however, I do not add that any longer as I felt it may have confused them or made them fight back harder stating it was not in separate areas and such. But the blurbs above have worked pretty well for me. Except for good ole Humana.
I hope this helps you. Jessica

thank you. I am asking about getting Codify, seems like a good option.