HP Provider Relations October 2010 National Correct Coding Initiative

2 October 2010 Agenda –National Correct Coding Initiative (NCCI) –NCCI editing –Correct use of modifiers –Avenues of resolution

3 National Correct Coding Initiative October 2010 Objectives –Understand what NCCI is –Understand who is affected and when the changes will take place –Understand the use of modifiers –Understand how to resolve NCCI questions

Change National Correct Coding Initiative implementation

5 National Correct Coding Initiative October 2010 What is it? National Correct Coding Initiative –In the 1990s, the Centers for Medicare & Medicaid Services (CMS) developed the NCCI to promote national correct coding methodologies and to control improper coding leading to inappropriate payment –NCCI has been in place for many years and most providers are familiar with the editing methodologies used with Medicare –Based on input from a variety of sources: American Medical Association (AMA) Current Procedural Terminology (CPT ® ) guidelines Coding guidelines developed by national societies Analysis of standard medical and surgical practices Review of current coding practices CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

6 National Correct Coding Initiative October 2010 National Correct Coding Initiative –The recent healthcare legislation passed into law (H.R. 3962), requires that Medicaid programs incorporate compatible methodologies of the NCCI into their claims processing system –Section 6507 mandates that NCCI methodologies must be effective for claims filed on or after October 1, 2010 –Initial editing will encompass three basic coding concepts: NCCI Column I and Column II Mutually Exclusive (ME) Edits Medically Unlikely Edits (MUE)

7 National Correct Coding Initiative October 2010 National Correct Coding Initiative –The NCCI Policy Manual is located at

8 National Correct Coding Initiative October 2010 How does it work? National Correct Coding Initiative –NCCI editing is applied to claims reporting: Same date of service Same member Same billing provider NPI –Also included in NCCI editing are: Claims with Third Party Liability (TPL) amounts Claims denied by the primary insurance

9 National Correct Coding Initiative October 2010 Who will be affected? National Correct Coding Initiative –Included in NCCI: Physician claims Institutional outpatient claims Type of bill 13X and 83X –Excluded from NCCI: Medicare crossover Dental Home health Hospice Inpatient Long-term care Waiver Pharmacy

10 National Correct Coding Initiative October 2010 When is implementation? National Correct Coding Initiative –Professional claims – October 28, 2010 Includes column I/II, ME, MUE –Healthcare reform legislation mandates NCCI methodologies must be effective for claims filed on or after October 1, 2010 –HP will mass adjust claims received on or after October 1, 2010, through the implementation date

11 National Correct Coding Initiative October 2010 Institutional outpatient National Correct Coding Initiative –Outpatient claims targeted for April 1, 2011 – Bill type 13X and 83X Column I and Column II ME MUE –HP will mass adjust claims received on or after October 1, 2010, through the implementation date

Define Column I/Column II, MUE, and ME

13 National Correct Coding Initiative October 2010 New Edits for NCCI –New explanation of benefit (EOB) codes have been developed that specifically identify: When a claim detail has encountered an NCCI edit When a claim could not process through NCCI editing for an unexpected event –BT defines these edits including: New EOB numbers EOB Descriptions Purpose of EOBs

14 National Correct Coding Initiative October 2010 New NCCI Edits Example New EOB EOB DescriptionPurpose of EOB 4181Service denied due to a National Correct Coding Initiative (NCCI) edit. Go to ctCodInitEd/ for information regarding NCCI coding policies. ctCodInitEd/ This EOB will identify when a detail on a professional (CMS- 1500) claim has denied for Column I/II and/or ME edit. 4183Units of service on the claim exceed the Medically Unlikely Edit (MUE) allowed per date of service. Go to ctCodInitEd/ for information regarding maximum number of units of service allowed for the service billed. ctCodInitEd/ This EOB will identify when the units of service allowed on a claim detail exceed the MUE unit limit as defined by CMS.

15 National Correct Coding Initiative October 2010 New NCCI Edits Example New EOB EOB DescriptionPurpose of EOB 4185The claim did not process through NCCI editing. The claim will be reprocessed or adjusted at a later date. Please monitor future Remittance Advice statements for processing activity related to this claim. This EOB will identify when a claim could not go through NCCI editing due to an unexpected event. The claim is allowed to continue through normal processing and will be subject to a mass adjustment at a later to date. 9092The claim was subjected to NCCI editing methodologies. This EOB will identify when a claim has gone through NCCI editing and did not encounter any Column I/II, ME, or MUE edits.

16 National Correct Coding Initiative October 2010 Define Column I and Column II –Column I/ Column II Procedures should be reported with the most comprehensive CPT code that describes the services performed –Physicians must not unbundle or report multiple Healthcare Common Procedure Coding System (HCPCS)/CPT codes when a single comprehensive HCPCS/CPT code describes the services that were furnished.

17 National Correct Coding Initiative October 2010 Column1/Column II Denial Line #From DOSTo DOSProcedure Code DescriptionNCCI Editing 0111/01/ Vaginal hysterectomy for uterus 250 grams or less Detail is allowed 0211/01/ Salpingo- oophorectomy, complete or partial, unilateral or bilateral Detail is denied with edit 4181

18 National Correct Coding Initiative October 2010 Column1/Column II Denial Line #From DOSTo DOSProcedure Code DescriptionNCCI Editing 0111/05/ Radiologic exam, mandible: complete, minimum of four views Detail is allowed 0211/05/ Radiologic exam, mandible; partial, less than four views Detail is denied with edit 4181

19 National Correct Coding Initiative October 2010 Define Mutually Exclusive Edits –Procedure codes that cannot be reported together because they are mutually exclusive of each other –Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same patient encounter –Two or more procedures performed during the same patient encounter on the same date of service and same billing provider that are not normally performed together

20 National Correct Coding Initiative October 2010 Mutually Exclusive (ME) Edits Line #From DOSTo DOSProcedure Code DescriptionNCCI Editing 0111/15/ Vaginal hysterectomy; with total or partial vaginectomy with repair of enterocele Detail is allowed 0211/15/ Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s), with repair of enterocele Detail is denied with edit 4181

21 National Correct Coding Initiative October 2010 Mutually Exclusive (ME) Edits Line #From DOSTo DOSProcedure Code DescriptionNCCI Editing 0111/21/ Arthroplasty, knee, tibial plateau Detail is allowed 0211/21/ Arthroplasty, patella, with prosthesis Detail is denied with edit 4181

22 National Correct Coding Initiative October 2010 Define Medically Unlikely Edits (MUE) –HCPCS/CPTs have a defined unit of service for reporting purposes –Providers that bill units of service for a HCPCS/CPT code using a criteria that differs from the code’s defined unit of service will experience a denial –MUE editing is based on the units of service allowed on the claim, not the units of service billed

23 National Correct Coding Initiative October 2010 Medically Unlikely Edits (MUE) Line # From DOSTo DOSProcedure Code DescriptionUnits of Service billed NCCI Editing 0112/11/ Subsequent hospital care for the evaluation and management of a patient, patient is not responding to therapy or has a minor complication 6Detail is denied with edit 4183 – Units of service on the claim exceed the Medically Unlikely Edit (MUE) allowed per date of service. **If the dates of service were consecutive, the date span should represent the appropriate ‘From and To’ period. The MUE units allowed for this code is one per day.

Exceptions

25 National Correct Coding Initiative October 2010 Exceptions Medically Unlikely Edits (MUE) To align with current IHCP policy, the following are exceptions to the MUE unit limit: –A4253 – Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips: The MUE unit limit is two and IHCP policy allows four units (or 200 test strips) per month –A4259 – Lancets, per box The MUE unit limit is one and IHCP policy allows two units per month These are examples only, not a complete list of unit limitations that may exist

26 National Correct Coding Initiative October 2010 Exceptions NCCI Code Auditing –Antepartum Care – Antepartum care only; four to six visits – Antepartum care only; seven or more visits Billed with modifiers −U1 – Trimester one – 0 through 14 weeks, 0 days −U2 – Trimester two – 14 weeks, one day through 28 weeks, 0 days −U3 – Trimester three – 28 weeks, one day, through delivery And when billed on the same date of service as the lab codes listed in BT will not be subject to NCCI Column I/II editing Chapter 8 of the IHCP Provider Manual “Obstetrical Care” section provides specific billing information and a complete list of lab services allowed for each trimester

Bill Modifiers and date spans

28 National Correct Coding Initiative October 2010 What is correct? Use of Modifiers –Modifiers may be appended to HCPCS/CPT codes only when clinical circumstances justify the use of the modifier –A modifier should not be appended to a HCPCS/CPT code solely to bypass NCCI editing –The use of modifiers affects the accuracy of: Claims billing Reimbursement NCCI editing Clarification of procedures Special circumstances

29 National Correct Coding Initiative October 2010 Use of modifiers –Correct use of modifiers is essential to accurate billing and reimbursement for services provided. –Chapter 8, Section 4 of the IHCP Provider Manual gives detailed descriptions of modifiers –The CMS provides carriers with guidance and instructions on the correct coding of claims and using modifiers through manuals, transmittals, and the CMS Web site Providers can access the CMS Web site at –The National Correct Coding Initiative (NCCI) provides updates each quarter for correct modifier usage for each CPT code

30 National Correct Coding Initiative October 2010 Distinct procedure or service on the same day Modifier 59 –Should only be used when there is no other modifier to correctly clarify the procedure or service –A distinct procedure may represent the following: Different session or patient encounter Different procedure or surgery Different site or organ system Separate incision or excision Separate lesion Separate injury or area of injury in extensive injuries –If multiple units of the same procedure are performed during the same session, the provider should report all the units on a single detail line, unless otherwise specified in medical policy

31 National Correct Coding Initiative October 2010 Bilateral procedure Modifier 50 –Bilateral procedures performed during the same operative session on both sides of the body by the same physician –Units billed would be entered as 1 because one procedure was performed bilaterally –Modifier 50 is only required when the use of 50 is mandated by verbiage within the CPT coding manual

32 National Correct Coding Initiative October 2010 Multiple procedures Modifier 51 –Multiple procedures or services are performed on the same day or during the same operative session by the same physician –The additional or secondary procedure or service must be identified by adding modifier 51 to the procedure or service code

33 National Correct Coding Initiative October 2010 Procedures that can be performed on paired organs Modifiers LT and RT –Identifies procedures that can be performed on paired organs such as ears, eyes, nostrils, kidneys, lungs, and ovaries –Should be used whenever a procedure is performed on only one side to identify which one of the paired organs was operated on –CMS requires these modifiers whenever appropriate

34 National Correct Coding Initiative October 2010 CMS-1500 Span Dates –Providers must be sure to complete the “From” and “To” dates on all claims even if the service was for one single date of service –Services within the same calendar month and in a consecutive day pattern, must be billed with the appropriate units of service and “From” and “To” dates –Failure to report the correct date span and the number of units performed during the date span could result in a claim denial

35 National Correct Coding Initiative October 2010 Example Span Dates –Detail is allowed and does not encounter NCCI edits. From DOSTo DOSProcedure CodeDescriptionUnits of Service 10/03/201010/07/2010E0202Phototherapy5

36 National Correct Coding Initiative October 2010 Processing expectations Web interChange –Claims are usually viewable within two hours via the Claim Inquiry function –On rare occasions, claims will not be available for viewing within the usual two-hour time frame –If the delay is longer than 24 hours, providers may contact HP Customer Assistance to determine the reason for the delay , or (317) in the Indianapolis local area

Inquire Avenues of resolution

38 National Correct Coding Initiative October 2010 Claims Denials/Inquiry –Follow normal avenues of resolutions –IHCP Web site at –Customer Assistance , or (317) in the Indianapolis local area –Written Correspondence Written Correspondence P.O. Box 7263 Indianapolis, IN –Provider relations field consultant

39 National Correct Coding Initiative October 2010 New options Claims Denials/Inquiry –New options – Column I and II, Mutually Exclusive (ME), and Medically Unlikely Edit files. These files contain specific code pairs for Column I /II and the Mutually Exclusive edits. Administrative review

40 National Correct Coding Initiative October 2010 Requirements Administrative Review –Administrative review must be requested within seven days of notification of claims payment or denial Used when there are unusual circumstances in which a provider believes the claim was coded correctly and would like reconsideration of the NCCI editing –Complete an IHCP Programs Inquiry form or write a letter stating: Reason for disagreement Denial or amount of reimbursement Clearly note “Administrative Review” on the form or letter Attach all pertinent documentation Add “Attention To: Health Care Administrative Review Specialist” –The IHCP Programs Inquiry form can be obtained from the Indiana Medicaid Web site in the forms section at

41 National Correct Coding Initiative October 2010 Address Administrative Review –Send forms or letters to: Attn: Healthcare Administrative Review Specialist Written Correspondence P. O. Box 7263 Indianapolis, IN

Contact

43 National Correct Coding Initiative October 2010 For NCCI information only Concerns about Specific NCCI Edits? –Submit comments in writing to: National Correct Coding Initiative Correct Coding Solutions, LLC P.O. Box 907 Carmel, IN –Send to the attention of Niles R. Rosen, M.D., Medical Director and Linda S. Dietz, RHIA, CCS, CCS-P, Coding Specialist –Send questions regarding NCCI table edits only; do not send claims questions or claim appeals

Questions